Before the invention of ventilator technology, circulatory death ('cardiorespiratory death') and brain death ('neurological death') were essentially the same thing, because one inevitably caused the other, very quickly. But now that circulation can be maintained after the brain has gone irreversibly/permanently silent, we can make distinctions. And some of those distinctions depend on the distinction between irreversibly and permanently. This post starts with a position statement, but then features the underlying debate, and in fact two of the dueling papers take opposite stands on 'irreversible' and 'permanent.'. (The difference is that e.g. heart stoppage might be possibly reversible, but a 'do not resuscitate' order would mean that it was nevertheless permanent.)
But before the debate, here's a position paper
Standards and Ethics Issues in the Determination of Death: A Position Paper From the American College of Physicians by DeCamp, Matthew, Kenneth Prager, and American College of Physicians Ethics, Professionalism and Human Rights Committee, Annals of Internal Medicine (2023).
"Abstract: The determination of a patient’s death is of considerable medical and ethical significance. Death is a biological concept with social implications. Acting with honesty, transparency, respect, and integrity is critical to trust in the patient–physician relationship, and the profession, in life and in death. Over time, cases about the determination of death have raised questions that need to be addressed. This American College of Physicians position paper addresses current controversies and supports a clarification to the Uniform Determination of Death Act; maintaining the 2 current independent standards of determining death, cardiorespiratory and neurologic; retaining the whole brain death standard; aligning medical testing with the standards; keeping issues about the determination of death separate from organ transplantation; reaffirming the importance and role of the dead donor rule; and engaging in educational efforts for health professionals, patients, and the public on these issues. Physicians should advocate for policies and practices on the determination of death that are consistent with the profession’s fundamental and timeless commitment to individual patients and the public."
...
"Scientific advances motivate revisiting foundational concepts, including those around death and dying. Decades ago, advanced cardiorespiratory support—because of its ability to maintain cardiac and respiratory functions in individuals whose brain function was thought to have ceased—contributed to the development of brain death as a concept. Studies now show restoration of cellular and molecular activity in whole pig brains (without restoration of brain functions) 4 hours postmortem using an ex vivo perfusion system called “BrainEx” (15, 16). Today, a controversial protocol known as thoracoabdominal normothermic regional perfusion with controlled donation after circulatory determination of death can result in the resuscitation of the asystolic heart to restore circulation after what was a determination of circulatory death—to increase organ availability for transplant—but this invalidates the determination of death and breaches ethical boundaries (17, 18). Moreover, there has been ongoing advancement in ancillary tests, such as electroencephalograms, magnetic resonance angiography, single-photon emission computed tomography, hypothalamic testing (19), computed tomography angiography, computed tomography perfusion (20), and others. Results of these methods of testing can raise questions about the accuracy of clinical determinations of death.
...
"Position 1
ACP supports revising the Uniform Determination of Death Act (UDDA) to replace the word “irreversible” with “permanent” in the first clause to read, “An individual who has sustained either (1) permanent cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.”
"The UDDA (21) currently states, “An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.”
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And here's a whole series of position papers in the journal Neurology:
The Uniform Determination of Death Act (UDDA) Revision Series
This series aims to educate the neurology community about the most important brain death controversies the US Uniform Law Commission must consider in rewriting the UDDA.
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