The Death Debate: Penumbra Conundrum

Determination and declaration of death by neurologic criteria, brain death, is an established and legally accepted clinical practice with profound implications. Concerns regarding the accuracy of this diagnosis raise important clinical, ethical, and legal issues. A recent magazine article highlights these concerns by describing a poignant example of a patient meeting accepted clinical and ancillary testing criteria for brain death in the setting of post cardiac arrest hypoxic ischemic encephalopathy (CA-HIE). With continuation of ventilatory and nutritional support, this patient not only survived but over time demonstrated findings that were no longer consistent with brain death. Offered here is a review of the course of events described in the article, an overview of the variable clinical implications of CA-HIE and their relationship to the diagnosis of brain death, a proposed pathophysiologic correlation, and recommendations for palliative clinicians providing consultation with regard to goals of care and intervention options in cases of CA-HIE with severe neurologic injury.