Published Ahead of Print on October 11, 2023 as 10.1212/WNL.0000000000207740
SPECIAL ARTICLE
Pediatric and Adult Brain Death/Death by Neurologic
Criteria Consensus Guideline
Report of the AAN Guidelines Subcommittee, AAP, CNS, and SCCM
David M. Greer, MD, MA,* Matthew P. Kirschen, MD, PhD,* Ariane Lewis, MD,* Gary S. Gronseth, MD, Correspondence
Alexander Rae-Grant, MD, Stephen Ashwal, MD, Maya A. Babu, MD, MBA, David F. Bauer, MD, MPH, American Academy of
Lori Billinghurst, MD, MSc, Amanda Corey, MD, Sonia Partap, MD, MS, Michael A. Rubin, MD, MA, Neurology
Lori Shutter, MD, Courtney Takahashi, MD, Robert C. Tasker, MBBS, MD,
Panayiotis Nicolaou Varelas, MD, PhD, Eelco Wijdicks, MD, PhD, Amy Bennett, JD, Scott R. Wessels, MPS, ELS,
and John J. Halperin, MD
®
Neurology 2023;101:1-21. doi:10.1212/WNL.0000000000207740
Abstract
Background and Objectives
The purpose of this guideline is to update the 2010 American Academy of Neurology (AAN)
brain death/death by neurologic criteria (BD/DNC) guideline for adults and the 2011
American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care
Medicine guideline for infants and children and to clarify the BD/DNC determination process
by integrating guidance for adults and children into a single guideline. Updates in this guideline
include guidance related to conducting the BD/DNC evaluation in the context of extracor-
poreal membrane oxygenation, targeted temperature management, and primary infratentorial
injury.
Methods
A panel of experts from multiple medical societies developed BD/DNC recommendations.
Because of the lack of high-quality evidence on the subject, a novel, evidence-informed formal
consensus process was used. This process relied on the panel experts’ review and detailed
knowledge of the literature surrounding BD/DNC to guide the development of preliminary
recommendations. Recommendations were formulated and voted on, using a modified Delphi
process, according to the 2017 AAN Clinical Practice Guideline Process Manual.
Major Recommendations
Eighty-five recommendations were developed on the following: (1) general principles for the
BD/DNC evaluation, (2) qualifications to perform BD/DNC evaluations, (3) prerequisites for
BD/DNC determination, (4) components of the BD/DNC neurologic examination, (5) apnea
testing as part of the BD/DNC evaluation, (6) ancillary testing as part of the BD/DNC
evaluation, and (7) special considerations for BD/DNC determination.
*These authors contributed equally to this work as colead authors.
From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and
Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of
Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of
Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University
School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children’s Hospital,
Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory
University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center,
Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children’s Hospital, MA;
Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.),
Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ.
Approved by the Guidelines Subcommittee on January 23, 2023, by the Quality Committee on February 11, 2023, and the American Academy of Neurology Institute Board of Directors on
July 20, 2023. The Neurocritical Care Society affirmed the value of this consensus guideline on September 28, 2023.
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Copyright © 2023 American Academy of Neurology 1
Copyright © 2023 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
, Glossary
AAN = American Academy of Neurology; AAP = American Academy of Pediatrics; ABG = arterial blood gas; AEP = auditory
evoked potential; APP = advanced practice provider; BBB = blood-brain barrier; BD/DNC = brain death/death by neurologic
criteria; COI = conflict of interest; CPAP = continuous positive airway pressure; CV = curriculum vitae; ECMO =
extracorporeal membrane oxygenation; ETT = endotracheal tube; HIBI = hypoxic-ischemic brain injury; MAP = mean arterial
pressure; OCR = oculocephalic reflex; OVR = oculovestibular reflex; PEEP = positive end-expiratory pressure; SBP = systolic
blood pressure; SCCM = Society of Critical Care Medicine; SEP = somatosensory evoked potential; UDDA = Uniform
Determination of Death Act; VA = venoarterial.
Introduction brainstem, resulting in (1) coma, (2) brainstem areflexia, and
(3) apnea in the setting of an adequate stimulus.
Determination that a patient meets neurologic criteria for
death is a medical responsibility that leads to a legal declara- In concert with the Ethics, Law, and Humanities Committee, a
tion. The purpose of this guideline is to clarify the brain death joint committee of the AAN, the American Neurological Asso-
determination process for integration of guidance for adults ciation, and the Child Neurology Society and with the support of
and children into a single guideline. Updates in this guideline AAN leadership and the AAN Quality Committee, the AAN
also include addressing issues related to determination of Guidelines Subcommittee (eAppendices 1 and 2, links.lww.
death by neurologic criteria in the setting of extracorporeal com/WNL/D73) formed a multidisciplinary panel with mem-
membrane oxygenation (ECMO), targeted temperature bers from multiple medical societies to make updated formal
management, and primary infratentorial injury. consensus recommendations about the process of BD/DNC
determination. The panel considered that the process for di-
Death by neurologic criteria, commonly referred to as agnosing death, either cardiopulmonary or neurologic, should to
brain death, occurs in individuals who have sustained cata- the fullest extent possible be independent of patient age, making
strophic brain injury, with no evidence of function of the brain note of where child-specific principles apply. This document
as a whole, a state that must be permanent. The process of this combines adult and pediatric recommendations to ensure ac-
determination always begins with the presumption that the curate, consistent determination of BD/DNC in persons of all
patient does not meet brain death/death by neurologic criteria ages. Most aspects of BD/DNC evaluation are the same, re-
(BD/DNC), a presumption that must then be disproved. BD/ gardless of age, with a few exceptions. By unifying recommen-
DNC determination must be accurate and consistent. As stated dations into 1 document, there is consistent guidance to
in the report of the 1968 Harvard Committee, reaffirmed by clinicians in various practice settings.
subsequent presidential reports and prior adult and pediatric
guidelines, the essential underlying concept that defines BD/
DNC is permanent coma and loss of all brainstem function, Author Panel Formation
coupled with the inability to breathe in the setting of an adequate
stimulus (i.e., hypercarbia and acidosis). Because complete loss
and Methodology
of the brainstem’s reticular activating system is the most robust Leadership from the AAN Guidelines Subcommittee (A.R.-G.,
predictor of the permanence of a comatose state, most of the J.J.H.) and the AAN Brain Death Working Group (D.M.G.,
neurologic assessment focuses on demonstrating the loss of all M.P.K., A.L.), a subgroup of the AAN Ethics, Law, and Hu-
brainstem reflexes. Of importance, BD/DNC determination is manities Committee, engaged a broad panel of stakeholders
based on clinical assessment; ancillary testing is required only if from multiple medical societies to collaborate on an updated
the clinical assessment cannot be safely or fully completed. BD/DNC guideline. Panel members were invited from the
following organizations: AAP, American College of Radiology,
The Uniform Determination of Death Act (UDDA), the legal Child Neurology Society, Congress of Neurological Surgeons,
foundation for the declaration of BD/DNC in the United Neurocritical Care Society, and SCCM. Clinicians with ex-
States, stipulated that determination of BD/DNC must be pertise in BD/DNC were also invited. The author panel in-
made in accordance with accepted medical standards.1 In 2018, cluded BD/DNC experts (D.M.G., M.P.K., A.L., G.S.G., S.A.,
multiple medical societies agreed that the accepted medical M.A.B., D.F.B., L.B., A.C., S.P., M.A.R., L.S., C.T., R.C.T.,
standards for determination of BD/DNC were the 2010 AAN P.N.V., and E.W.), process facilitators (A.R.-G., J.J.H.), and a
guideline for adults and the 2011 Society of Critical Care methodologist (G.S.G.). Each potential author was required to
Medicine (SCCM)/American Academy of Pediatrics (AAP)/ submit an AAN relationship disclosure form and a copy of his
Child Neurology Society guideline for infants and children.2-4 or her curriculum vitae (CV). The panel leadership (A.R.-G.,
These guidelines stipulate that BD/DNC should be declared J.J.H., G.S.G., D.M.G., M.P.K., A.L.) and AAN staff reviewed
when a patient with a known cause of catastrophic brain injury the relationship disclosure forms and CVs for financial and
has permanent loss of function of the entire brain, including the intellectual conflict of interest (COI). These documents were
2 Neurology | Volume 101, Number 24 | December 12, 2023 Neurology.org/N
Copyright © 2023 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
, specifically screened to exclude those individuals with a clear action verbs are 7b, 11b, 11c, 13d, 18c, 24c, 25b, 25i, 25j, 25k,
financial conflict and those whose profession and intellectual bias 25l, 25m, 26, 27b, 29, 30, 31, 35, 37a, 37b, 38, and 39.
would diminish the credibility of the guideline in the eyes of the
intended users. Before the formation of the author panel, it was After the first round of voting, the preliminary manuscript and
determined that a financial link with organ procurement organi- initial rationales and recommendations were reviewed by the
zations in the prior 5 years would preclude participation as a direct AAN Guidelines Subcommittee for comment on January 11,
conflict to participation. As required by the AAN, most (51%) of 2020, and revised by panel members. After the second round
the members (A.L., G.S.G., A.R.-G., S.A., M.A.B., D.F.B., L.B., of voting, the document was distributed for public comment
A.C., S.P., M.A.R., C.T., R.C.T., E.W., and J.J.H.) of the author (December 14, 2020, through January 12, 2021), and all
panel and the lead authors (D.M.G., M.P.K., and A.L.) are free of comments were analyzed and incorporated where appropriate.
COI relevant to the subject matter of this practice guideline. The panel met virtually on January 13, 2022, to review public
comment revisions and discuss plans for the third round of
The author panel met in person on October 11, 2019, to define voting. Because of concerns for potential ambiguity in the
the methodology and develop initial rationales and recom- questions used to determine the strength of recommendations,
mendations. Because of the lack of high-quality evidence on the panel members revised the questions for the recommendations
subject, a novel, evidence-informed formal consensus process related to increasing the accuracy of BD/DNC determination.
was used. This process relied on the panel experts’ detailed
knowledge of the literature surrounding BD/DNC to guide the The panel also added a question so that panel members would
development of preliminary recommendations, followed by 3 self-identify the primary population (adult or children) they
iterative rounds of anonymous voting on each rationale and treated. This was done in case it was necessary to stratify
recommendation (modified Delphi process), with prespecified recommendations by adult and pediatric populations to attain
rules for determining consensus attainment and the strength of consensus.
each recommendation. The intent was for recommendations
to be conservative to minimize the risk of a false-positive de- The author panel met virtually on April 28, 2022, to finalize the
termination of BD/DNC (determining BD/DNC in a patient revised voting questions and instructions (eAppendix 4, links.
who does not have permanent catastrophic brain injury with no lww.com/WNL/D73). After the third round of voting, it was
evidence of brain function), yet practical. determined that differences between pediatric and adult rec-
ommendations warranted separate considerations, with voting
A subset of the panel (D.M.G., A.R.-G., M.P.K., A.L., and J.J.H.) for each by the panel members with relevant self-identified
drafted recommendations with input from the methodologist expertise. After multiple rounds of voting and revisions to attain
(G.S.G.). Panel members answered a series of questions for consensus, the rationales and recommendations were finalized
each recommendation to determine the cogency of the ratio- for the manuscript.
nale supporting the recommendation and the strength of the
recommendation (eAppendix 3, links.lww.com/WNL/D73).
Recommendations were formulated according to the 2017
Terminology
AAN Clinical Practice Guideline Process Manual.5 Each rec- The term brain death has been used in common parlance,
ommendation statement includes an action verb of must, but the panel chose to use brain death/death by neurologic
should, or may reflecting the strength of the recommendation. criteria or BD/DNC to both embrace the colloquial term
The action verb corresponds to the level of consensus reached. and emphasize that a determination means more than death
Level A voting consensus resulted in a must statement. Level B of the brain and that, rather, death of the person has oc-
voting consensus resulted in a should statement. Level C voting curred, equivalent to death by cardiopulmonary criteria.
consensus resulted in a may statement. This terminology was also used in the World Brain Death
Project.6
Before initiation of voting, each recommendation draft
statement action verb was anchored at must, should, or may, The terms irreversible and permanent have both been used
as deemed appropriate by the panel. This anchoring pre- to describe the extent of loss of function that must be present
vented the statement from reaching a higher strength of to determine BD/DNC. The panel chose to use the term
recommendation. Because of this anchoring, there are rec- permanent to mean function was lost and (1) will not resume
ommendation statements that have reached a high level of spontaneously, and (2) medical interventions will not be used
consensus with a lower action verb. For example, Recom- to attempt restoration of function. This terminology was also
mendation statement 7b states, “Clinicians should conduct used in the World Brain Death Project.
further diagnostic evaluation and not undertake evaluation for
BD/DNC if a patient is comatose, apneic and has absent The term child has been defined for purposes of this document as
brainstem reflexes, and there is not an identified mechanism any patient who is at least 37 weeks old, corrected gestational
of brain injury that is known to lead to BD/DNC” with Level age, and younger than 18 years old. There are several individual
A consensus. The recommendation statements with anchored recommendations that detail specific age ranges.
Neurology.org/N Neurology | Volume 101, Number 24 | December 12, 2023 3
Copyright © 2023 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
SPECIAL ARTICLE
Pediatric and Adult Brain Death/Death by Neurologic
Criteria Consensus Guideline
Report of the AAN Guidelines Subcommittee, AAP, CNS, and SCCM
David M. Greer, MD, MA,* Matthew P. Kirschen, MD, PhD,* Ariane Lewis, MD,* Gary S. Gronseth, MD, Correspondence
Alexander Rae-Grant, MD, Stephen Ashwal, MD, Maya A. Babu, MD, MBA, David F. Bauer, MD, MPH, American Academy of
Lori Billinghurst, MD, MSc, Amanda Corey, MD, Sonia Partap, MD, MS, Michael A. Rubin, MD, MA, Neurology
Lori Shutter, MD, Courtney Takahashi, MD, Robert C. Tasker, MBBS, MD,
Panayiotis Nicolaou Varelas, MD, PhD, Eelco Wijdicks, MD, PhD, Amy Bennett, JD, Scott R. Wessels, MPS, ELS,
and John J. Halperin, MD
®
Neurology 2023;101:1-21. doi:10.1212/WNL.0000000000207740
Abstract
Background and Objectives
The purpose of this guideline is to update the 2010 American Academy of Neurology (AAN)
brain death/death by neurologic criteria (BD/DNC) guideline for adults and the 2011
American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care
Medicine guideline for infants and children and to clarify the BD/DNC determination process
by integrating guidance for adults and children into a single guideline. Updates in this guideline
include guidance related to conducting the BD/DNC evaluation in the context of extracor-
poreal membrane oxygenation, targeted temperature management, and primary infratentorial
injury.
Methods
A panel of experts from multiple medical societies developed BD/DNC recommendations.
Because of the lack of high-quality evidence on the subject, a novel, evidence-informed formal
consensus process was used. This process relied on the panel experts’ review and detailed
knowledge of the literature surrounding BD/DNC to guide the development of preliminary
recommendations. Recommendations were formulated and voted on, using a modified Delphi
process, according to the 2017 AAN Clinical Practice Guideline Process Manual.
Major Recommendations
Eighty-five recommendations were developed on the following: (1) general principles for the
BD/DNC evaluation, (2) qualifications to perform BD/DNC evaluations, (3) prerequisites for
BD/DNC determination, (4) components of the BD/DNC neurologic examination, (5) apnea
testing as part of the BD/DNC evaluation, (6) ancillary testing as part of the BD/DNC
evaluation, and (7) special considerations for BD/DNC determination.
*These authors contributed equally to this work as colead authors.
From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and
Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of
Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of
Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University
School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children’s Hospital,
Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory
University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center,
Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children’s Hospital, MA;
Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.),
Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ.
Approved by the Guidelines Subcommittee on January 23, 2023, by the Quality Committee on February 11, 2023, and the American Academy of Neurology Institute Board of Directors on
July 20, 2023. The Neurocritical Care Society affirmed the value of this consensus guideline on September 28, 2023.
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Copyright © 2023 American Academy of Neurology 1
Copyright © 2023 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
, Glossary
AAN = American Academy of Neurology; AAP = American Academy of Pediatrics; ABG = arterial blood gas; AEP = auditory
evoked potential; APP = advanced practice provider; BBB = blood-brain barrier; BD/DNC = brain death/death by neurologic
criteria; COI = conflict of interest; CPAP = continuous positive airway pressure; CV = curriculum vitae; ECMO =
extracorporeal membrane oxygenation; ETT = endotracheal tube; HIBI = hypoxic-ischemic brain injury; MAP = mean arterial
pressure; OCR = oculocephalic reflex; OVR = oculovestibular reflex; PEEP = positive end-expiratory pressure; SBP = systolic
blood pressure; SCCM = Society of Critical Care Medicine; SEP = somatosensory evoked potential; UDDA = Uniform
Determination of Death Act; VA = venoarterial.
Introduction brainstem, resulting in (1) coma, (2) brainstem areflexia, and
(3) apnea in the setting of an adequate stimulus.
Determination that a patient meets neurologic criteria for
death is a medical responsibility that leads to a legal declara- In concert with the Ethics, Law, and Humanities Committee, a
tion. The purpose of this guideline is to clarify the brain death joint committee of the AAN, the American Neurological Asso-
determination process for integration of guidance for adults ciation, and the Child Neurology Society and with the support of
and children into a single guideline. Updates in this guideline AAN leadership and the AAN Quality Committee, the AAN
also include addressing issues related to determination of Guidelines Subcommittee (eAppendices 1 and 2, links.lww.
death by neurologic criteria in the setting of extracorporeal com/WNL/D73) formed a multidisciplinary panel with mem-
membrane oxygenation (ECMO), targeted temperature bers from multiple medical societies to make updated formal
management, and primary infratentorial injury. consensus recommendations about the process of BD/DNC
determination. The panel considered that the process for di-
Death by neurologic criteria, commonly referred to as agnosing death, either cardiopulmonary or neurologic, should to
brain death, occurs in individuals who have sustained cata- the fullest extent possible be independent of patient age, making
strophic brain injury, with no evidence of function of the brain note of where child-specific principles apply. This document
as a whole, a state that must be permanent. The process of this combines adult and pediatric recommendations to ensure ac-
determination always begins with the presumption that the curate, consistent determination of BD/DNC in persons of all
patient does not meet brain death/death by neurologic criteria ages. Most aspects of BD/DNC evaluation are the same, re-
(BD/DNC), a presumption that must then be disproved. BD/ gardless of age, with a few exceptions. By unifying recommen-
DNC determination must be accurate and consistent. As stated dations into 1 document, there is consistent guidance to
in the report of the 1968 Harvard Committee, reaffirmed by clinicians in various practice settings.
subsequent presidential reports and prior adult and pediatric
guidelines, the essential underlying concept that defines BD/
DNC is permanent coma and loss of all brainstem function, Author Panel Formation
coupled with the inability to breathe in the setting of an adequate
stimulus (i.e., hypercarbia and acidosis). Because complete loss
and Methodology
of the brainstem’s reticular activating system is the most robust Leadership from the AAN Guidelines Subcommittee (A.R.-G.,
predictor of the permanence of a comatose state, most of the J.J.H.) and the AAN Brain Death Working Group (D.M.G.,
neurologic assessment focuses on demonstrating the loss of all M.P.K., A.L.), a subgroup of the AAN Ethics, Law, and Hu-
brainstem reflexes. Of importance, BD/DNC determination is manities Committee, engaged a broad panel of stakeholders
based on clinical assessment; ancillary testing is required only if from multiple medical societies to collaborate on an updated
the clinical assessment cannot be safely or fully completed. BD/DNC guideline. Panel members were invited from the
following organizations: AAP, American College of Radiology,
The Uniform Determination of Death Act (UDDA), the legal Child Neurology Society, Congress of Neurological Surgeons,
foundation for the declaration of BD/DNC in the United Neurocritical Care Society, and SCCM. Clinicians with ex-
States, stipulated that determination of BD/DNC must be pertise in BD/DNC were also invited. The author panel in-
made in accordance with accepted medical standards.1 In 2018, cluded BD/DNC experts (D.M.G., M.P.K., A.L., G.S.G., S.A.,
multiple medical societies agreed that the accepted medical M.A.B., D.F.B., L.B., A.C., S.P., M.A.R., L.S., C.T., R.C.T.,
standards for determination of BD/DNC were the 2010 AAN P.N.V., and E.W.), process facilitators (A.R.-G., J.J.H.), and a
guideline for adults and the 2011 Society of Critical Care methodologist (G.S.G.). Each potential author was required to
Medicine (SCCM)/American Academy of Pediatrics (AAP)/ submit an AAN relationship disclosure form and a copy of his
Child Neurology Society guideline for infants and children.2-4 or her curriculum vitae (CV). The panel leadership (A.R.-G.,
These guidelines stipulate that BD/DNC should be declared J.J.H., G.S.G., D.M.G., M.P.K., A.L.) and AAN staff reviewed
when a patient with a known cause of catastrophic brain injury the relationship disclosure forms and CVs for financial and
has permanent loss of function of the entire brain, including the intellectual conflict of interest (COI). These documents were
2 Neurology | Volume 101, Number 24 | December 12, 2023 Neurology.org/N
Copyright © 2023 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
, specifically screened to exclude those individuals with a clear action verbs are 7b, 11b, 11c, 13d, 18c, 24c, 25b, 25i, 25j, 25k,
financial conflict and those whose profession and intellectual bias 25l, 25m, 26, 27b, 29, 30, 31, 35, 37a, 37b, 38, and 39.
would diminish the credibility of the guideline in the eyes of the
intended users. Before the formation of the author panel, it was After the first round of voting, the preliminary manuscript and
determined that a financial link with organ procurement organi- initial rationales and recommendations were reviewed by the
zations in the prior 5 years would preclude participation as a direct AAN Guidelines Subcommittee for comment on January 11,
conflict to participation. As required by the AAN, most (51%) of 2020, and revised by panel members. After the second round
the members (A.L., G.S.G., A.R.-G., S.A., M.A.B., D.F.B., L.B., of voting, the document was distributed for public comment
A.C., S.P., M.A.R., C.T., R.C.T., E.W., and J.J.H.) of the author (December 14, 2020, through January 12, 2021), and all
panel and the lead authors (D.M.G., M.P.K., and A.L.) are free of comments were analyzed and incorporated where appropriate.
COI relevant to the subject matter of this practice guideline. The panel met virtually on January 13, 2022, to review public
comment revisions and discuss plans for the third round of
The author panel met in person on October 11, 2019, to define voting. Because of concerns for potential ambiguity in the
the methodology and develop initial rationales and recom- questions used to determine the strength of recommendations,
mendations. Because of the lack of high-quality evidence on the panel members revised the questions for the recommendations
subject, a novel, evidence-informed formal consensus process related to increasing the accuracy of BD/DNC determination.
was used. This process relied on the panel experts’ detailed
knowledge of the literature surrounding BD/DNC to guide the The panel also added a question so that panel members would
development of preliminary recommendations, followed by 3 self-identify the primary population (adult or children) they
iterative rounds of anonymous voting on each rationale and treated. This was done in case it was necessary to stratify
recommendation (modified Delphi process), with prespecified recommendations by adult and pediatric populations to attain
rules for determining consensus attainment and the strength of consensus.
each recommendation. The intent was for recommendations
to be conservative to minimize the risk of a false-positive de- The author panel met virtually on April 28, 2022, to finalize the
termination of BD/DNC (determining BD/DNC in a patient revised voting questions and instructions (eAppendix 4, links.
who does not have permanent catastrophic brain injury with no lww.com/WNL/D73). After the third round of voting, it was
evidence of brain function), yet practical. determined that differences between pediatric and adult rec-
ommendations warranted separate considerations, with voting
A subset of the panel (D.M.G., A.R.-G., M.P.K., A.L., and J.J.H.) for each by the panel members with relevant self-identified
drafted recommendations with input from the methodologist expertise. After multiple rounds of voting and revisions to attain
(G.S.G.). Panel members answered a series of questions for consensus, the rationales and recommendations were finalized
each recommendation to determine the cogency of the ratio- for the manuscript.
nale supporting the recommendation and the strength of the
recommendation (eAppendix 3, links.lww.com/WNL/D73).
Recommendations were formulated according to the 2017
Terminology
AAN Clinical Practice Guideline Process Manual.5 Each rec- The term brain death has been used in common parlance,
ommendation statement includes an action verb of must, but the panel chose to use brain death/death by neurologic
should, or may reflecting the strength of the recommendation. criteria or BD/DNC to both embrace the colloquial term
The action verb corresponds to the level of consensus reached. and emphasize that a determination means more than death
Level A voting consensus resulted in a must statement. Level B of the brain and that, rather, death of the person has oc-
voting consensus resulted in a should statement. Level C voting curred, equivalent to death by cardiopulmonary criteria.
consensus resulted in a may statement. This terminology was also used in the World Brain Death
Project.6
Before initiation of voting, each recommendation draft
statement action verb was anchored at must, should, or may, The terms irreversible and permanent have both been used
as deemed appropriate by the panel. This anchoring pre- to describe the extent of loss of function that must be present
vented the statement from reaching a higher strength of to determine BD/DNC. The panel chose to use the term
recommendation. Because of this anchoring, there are rec- permanent to mean function was lost and (1) will not resume
ommendation statements that have reached a high level of spontaneously, and (2) medical interventions will not be used
consensus with a lower action verb. For example, Recom- to attempt restoration of function. This terminology was also
mendation statement 7b states, “Clinicians should conduct used in the World Brain Death Project.
further diagnostic evaluation and not undertake evaluation for
BD/DNC if a patient is comatose, apneic and has absent The term child has been defined for purposes of this document as
brainstem reflexes, and there is not an identified mechanism any patient who is at least 37 weeks old, corrected gestational
of brain injury that is known to lead to BD/DNC” with Level age, and younger than 18 years old. There are several individual
A consensus. The recommendation statements with anchored recommendations that detail specific age ranges.
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