brain death

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When brain death ( adjective : brain dead ) is the irreversible end of all brain functions due to a wide area with existing circulatory activity and artificially maintained preserved respiratory dead neurons understood. The term brain death is a definition of death that was introduced in 1968 in connection with the developing intensive care and transplant medicine . Brain death is often viewed as a sure internal sign of death or the "equivalent of human death".

history

In the ancient Egyptians' image of man, the heart was seen as the central organ of the body and therefore also represented the soul of the dead. Therefore, during mummification , the heart was left with the body as the seat of all physical and intellectual forces, while the intestines and various organs were placed in their own vessels. This cardiocentric image of man has shaped most of the subsequent religions and cultures for millennia. The absence of heartbeat, breathing and spontaneous movements remained until the Age of Enlightenment the universally valid, but nowhere normatively defined, sign of death.

In 1744 a choked miner in England is said to have been successfully ventilated by a surgeon. In 1774 the "Transactions of the Royal Humane Society" reported the resuscitation of a girl who fell from the first floor and was believed to be dead by doctors in the hospital. Electric shocks would have restored the heartbeat.

The dogma of cardiac arrest as the ultimate death of humans was shaken by this, but also by the results of the electrical experiments carried out on the brains and bodies of the recently deceased. This led to the apparent death hysteria at the end of the 18th and early 19th centuries: Because the process of resuscitation was not understood, people were worried that they would appear to be buried dead . In the search for new sure signs of death , rigor mortis and death spots were found .

M.-F.-X. Around 1800, Bichat concluded from his extensive anatomical, histological and physiological investigations that the maintenance of a cellular order was an essential characteristic of life and that the dissolution of this order meant death. He postulated that an organism is based on functions on different cellular levels and that these functions do not necessarily have to end at the same time. He distinguished basic vegetative functions (breathing, circulation , metabolism ) as “organic life” from the complex of higher brain performance (consciousness, sensory perception). As a consequence of these results, he coined the term “brain death”.

Despite Bichat's findings, a person was still considered dead in medicine when his breathing and heart stopped. The Russian resuscitation researcher Vladimir A. Negowski (1909–2003) found that attempting resuscitation is pointless if the brain has died. As he wrote in the 1940s: “For a long time we believed that the most recent contraction of the heart was the last 'chord of life'. We do not speak like that now, because after the cardiac activity has stopped, the central nervous system can be restored for a few minutes. Indeed, the last 'chord of life' is the remaining sign of the vitality of the brain. "

With the introduction of artificial ventilation and other intensive care techniques, from the 1950s onwards there were repeatedly patients with severe brain damage who did not breathe themselves. It was soon discovered that after a few days in a deep coma, some of them inevitably lose their blood circulation. When asked how to deal with them, Pope Pius XII replied in 1957 . : “If deep unconsciousness is found to be permanent, then extraordinary means of maintaining life are not mandatory. You can stop it and allow the patient to die. "

In 1959, Pierre Mollaret and Maurice Goulon first described the term "coma depassé" (beyond / below the coma), a condition that did not show any signs of life in the brain with artificial ventilation, which was irreversible and eventually led to death from heart failure . The term “brain death” from Bichat was not taken up by them.

In 1960, Wertheimer, Rougemont, Jouvet and Descotes published an article stating that they had stopped artificial respiration. As criteria for their actions they named: Proof of complete areflexia , no self-breathing, the zero line in the EEG and a lack of angiographic representation of the cerebral blood flow. These examinations are still the basis of brain death diagnostics today.

On May 10, 1966, the commission of the French “Académie Nationale de Médicine” presented the result of their work: the irreversible loss of function of the brain was introduced as a new criterion for death.

In April 1968 the commission of the German Society for Surgery presented the result of its work under the title "Death Signs and Determination of the Time of Death". After the French medical academy, the German Society for Surgery also affirmed the concept of brain death. People with irreversible loss of brain function are considered dead.

A Harvard Medical School commission published a definition of this term on August 5, 1968, proposing that the condition in question be designated as brain death and set as a new criterion for death. This was justified on the one hand with clarifying the status of comatose patients and being able to stop artificial ventilation, and on the other hand with avoiding controversies in the procurement of organs for transplantation.

This new definition of death was adopted by many countries in the years that followed.

In Germany, the Scientific Advisory Board of the German Medical Association published a "Decision-making aid for determining brain death" in 1982. It has characterized brain death as an "irreversible loss of cerebral and brain stem function ". The first update was made in 1986. It defined brain death as an "irreversible loss of cerebral and brain stem function". The second update followed in 1991, in which brain death was defined “as the state of irreversible extinction of the overall function of the cerebrum, the cerebellum and the brain stem”. In 1997 the 3rd update followed with a similar wording.

In autumn 1997, the Transplantation Act (TPG) was passed in Germany . There, in Section 3 (2), brain death was legally defined as the “irreversible failure of the overall function of the cerebrum , the cerebellum and the brain stem according to procedural rules that correspond to the state of the art in medical science ” . In 1998, a new edition of the 3rd update was published in linguistic adaptation to the TPG, which has now been upgraded to a " guideline ". On March 30, 2015, the Federal Ministry of Health published the 4th update as a new guideline "for determining death". Based on Section 3 (2) TPG, it says:

"With the determination of the final, irreversible failure of the overall function of the cerebrum , the cerebellum and the brain stem (irreversible brain function failure ), the death of the person is determined scientifically and medically ."

Brain death as death of man

Germany

In Germany no body of law defines death. In the Transplantation Act (TPG), human death is indirectly linked to brain death:

  • In § 3 , para. 1 TPG, it says that the removal of organs is allowed only if "is determined the death of the organ or tissue donor after rules that correspond to the state of knowledge of medical science."
  • Paragraph 2 also states that an organ removal is not permitted if “the final, irreversible failure of the overall function of the cerebrum, the cerebellum and the brain stem in accordance with procedural rules that reflect the state of knowledge of the organ or tissue donor does not occur before the removal medical science is established “.

On June 6, 2015, the “Guideline pursuant to Section 16 Paragraph 1 Sentence 1 No. 1 TPG for the rules for determining death according to Section 3 Paragraph 1 Sentence 1 No. 2 TPG and the procedural rules for determining the final, irrecoverable failure of the overall function of the cerebrum, the cerebellum and the brain stem according to Section 3 (2) No. 2 TPG ”in force. It contains some references to human death:

  • Page 2: "With the determination of the final, irreparable failure of the overall function of the cerebrum, the cerebellum and the brain stem (irreversible brain function failure), the death of the person is scientifically and medically determined."
  • Page 3: "The cause and severity of the brain damage leading to death must be proven beyond doubt."
  • Page 23 and 25: "This means that the patient's death is determined on ... at ... o'clock." (Protocol sheet that the examining doctor has to sign.)

Austria

In Austria, the Supreme Sanitary Council issued a recommendation on the determination of death in 2013. In it the "definition of death":

“A person is dead when the function of the entire brain (= cerebrum, cerebellum and brain stem) has irreversibly failed. Due to the failure of the central control functions, this leads to the death of all organs, tissues and cells.

The cause of death can occur through

  • irreversible functional failure of the entire brain as a result of primary or secondary brain damage (brain death with preserved circulation),
  • persistent cardiac arrest, which interrupts the blood flow to the point of irreversible functional failure of the entire brain (brain death after cardiac arrest). "

Switzerland

In Switzerland, death is defined in Article 9 of the Transplantation Act:

"

  1. Humans are dead when the functions of their brain, including the brain stem, have failed irreversibly.
  2. The Federal Council issues regulations on the determination of death. In particular, it stipulates:

a. which clinical signs must be present so that conclusions can be drawn about the irreversible failure of the functions of the brain, including the brain stem;
b. the demands on the doctors who determine death. "

Diagnostics and procedures

The diagnosis of brain death can only be made during intensive medical treatment with artificial ventilation, circulatory therapy and hormone replacement therapy in the hospital. The mechanical support measures can maintain the blood flow and the oxygen supply to the organs in the long term if no further complications occur.

Before the examinations to determine brain death are initiated, the following requirements must be verifiably met:

  1. Presence of acute primary or secondary brain damage,
  2. Exclusion of another cause or contributory cause for a (possibly only temporary) failure of the brain functions (e.g. poisoning or similar).

The unequivocal determination of brain death is based on clinical and optional equipment criteria.

The clinical criteria are:

  1. loss of consciousness ( coma ),
  2. an areflexia of the brain stem (e.g. medium to maximally wide and light-rigid pupils , lack of pain reaction in the trigeminal region , lack of eyelid closing reflex , doll's head phenomenon , lack of swallowing and coughing reflex ), whereby autonomous reflexes at the spinal cord level may be preserved,
  3. the loss of spontaneous breathing (apnea).
Missing cerebral perfusion on cerebral perfusion scintigraphy

The fact that this is an irreversible failure of all brain functions ( i.e. brain death ) is proven by a renewed examination of the clinical criteria after a specified, adequate waiting time (12, 24 or 72 hours depending on the age and location of the primary brain lesion ), or by a supplementary technical examination.

The equipment criteria include:

  1. A baseline electroencephalogram (EEG). The EEG examination should be carried out based on the guidelines of the German Society for Clinical Neurophysiology. If the EEG derivation reveals a brain-electrical silence over a period of at least thirty minutes, i.e. a so-called zero line EEG, the irreversibility of the brain function failure is proven without further observation time. According to statements by the German Organ Transplantation Foundation (DSO), EEG activities could be observed in exceptional cases despite clinical signs of brain death and proven circulatory arrest. The cause: "so-called. Anastomoses (vascular connections) in the border areas between the (interrupted) blood supply of the brain's own arteries and the still intact circulation of the external carotid artery [...], which supplies the soft facial tissues, but also the meninges. This can lead to a survival of circumscribed nerve cell populations after the occurrence of brain death. "
  2. A cerebral perfusion scintigraphy or Doppler sonography determined blood flow stop in all brain supplying vessels. In perfusion scintigraphy, a weakly radioactively labeled substance is injected and its distribution in the brain is followed. If the cerebral blood flow is intact, the marker substance can be detected for hours in the regions of the brain that are supplied with blood. In the case of a brain dead person, on the other hand, the cranial cavity appears “empty” as a result of a breakdown in the entire cerebral blood flow. In Doppler sonography, the brain base arteries are sonicated. The blood flow velocity in the cerebral vessels is measured based on the reflection of the sound signal. The Doppler sonography may only be performed by an examiner experienced in this and must be performed at least twice with an interval of at least 30 minutes.
  3. The loss of acoustic or somatosensitive evoked potentials in the case of a primary lesion of the cerebrum and secondary brain damage (lack of oxygen in the brain e.g. after resuscitation of the heart). The brain's response to a peripheral nerve stimulus is irreversibly canceled. Evoked potentials are brain electrical potential fluctuations in response to acoustic (AEP, acoustic evoked potentials) or electrical (SEP, somatosensitive evoked potentials) stimuli.

Since the beginning of the 2000s, a better understanding of the processes involved in dying has increased the success rate in resuscitation of patients with cardiac arrest . In 2013, researchers observed an extremely intense pattern of activity in the brain of dying rats for a short period after cardiac arrest, suggesting a similar short-term increase in neuronal activity in humans before brain death occurred.

Legally certain determination of death

After a brain death diagnosis has been completed and a brain death has been determined, a death certificate can be issued. “What is determined is not the time of the occurring, but the state of the death that has already occurred. The time at which the diagnosis and documentation of the irreversible brain dysfunction were completed is recorded as the time of death . "

In order to determine brain death with legal certainty, the criteria for examining doctors have been raised in Germany with the new guideline "To determine death" (2015): "Doctors who determine and record irreversible brain dysfunction in intensive care medicine must be specialists and have to last for several years Have experience in the intensive care of patients with acute severe brain damage. ... At least one of the doctors diagnosing the irreversible brain dysfunction must be a specialist in neurology or neurosurgery who meets the above requirements. When determining irreversible brain dysfunction in children up to the age of 14, one of the doctors must also be a specialist in pediatric and adolescent medicine who meets the above requirements. "

Since the "Decision-making aid for determining brain death" from 1982 until the 4th update (2015), brain death diagnostics have consistently been built on 3 pillars:

  1. requirements
    1. Severe acute brain damage
    2. No other causes of the failure symptoms of the brain (e.g. intoxication , primary hypothermia, circulatory shock )
  2. Clinical symptoms
    1. coma
    2. Brain stem - areflexia
    3. Apnea
  3. Proof of irreversibility
    1. Observation time
    2. additional examinations (alternative)

If organs are to be removed from the patient after the diagnosis, the diagnosis of brain death must be carried out by doctors who are not involved in the organ removal or transplantation . An additional apparatus-based examination is only necessary in those cases in which the primary damage was in the area of ​​the brain stem or the cerebellum (primary infratentorial brain damage). The additional apparatus-based examination can, however, shorten the waiting time as proof of the irreversibility of the clinical failure symptoms.

The procedure for determining death that is applicable in Switzerland can be found in the medical-ethical guidelines for determining death with reference to organ transplants of the Swiss Academy of Medical Sciences (SAMS).

In the information brochure No way back ... of the organ donation working group, the following statement is made:

“It is true that the vast number of brain functions cannot be captured in their entirety by clinical or technical examinations. This is also unnecessary from a medical point of view. Rather, brain death diagnostics should determine the completeness and finality of damage to the brain as a functioning whole. The validity of this concept is based on empirical evidence; H. proven by experience in many thousands of brain death cases. It does not claim to prove the death of every single brain cell. "

Importance regarding organ donation

The determination of brain death is not done primarily for the purpose of organ removal, but to end a therapy that has become pointless. However, since organs can be donated before the end of intensive care treatment, the question of the possibility of organ removal arises. The determination of brain death is the prerequisite for organ removal.

At the latest with the determination of brain death, the doctor's duty (and right) to take therapeutic measures no longer applies. Therefore, the organ-protective intensive therapy and the preparations for organ removal and transplantation can only follow with consent to the organ donation . If organ donation is not approved, medical therapy is usually ended and the ventilator is switched off. An exception could be an existing pregnancy.

According to § 3 of the German Transplantation Act (TPG), the determination of brain death is a prerequisite for organ removal according to the rules that correspond to the state of the art in medical science. The rules that correspond to the state of the art are currently identical to brain death. B. is accepted in inheritance law or civil status law .

Ethical points of view

Christian churches

In 1990 the two large churches adopted the joint declaration "Organ Transplants - Declaration of the German Bishops' Conference and the Council of the EKD". It says: “Most of the organs to be transferred are not taken from living, but brain-dead donors. The external difference between cardiac death and brain death can be mistakenly interpreted as if tissue and organs were removed before and not after the death of the donor. Therefore, for trust in transplant medicine, it is not only the medically self-evident, reliable determination of death before organ donation that is crucial, but also the general knowledge of the difference between cardiac death and brain death.

It goes on to say: “Brain death, like cardiac death, means the death of a person. With brain death, a person lacks the irreplaceable and irrecoverable physical basis for his spiritual existence in this world. "

From the point of view of the Roman Catholic Church , the definition of brain death applies, according to which the absence of measurable brain waves over a period of at least six hours indicates human death.

On April 27, 2015, the German Bishops' Conference published the working aid “Brain death and organ donation”. It says on page 6: “According to the current state of science, the brain death criterion in the sense of whole brain death - provided it is properly applied in practice - is the best and safest criterion for determining the death of a person, so that potential organ donors will We can rightly assume that they are really dead and not just dying at the time of organ removal. "

Islam

The attitude towards brain death is inconsistent in the Islamic religion . However, if one looks at the development from 1981 to 1997, one can see a trend:

  • In 1981 the Kuwaiti Ministry of Religions ruled that a person could not be considered dead as long as their cardiovascular activities - albeit artificial - are present: “It is not possible to regard this person as dead because of brain death when in yours Circulatory and respiratory system Life is, even if it is an apparatus. "
  • In 1986, at a conference of Islamic legal scholars in Amman, brain death was equated with cardiac death in a fatwa. It says: “Human death, and all the resulting Islamic legal consequences, apply in the presence of one of the following two conditions:
    1. In the event of complete, irreversible, medically determined cardiac and respiratory arrest,
    2. In the event of irreversible, medically determined failure of the Brain function, even if the heart and respiratory functions are still mechanically maintained or can be maintained mechanically. "
  • In 1997 the Central Council of Muslims in Germany recommended setting brain death as a criterion for death, which is consistent with the opinion of most Islamic scholars.

German Bundestag

As part of the legislation on the Transplantation Act, the German Bundestag has repeatedly dealt with the subject. The currently applicable legal provisions were discussed again in 2013 due to a small question on the subject of brain death and the response from the Federal Government, as there are considerable doubts about the underlying definitions and the question of whether the brain-dead should not be described as dying rather than dead, seems to have not been conclusively clarified.

German Ethics Council

On February 24, 2015, the German Ethics Council published the "Statement on brain death and decision on organ donation". 7 members spoke out against seeing brain death as human death, for 18 members brain death is human death.

Dignity of the brain dead

The high level of legal protection of dignity during one's lifetime ends with the death of the human being as a living organism, i.e. with death. However, the dignity of dead people is not completely unprotected, but limited protection of dignity extends beyond the time of death. Section 168 of the Criminal Code protects the rest of the dead , and most of the federal state burial laws expressly respect the dignity of the dead and stipulate that they should be treated appropriately.

In the Transplantation Act , Section 6 is devoted to "respect for the dignity of the organ and tissue donor":
"(1) The removal of organs or tissue from deceased persons and all related measures must be carried out in one of the medical departments while respecting the dignity of the organ or tissue donor due diligence appropriate manner be performed.
(2) the body of the organ or tissue donor must pass for burial in a dignified state are. Previously be given the opportunity to the next of kin to see the body. "

Common declarations and guidelines

Joint statements of medical societies

Various medical societies have issued joint statements on brain death since 1994. Apart from the BÄK , none of these societies has anything to do with organ donation. In all of these joint declarations, brain death is mentioned as a sure sign of death.

The joint declarations of the DGN , DGNI , DGNC , DPG , DIVI , BÄK and WB-BÄK on brain death are:

1994 DGNI DGN DGNC DPG 1997 BÄK DGAI DGCH DGIM DGNC DGN DPG
2001 DGAI DGN DGNC BÄK WB-BÄK 2002 DGN DIVI DGNC
2012 DGNI DGN DGNC (PDF) 2014 DGNI DGN DGNC (PDF) 2015 DGNI DGN DGNC (PDF)

The joint declaration of the DGAI, DGNC, DGN and DPG (1994) begins with the words:
“Misleading and inaccurate statements, even by doctors about death from complete and permanent brain failure ('brain death'), can unsettle the population and damage their trust in doctors . "

The joint declaration of the DGAI, DGN, DGNC BÄK and WB-BÄK (2001) contains: "In line with the more recent scientific literature, it is made clear against different and misleading statements - unfortunately also by individual doctors:"

The key messages of these joint declarations are summarized as follows:

  • 1994 - DGNI, DGN, DGNC, DPG
    • There is only one death, brain death.
    • Its determination is made as evidence of an already unchangeable state.
    • A person whose brain has died can no longer perceive, perceive, observe and answer anything from within and from his surroundings, no longer think, no longer decide anything.
    • With the complete and final failure of the activity of his brain, the human being has ceased to be a living being in physical-spiritual or in physical-spiritual unity.
    • The brain dies when the oxygen supply to the brain tissue is interrupted for several minutes or when the pressure in the skull exceeds the arterial blood pressure and the cerebral blood flow ceases.
    • Even when the brain has died, the heart activity itself can be maintained through intensive medical measures and ventilation.
    • Death is determined regardless of whether a subsequent organ removal is possible.
  • 1997 - BÄK DGAI DGCH DGIM DGNC DGN DPG
    • The often misleading public discussion has led to uncertainty among the population.
    • The TPG must create legal certainty that the brain dead are dead.
    • The TPG is to retain the extended consent solution that is practiced.
    • The TPG should prescribe a patient-oriented distribution of organs.
  • 2001 - DGAI, DGN, DGNC, BÄK, WB-BÄK
    • Decision aids for determining brain death have been available since 1982.
    • In 1993 the WB-BÄK presented the anthropological justification for the importance of brain death as a certain inner sign of death in humans.
    • In line with the more recent scientific literature, the following is made clear to different and misleading statements - unfortunately also from individual doctors:
      • Nothing has changed in the biologically based definition of brain death, in the certainty of the determination of brain death and in the meaning of brain death as a certain inner sign of death in humans.
      • After brain death there is no more pain sensation. Therefore, after brain death, no pain prevention measures (e.g. anesthesia) are necessary when organs are removed. The activity of an anesthetist in organ removal ... serves exclusively to maintain the functionality of the organs to be removed.
  • 2002 - DGN DIVI DGNC
    • Nothing has changed in the definition, in the certainty of the determination and in the meaning of brain death as a certain inner sign of death.
    • After brain death there is no more pain sensation. No anesthesia is required to prevent pain when organs are removed after brain death.
    • Brain death means irreversibly extinguished overall function of the cerebrum, the cerebellum and the brain stem, determined during intensive treatment and controlled ventilation with the sole result that the cardiovascular function is still maintained.
    • This definition of brain death ... is based solely on scientific findings and connections.
    • Brain death as the irreversible loss of the entire brain activity can and must be clearly distinguished from all states of reversible or partial brain failure.
    • Death as the biological end of human life can and must be clearly distinguished from the death of body parts.
    • Medicine owes its progress to the natural sciences, the humanities its humanity. Only with both together can the doctor serve people.
  • 2012 - DGNI, DGN, DGNC (PDF)
    • Proven brain death is a scientifically proven sure sign of death. Concerns about this do not stand up to scientific scrutiny.
    • Evidence of brain death is set out in guidelines. They reflect the state of the art in medical science.
    • Apparent contradictions between the results of the investigations with and without devices have been clarified beyond any doubt.
    • The apnea test is essential to detect any brain failure findings. If the examination is carried out according to the instructions, no additional damage to the brain is to be feared.
    • No recovery of the brain function of a person has been proven anywhere in the world who has received further treatment after the failure of the overall brain function has been determined and documented in accordance with the guidelines.
  • 2014 - DGNI, DGN, DGNC (PDF)
    The DSO names 8 organ donors for 3 years for whom brain death was not formally diagnosed correctly. In all cases, the error was noticed before the organs were removed. The DGNI, DGN and DGNC comment on this:
    • Brain death diagnosis is the safest diagnosis in medicine if it is carried out according to the applicable criteria. In order to ensure the high quality standard, at least one neurologist or neurosurgeon with many years of experience in brain death diagnostics should be involved.
    • The discussed concept of the non-heart-beating donor (NHBD, see cardiac death criterion ) must continue to be strictly rejected, as it carries a higher risk of misdiagnosis.
    • Brain death means the death of the individual.
    • The determination of brain death is carried out against the background of a possible transplant.
  • 2015 - DGNI, DGN, DGNC (PDF)
    • A neurologist or neurosurgeon should be present for the brain death diagnosis . This is currently the case for around ¾ of brain death diagnostics.
    • NHBD is strictly to be rejected.
    • Brain death is diagnosed in more than half of the patients, even if no organs are removed after the diagnosis.

Guidelines for Determining Brain Death

In 1982 the Scientific Advisory Board of the German Medical Association brought out its first "Decision-making aid for determining brain death". In 1986, 1991 and 1997 an update was made that was necessary due to further investigation possibilities. The linguistic adaptation to the Transplantation Act passed in 1997 led to the "Guideline for the Determination of Brain Death" in 1998. This states:

  • 1982: “Brain death is human death. ... brain death and thus the death of the patient diagnosed on "
  • 1986: “Brain death is human death. ... brain death and thus the death of the patient diagnosed on "
  • 1991: “Brain death is human death. ... the brain death and thus the death of the patient is determined on "
  • 1997: “The clinical signs of brain death, however, have been unreservedly valid for three decades and evidence of brain death is recognized worldwide as a sure sign of death. ... With the death of the brain, the death of the person is determined scientifically and medically. ... the brain death and thus the death of the patient is determined on "
  • 1998: “With the death of the brain, the death of the human is determined scientifically and medically. If the doctor determines an external sure sign of death, then brain death is also proven. ... the brain death and thus the death of the patient is determined on "

On March 30, 2015, the Federal Ministry of Health (BMG) put the fourth update of the guideline for the determination of brain death into force. It says:

  • 2015: “With the determination of the final, irreversible failure of the overall function of the cerebrum, the cerebellum and the brain stem (irreversible brain function failure), the death of the person is scientifically and medically determined. The irrevocable cessation of brain function is demonstrated either by the procedural rules outlined in this guideline or by the presence of other certain signs of death, such as death spots or rigor mortis. If there is another sure sign of death, the irreversible brain dysfunction has also occurred and proven. ... The death of the patient is thus determined on "

In 1997 the above mentioned pregnancies, which are frequently cited as a criterion for a non-occurrence of brain death, are mentioned. Decision-making aid: “The continuation of a pregnancy does not contradict the mother's brain death. A pregnancy is endocrinologically sustained by the placenta and not by the mother's brain. "
With its guideline from 2015, the BMG confirmed this statement with the words:" The continued existence of a pregnancy does not contradict the irreversible loss of brain function of the mother. A pregnancy is endocrinologically sustained by the placenta. "
Regarding the other, frequently mentioned" signs of life "of the brain dead, the BMG writes: Lazarus sign) and vegetative symptoms (e.g. sweating) as well as the conductivity of the peripheral section of cranial nerves, the peripheral excitability and spontaneous discharges in the electromyogram of the facial muscles are temporarily retained or recur as long as the body circulation and ventilation are maintained become. Diagnostic restrictions due to fluctuations in blood pressure or fever are not known. Even during the development of the irreversible brain dysfunction, the core body temperature can drop, depending on the temperature of the environment and the ventilation air. The time at which diabetes insipidus occurs varies. "

Death certificates

The death certificate to be filled out by a doctor contains brain death as a sure sign of death in all German federal states. In the article " Ärztliche Leichenschau" and death certificate , published on November 28, 2003 in Deutsches Ärzteblatt , brain death is mentioned as a sure sign of death.

Controversy

Various physicians and scientists criticize the definition of brain death as the ultimate death of humans.

The alternative physician and cardiologist Paolo Bavastro, for example, thinks that the term “brain-dead person” is a “malicious deception”, since a person with brain failure is “a person” whose “brain has been seriously damaged” and “is seriously ill, dying person ”, but“ not yet dead ”. Doctors could still perceive a heartbeat in brain-dead people, they would regulate their body temperature, pass urine and stool , they could sweat, react to pain stimuli and even form antibodies, men could get erections and women could become pregnant and give birth to healthy children. The notion that “only brain activity makes people human” and that “the death of the brain also means death of the person” is outdated, according to Bavastro.

The medical ethicist Axel W. Bauer , who was a member of the German Ethics Council from 2008 to 2012 , points to the argumentation technique that is problematic from an ethical perspective and is intended to support the concept of brain death. Three central reasons that spoke in favor of the concept of brain death when the Transplantation Act was passed in 1997 did not refer to objective physiological facts, but described potential social and individual ethical dangers that could arise if the legislature deviated from the criterion of brain death as the time of death: 1. The doctor would kill the patient when removing the organs; 2. Active euthanasia could be favored; 3. The population's willingness to donate organs could decrease. In order to be able to avoid these three scenarios, brain death has been declared a legally binding criterion for human death. From a scientific and ethical point of view, this argument is dubious because it does not derive the justification of the criterion of brain death from the matter itself, but from the undesirable consequences of its rejection. This promotes a functional use of the brain death concept and creates the impression that the potential organ donor should be instrumentalized for foreign purposes by being formally "declared dead".

The US doctor Alan Shewmon, who used to be a well-known proponent of the concept of brain death, takes the view that “the brain does not act as the central integrator of all human bodily functions”. The neurologist had found until 1998, more than 170 documented cases of cardiac arrest had passed a lot of time between determination of brain death and entrance. The ranges ranged from at least one week to 14 years. The US President's Council on Bioethics agreed with this assessment. According to the Council, the idea of ​​equating brain death and death is “no longer sustainable”. The brain is “not the integrator of the various body functions”, rather “integration is an emergent property of the whole organism”.

The United States Neurological Society also warns that "the criteria for determining brain death are not scientifically supported". For example, the "prescribed waiting times between the first and second neurological examination" (also in Germany) are only "rough empirical values ​​and not reliable". It is also criticized that “additional apparatus-based examinations”, such as “measurements of electrical activity and blood flow to the brain”, are not “part of the mandatory standard”. Under certain circumstances, “neurologically inexperienced doctors could therefore declare a coma patient dead”, even though “his cerebral cortex is still conscious”.

In addition, the determination of brain death is fraught with a number of uncertainties, according to Joseph Verheijde, Mohamed Rady and Joan McGregor from the non-profit organization Mayo Clinic . They doubt that the established guidelines are suitable for "establishing irreversible damage to the brain with sufficient certainty". The brains of patients pronounced brain dead did not all show the severe damage expected. In Germany, the criteria of the German Medical Association apply to brain death diagnostics . An apparatus-based examination is only intended for children up to the age of two. The clinical diagnostics considered sufficient in the other cases “only cover parts of the brain”. The functions of the midbrain , the cerebellum and the cerebral cortex would not be examined at all, says the German physicist and philosopher Sabine Müller from the Charité in Berlin. Investigations with imaging methods such as positron emission tomography or functional magnetic resonance tomography on patients with severe impaired consciousness raised doubts about the assertion of the irreversible failure of all brain functions.

Survivor of a supposed brain death

There have been cases of people described as brain dead in the media but regained consciousness. The possible explanation is:

  • Brain death was assumed, but the brain death diagnosis had not yet been completed so that no brain death had occurred. For example, in May 2018 it was reported worldwide that a 13-year-old boy from the US state of Alabama allegedly woke up from brain death. Doctors assumed brain death, and the boy's parents released the organs for transplant. One day before the planned final EEG test, the boy showed signs of life again and later awoke from the coma .
  • The brain death diagnosis was not performed correctly. For example, a 41-year-old woman came to a New York clinic in 2009 after a drug overdose. There the examinations were not carried out correctly and signs of life were ignored. Shortly before the organ removal, the woman came to. The clinic was fined $ 22,000 in September 2012.

Basics

The American neurologist Alan Shewmon published the results of his study in 1998. He collected the data from a total of more than 170 people who received further intensive care after they were diagnosed with brain death. It took between a week and 14 years for an irreversible cardiac arrest to occur. None of these brain dead came back to life. All remained in their state of brain death until cardiac arrest.

It should be noted about the study: Of the 175 brain deaths documented by Alan Shewmon, 56 brain death has been documented with sufficient certainty.

Alan Shewmon summarizes the brain dead themselves: The three brain dead with the longest times (2.7 and 5.1 and 14.5 years) were newborns and small children. All 9 brain dead with times over 4 months were younger than 18 years. All 17 brain dead over 30 years of age had a blood circulation failure within the first 2.5 months.

Lawyer (Hong Kong, 2009)

A Hong Kong lawyer suffered a heart attack in April 2009 and fell into a coma as a result. The death of her brain stem was declared. However, she regained consciousness three days after being admitted.

Youth (England 2008)

A 17-year-old boy had suffered severe head injuries after a car accident and was falsely declared brain dead by four doctors at a clinic two days after they had assumed irreversible brain damage on the basis of CT scans. However, he was kept alive. A neurologist checked the diagnosis and gave a positive prognosis. After two weeks, the supposedly brain-dead woke up from his coma. In 2012, the then 21 year old man studied accounting.

Brain dead pregnant women

In 1997 the German Medical Association's “Decision-making aid for establishing brain death” states: “The continued existence of a pregnancy does not contradict the mother's brain death. A pregnancy is endocrinologically sustained by the placenta and not by the mother's brain. "The Federal Ministry of Health confirmed this in its guideline on determining death issued on March 30, 2015:" The continued existence of a pregnancy does not contradict the irreversible loss of brain function in the mother. A pregnancy is endocrinologically supported by the placenta. "

Business economist (1991)

A 33-year-old business economist was 17 weeks pregnant when she collapsed unconscious on July 4, 1991 from an unknown cause. The woman was found by a walker without a heartbeat, successfully reanimated and taken to a clinic. There, on July 14th, the death of her brainstem was determined on the basis of tests, but the diagnosis of brain death was not yet completed because no breath test was carried out. In order to save the child, the pregnant woman continued to receive medical care in the anthroposophical Filder Clinic . On September 26, 1991 - after 84 days of care in the intensive care unit - premature labor began in the 28th week of pregnancy. Her son was born alive by caesarean section, the mother died two days later.

Erlanger Baby (1992)

In the case of the Erlangen baby , during the preparations for organ removal from a brain-dead woman, pregnancy was found in the 15th week. The organ removal was then canceled and the decision was made to carry the pregnancy to term. The woman was further treated in intensive care with ventilation, circulatory therapy and hormone replacement, so that her body and thus also the uterus remained in its basic function. The fetus grew normally until an infection resulted in a premature birth in the 20th week of pregnancy, which the child did not survive. On the day of the birth, the life-sustaining measures for the brain-dead mother were stopped; at this point in time, organ removal was no longer possible.

A legal guardian had been appointed to the brain-dead pregnant woman to decide on further medical treatment. The decision of the Hersbruck District Court states:

"The appointment of a provisional supervisor for the mentioned task groups appeared necessary, regardless of the fact that the person concerned is dead within the meaning of the law ... For clarification, it is pointed out that the decision of the provisional supervisor about switching off the function-maintaining apparatus before delivery or death of the A womb in the womb requires approval by the court. After this point in time, approval is no longer required. "

The question arose whether it can be ethically justified to artificially ventilate and feed the brain-dead mother until the fetus can be brought into the world by caesarean section , and whether it can be ethically justified to have a fetus in a brain-dead mother to grow until birth.

The Federal Constitutional Court upheld in 1975 the protection of the unborn child: "Where human life exists, it comes to human dignity; it is not decisive whether the wearer is aware of this dignity and knows how to preserve it himself. The potential abilities laid out in human existence from the beginning are sufficient to establish human dignity. "

Brain-dead medical technician (2013)

On November 26, 2013, a 33-year-old medical technician 14 weeks pregnant collapsed due to a severe pulmonary embolism . In John Peter Smith Hospital in Fort Worth , Texas , brain death has been diagnosed. The family members, including the husband, spoke out in favor of ending life-support measures, as the person concerned had spoken out against it in previous discussions with the husband. However, this was refused by the treating hospital with reference to Texas law. The husband then sued the hospital. The case sparked intense ethical discussions. After two months the plaintiff was found to be right, and the patient and the unborn child died after the life-support medical care was switched off.

See also

literature

  • Johann S. Ach, Michael Quante (Ed.): Brain death and organ transplantation. Ethical, medical, psychological and legal aspects of transplant medicine. Frommann-Holzboog, Stuttgart 1999, ISBN 3-7728-1992-3 .
  • Karim Akerma: End of Life and Beginning of Life. Philosophical implications and mentalistic justification of the brain death criterion. Lit, Münster u. a. 2006, ISBN 3-8258-9744-3 .
  • Axel W. Bauer : brain death, organ removal, death: the silent dilemma of transplant medicine. In: Ders .: Normative Delimitation. Topics and dilemmas in medical and bioethics in Germany. Springer VS, Wiesbaden 2017, ISBN 978-3-658-14033-5 , pp. 248-263.
  • Lorenz Bode: Time of Death of Man - On the Necessity of a "New Definition". In: Journal for Right to Live. No. 4, 2015, p. 111. ISSN  0944-4521 ( online ( Memento from January 5, 2016 in the Internet Archive ))
  • Alberto Bondolfi (Ed.): Brain death and organ donation. Schwabe, Basel 2003, ISBN 3-7965-1968-7 .
  • Johannes Hoff, Jürgen in der Schmitten (Ed.): When is a person dead? Organ transplant and “brain death” criterion. Rowohlt, Reinbek 1995, ISBN 3-499-19991-2 .
  • Ludger Honnefelder : brain death and understanding of death. The criterion of death as an anthropological and ethical problem. In: Ludger Honnefelder, Christian Streffer (Hrsg.): Yearbook for Science and Ethics. Volume 3. Walter de Gruyter, Berlin 1998, ISBN 3-11-016394-2 , pp. 56-78.
  • Dag Moskopp : brain death: concept - communication - responsibility. Thieme, Stuttgart 2015, ISBN 978-3-13-198661-0 .
  • Fuat Oduncu : Brain Death and Organ Transplantation. Medical, legal and ethical issues. Vandenhoeck & Ruprecht , Göttingen 1998, ISBN 3-525-45822-3 .
  • Klaus Schäfer : brain death. Medical facts - diffuse fears - help for relatives. topos, Regensburg 2014, ISBN 978-3-8367-0879-1 .
  • Klaus Schäfer: From coma to brain death. Care and support in the intensive care unit. Kohlhammer Verlag , Stuttgart 2017, ISBN 978-3-17-033088-7 .
  • Klaus Schäfer: Correct understanding of brain death ; New Justice (NJ) 2018, page 190 ff
  • Frank Schadt: On the living status of humans in a state of isolated brain function failure (dissociated brain death). Annex to the constitutional complaint against Section 4 of the Transplantation Act. Schadt, Dinslaken 1999, ISBN 3-934039-32-4 ( digitizedhttp: //vorlage_digitalisat.test/1%3D~GB%3DWi8XAwAAQBAJ~IA%3D~MDZ%3D%0A~SZ%3D~ double-sided%3D~LT%3D~PUR%3D ).
  • Hans-Peter Schlake, Klaus Roosen: Brain death as the death of humans. 2nd Edition. German Foundation for Organ Transplantation , Neu-Isenburg 2001, ISBN 3-9807327-0-3 .
  • Ralf Stoecker: Brain death. A medical-ethical problem and its moral-philosophical transformation. Alber, Freiburg u. a. 2006, ISBN 3-495-48181-8 .
  • Hartwig Wiedebach: brain death as a value. Medical building blocks from Jonas Cohn's value science and Maimonides' theology. Lit, Münster u. a. 2003, ISBN 3-8258-7098-7 .
  • Thomas Schlich, Claudia Wiesemann (Ed.): Brain death. Cultural history of the determination of death. Frankfurt am Main 2001.

Web links

Wiktionary: brain death  - explanations of meanings, word origins, synonyms, translations

Remarks

  1. ↑ The entire address of November 24, 1957 is contained in: AAS . XLIX, 1957, pp. 1027-1033. It was translated by Dag Moskopp: brain death. Stuttgart 2015, pp. 160-163.
  2. ↑ The Central Council of Muslims in Germany commented on this on June 4, 2013 with the words: "This Islamic legal opinion was widely accepted in Islamic countries and is considered an Islamic principle on this subject." (MZS Halabi: Organ and tissue donation from an Islamic perspective . (PDF) Central Council of Muslims in Germany).
  3. ↑ The WB-BÄK creates the guidelines for the determination of brain death. The BÄK defines the guidelines for the distribution of organs ( allocation ). In addition, the BÄK has the reporting office for irregularities: truststelle_transplantationsmedizin.at.baek.de In addition, the BÄK and the WB-BÄK have nothing to do with organ transplants. In making these joint explanations, they must have been concerned with the correct understanding of brain death, which is sometimes not always available even in medical circles.
  4. ↑ According to the annual reports of the DSO, organ removal is rejected in 25–32% of potential organ donors (brain death has been established and the brain dead has healthy organs). This does not cover more than 50% of non-organ removal. In addition, there is a non-quantifiable proportion of brain deaths from whom organ removal is excluded from the outset for medical reasons.
  5. ↑ The italics at the end of the quotations indicate that this sentence comes from the doctor's protocol sheet used to determine brain death. No formatting (bold or italic) was adopted from the texts in the quotations.

Individual evidence

  1. ↑ Claudia Wiesemann : Brain death. In: Werner E. Gerabek , Bernhard D. Haage, Gundolf Keil , Wolfgang Wegner (eds.): Enzyklopädie Medizingeschichte. de Gruyter, Berlin / New York 2005, ISBN 3-11-015714-4 , p. 601 f., here: p. 601.
  2. ↑ Claudia Wiesemann: Brain death. 2005, p. 601.
  3. ↑ Dag Moskopp: brain death. Stuttgart 2015, p. 38.
  4. ↑ Dag Moskopp: brain death. Stuttgart 2015, p. 44.
  5. ↑ Klaus Schäfer: From apparent death to brain death . Karlsruhe 2016, p. 16 f.
  6. ↑ Klaus Schäfer: From apparent death to brain death. Karlsruhe 2015.
  7. ↑ M.-F.-X. Bichat: Physiological Researches Upon Life and Death. Smith & Maxwell, Philadelphia 1809.
  8. ^ G. Sutton: The Physical and Chemical Path to Vitalism: Xavier Bichat's Physiological Researcheson Life and Death. In: Bull. Hist. Med. 58, 1984, pp. 53-71.
    Federal Center for Health Education, German Organ Transplantation Foundation: No turning back ... Information on brain death. Frankfurt am Main 2012, p. 10.
  9. ↑ Klaus Schäfer: From coma to brain death. Care and support in the intensive care unit . Stuttgart 2017, p. 32.
  10. ↑ Pope Pius XII. : Moral problems of resuscitation. November 24, 1957, In response to a questionnaire from senior anesthetists. Quoted from: Matthias Thöns: When is a person dead? Academy lecture. March 26, 1996. der-schlafdoktor.de (PDF) accessed on September 29, 2016
  11. ↑ Dag Moskopp: brain death. Stuttgart 2015, p. 76.
  12. ↑ Dag Moskopp: brain death. Stuttgart 2015, p. 76.
  13. ^ Gesa Lindemann: Worrying certainties. Konstanz 2003, p. 99.
  14. ^ Gesa Lindemann: Worrying certainties. Konstanz 2003, p. 113 f.
  15. ^ A definition of irreversible coma. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. In: JAMA . Volume 205, No. 6, August 1968, pp. 85-88.
  16. ↑ The wording of these two reasons is translated: "Our primary concern is to define the irreversible coma as a new criterion for death. There are two reasons for the need for a new definition:
    1. Medical advances in resuscitation and support for life-sustaining functions have led to increased efforts to save the lives of the most seriously injured. Sometimes these efforts are only partially successful: the result is individuals whose hearts continue to beat while their brains are irreversibly destroyed. A heavy burden rests on the patients who suffer the permanent loss of their intellect, on their families, on the hospitals, and on those patients who depend on hospital beds occupied by these comatose patients.
    2. Outdated criteria for defining death can lead to controversy over how to source organs for transplantation. "
    Translation from English into German by Hoff. In: J. id Schmitten (ed.): When is man dead? Reinbek 1994, p. 157.
    Quotation: “Our primary purpose is to define irreversible coma as a new criterion for death. There are two reasons why there is need for a definition: (1) Improvements in resuscitative and supportive measures have led to increased efforts to save those who are desperately injured. Sometimes these efforts have only partial success so that the result is an individual whose heart continues to beat but whose brain is irreversibly damaged. The burden is great on patients who suffer permanent loss of intellect, on their families, on the hospitals, and on those in need of hospital beds already occupied by these comatose patients. (2) Obsolete criteria for the definition of death can lead to controversy in obtaining organs for transplantation. "('AD HOC' COMMITTEE (1968), p. 337.)
  17. ^ Statement of the Scientific Advisory Board of the German Medical Association on the question of the criteria of brain death. accessed on August 1, 2016.
  18. ^ Criteria of brain death. accessed on August 1, 2016.
  19. ↑ Criteria of brain death Decision-making aid for determining brain death. accessed on August 1, 2016.
  20. ↑ Criteria of brain death Decision-making aid for determining brain death. Z accessed August 1, 2016.
  21. ↑ a b c d Guideline for determining brain dysfunction. accessed on August 1, 2016.
  22. ↑ austrotransplant.at (PDF) p. 3; accessed on December 23, 2018.
  23. ↑ admin.ch accessed on December 23, 2018.
  24. ↑ DA Shewmon: Chronic "brain death": meta-analysis and conceptual consequences. In: Neurology . 51 (6), Dec 1998, pp. 1538-1545.
  25. ^ Brain death and brain death diagnostics ( Memento from January 3, 2013 in the Internet Archive ) at the German Organ Transplantation Foundation (dso.de); Retrieved December 8, 2012.
  26. ↑ German Foundation for Organ Transplantation (DSO): Brain death as the death of humans. 1. A.30.12 / 95, p. 36.
  27. ↑ Sam Parnia : Death is reversible . In: Der Spiegel . No. 30 , 2013 ( online ).
  28. ^ Antoine Lutz, Richard Davidson et al. a .: Long-term meditators self-induce high-amplitude gamma synchrony during mental practice. November 8, 2004.
  29. ↑ Federal Ministry of Health: Guideline according to § 16 Paragraph 1 Sentence 1 No. 1 TPG for the rules for determining death according to § 3 Paragraph 1 Sentence 1 No. 2 TPG and the procedural rules for determining the final, unrecoverable failure of the overall function of the cerebrum, the cerebellum and the brain stem according to § 3 Paragraph 2 No. 2 TPG. (March 30, 2015). In: brain dysfunction. (PDF) accessed on September 29, 2016.
  30. ↑ On the question of the criteria of brain death. accessed on August 2, 2016.
  31. ↑ Guidelines: Determining Death with Relation to Organ Transplants. Swiss Academy of Medical Sciences, 2005; PDF with guidelines, literature and protocol annex; Retrieved July 27, 2008.
  32. ↑ Organ donation working group: No way back ... Information on brain death. 1. A.100.8 / 99, p. 29.
  33. ↑ Dag Moskopp: brain death. Stuttgart 2015.
  34. ↑ Brain death and the decision to donate organs. Statement by the German Ethics Council. ( BT-Drs. 18/4256 , p. 40).
  35. ^ Organ transplants , declaration by the German Bishops' Conference and the Council of the EKD. Bonn / Hanover 1990.
  36. ↑ Vatican Radio : How dead is brain dead? ( Memento of September 11, 2008 in the Internet Archive ) September 4, 2008.
  37. ↑ Die Tagespost: Six hours without brain waves, accessed on July 19, 2019
  38. ^ Secretariat of the German Bishops' Conference (ed.): Brain death and organ donation. ( Memento of the original from April 17, 2018 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Bonn April 27, 2015, accessed on April 16, 2018. @1@ 2Template: Webachiv / IABot / www.dbk-shop.de
  39. ↑ Omar Samadzade: Brain death and organ transplantation from an Islamic perspective. Bauz, Traugott 2009, ISBN 978-3-88309-542-4 , p. 11.
  40. ↑ Quoted from Martin Kellner: Islamic legal opinions on medical interventions at the limits of life. A contribution to cross-cultural bioethics . Ergon, Würzburg 2010, p. 135.
  41. ↑ Abdel Moneim Hassaballah: Mini Symposium. Definition of death, organ donation and interruption of treatment of Islam. In: Nephrology Dialysis Transplantation. 11, No. 6, June 1996, pp. 964-965. ISSN  0931-0509 . PMID 8671951 .
  42. ^ MZS Halabi: Organ and tissue donation from an Islamic perspective. (PDF) Central Council of Muslims in Germany, accessed on September 29, 2016.
  43. ↑ Organ transplant and brain death. Central Council of Muslims in Germany, July 2, 1997.
  44. ↑ Small question from member of the Bundestag Kathrin Vogler, Dr. Martina Bunge, Diana Golze, Heidrun Dittrich, Ilja Seifert, Kathrin Senger-Schäfer, Harald Weinberg, Sabine Zimmermann and the Die Linke parliamentary group on July 23, 2013 on the subject of brain death, BT-Drs. 17/14434 .
  45. ^ Reply of the Federal Government of August 9, 2013, BT-Drs. 17/14527 .
  46. ↑ How dead are the brain dead? Old question - new answers. on www.bpb.de .
  47. ↑ Herdegen in Maunz / Dürig, Article 1, Paragraph 1 of the Basic Law, marginal no. 56 2014.
  48. ↑ Baden-Württemberg : § 50 legal provisions = "to preserve the dignity"
    Berlin : § 2 reverence for the dead = "to preserve the necessary reverence for the dead person"
    Brandenburg : § 1 principles = "the dignity of the deceased"
    Bremen : § 2 Reverence for the dead = "to maintain the necessary reverence for the dead person"
    Mecklenburg-Western Pomerania : § 2 Reverence for the dead = "to maintain the necessary reverence for the dead person"
    Lower Saxony : § 1 principle = "that the necessary awe is protected from death "
    North Rhine-Westphalia : § 7 dignity of the dead, health protection =" have to respect the respect for the dead "
    Rhineland-Palatinate : § 8 burial =" the dignity of the dead ... must be respected. "
    Saarland : § 12 general Regulations = "The dignity of the human being persists beyond death."
    Saxony : § 18 General regulations on burial = "the dignity ... of the deceased ... must be respected"
    Saxony-Anhalt : § 1 principles = "has the required dignity and with respect for the verse torbenen to take place "
    Schleswig-Holstein : § 1 principles =" must be done with the necessary dignity and with respect for the deceased "
    Thuringia : § 1 principles =" Aims of the law are in particular to maintain respect for the dead, respect for Dignity of the dead as well as the protection of the dead rest and the honor of the dead. "
  49. ↑ Deutscher Ärzteverlag GmbH, editorial office of Deutsches Ärzteblatt: Statement by the Scientific Advisory Board of the German Medical Association on the question of the criteria of brain death. April 9, 1982, accessed June 9, 2020 .
  50. ↑ Deutscher Ärzteverlag GmbH, editorial office of Deutsches Ärzteblatt: ANNOUNCEMENT OF THE FEDERAL MEDICAL CHAMBER: OPINION OF THE SCIENTIFIC ADVISORY BOARD OF THE FEDERAL DOCTOR'S CHAMBER - Criteria of brain death. October 22, 1986, accessed June 9, 2020 .
  51. ↑ Deutscher Ärzteverlag GmbH, editorial office of the Deutsches Ärzteblatt: OPINION OF THE SCIENTIFIC ADVISORY BOARD OF THE FEDERAL MEDICAL CHAMBER: Criteria of brain death - decision-making aids for determining brain death. December 5, 1991, accessed June 9, 2020 .
  52. ^ A b Deutscher Ärzteverlag GmbH, editorial office of Deutsches Ärzteblatt: Announcements: Statement by the Scientific Advisory Board of the German Medical Association Criteria of brain death Decision-making aids for determining ... May 9, 1997, accessed on June 9, 2020 .
  53. ↑ Guidelines for determining brain death (PDF) accessed on December 26, 2017.
  54. ↑ a b c Guideline according to § 16 para. 1 sentence 1 no. 1 TPG for the rules for determining death according to Article 3 para. 1 sentence 1 no. 2 TPG and the procedural rules for determining the final, unrecoverable failure of the Overall function of the cerebrum, the cerebellum and the brain stem according to Section 3 Paragraph 2 No. 2 TPG, Fourth Update (PDF), accessed on December 26, 2017.
  55. ^ Medical examination and death certificate . In: Deutsches Ärzteblatt , Issue 48, November 28, 2003, A 3161. From: aerztekammer-bw.de (PDF) accessed on October 30, 2017.
  56. ↑ Brain death is not human death. In: Deutschlandradio Kultur. July 14, 2011.
  57. ↑ Violent controversy: When is a person dead? In: Doctors newspaper. February 22, 2012.
  58. ↑ Axel W. Bauer : Brain death, organ removal, death: The silent dilemma of transplant medicine. 2017, p. 256.
  59. ↑ Alan Shewmon. organspende-wiki.de; accessed on August 2, 2016.
  60. ↑ How dead are the brain dead? Old question - new answers. ( Memento of August 24, 2014 in the Internet Archive ) In: Parliament. 2011.
  61. ↑ New doubts about brain death. In: TAZ. 5th November 2010.
  62. ↑ When is a person really dead? In: Der Tagesspiegel. September 28, 2010.
  63. ↑ Can organ donation still be saved? In: FAZ. October 14, 2010. - See: Martina Keller : Das Ende . ( Memento of the original from July 11, 2016 in the Internet Archive ) Info: The archive link was automatically inserted and not yet checked. Please check the original and archive link according to the instructions and then remove this notice. In: Bild der Wissenschaft online. 4/2012 ("With the Berlin physicist and philosopher Sabine Müller, this approach gives the» impression of an ethics based on interests that also disregards the scientific principle of falsifiability «"). @1@ 2Template: Webachiv / IABot / www.bild-der-wissenschaft.de
  64. ↑ How sure is a brain death diagnosis? , quark.de, February 14, 2019
  65. ↑ a b Alabama 'miracle' boy wakes before doctors pull plug , quarks.de, February 14, 2019
  66. ↑ Terrible mistake "Hirntote" wakes up after organ removal , berliner-kurier.de , accessed on February 17, 2014
  67. ↑ Alan Shewmon: Chronic "brain death" Meta-analysis and conceptual Consequences . In: Neurology , 1998, 51, pp. 1538-1545. Currently from September 7, 2009. From: jacek.norkowski.info (PDF). Retrieved on April 3, 2014.
  68. ↑ "More than 12,200 sources yielded approximately 175 cases meeting selection criteria; 56 had sufficient information for meta-analysis."
  69. ↑ Lawyer declared brain dead wakes up after calls to pull plug on her , Straits Times , March 24, 2013
  70. ↑ dead 'Steven Thorpe defies doctors' predictions' , bbc.com, April 19, 2012
  71. ^ Organ donation The student who was recently "brain dead" , berliner-zeitung.de, May 9, 2012
  72. ↑ brain death . (PDF) accessed on August 1, 2016.
  73. ↑ Bernhard Albrecht: Born from a corpse . In: Der Spiegel . No. 25 , 2011, p. 112-116 ( online ).
  74. ↑ Hersbruck Local Court, decision of October 16, 1992, Az. XVII 1556/92, Leitsatz = NJW 1992, 3245 = FamRZ 1992, 1471.
  75. ↑ BVerfG, judgment of February 25, 1975, Az. 1 BvF 1, 2, 3, 4, 5, 6/74, BVerfGE 39, 1 - Abortion I.
  76. ↑ JL Ecker: Death in pregnancy - an American tragedy. In: N Engl J Med. 370 (10), 2014, pp. 889-891. doi: 10.1056 / NEJMp1400969 . PMID 24499176 .
  77. ↑ Texas hospital acknowledges brain-dead status of pregnant woman , The Guardian , Jan. 24, 2014