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Prolonging Support After Brain Death: When Families Ask for More



The manner in which brain death protocols in the United States address family objection to death by neurologic criteria has not been explored.


Institutional brain death protocols from hospitals in the United States were reviewed to identify if and how the institution addressed situations in which families object to determination of brain death or discontinuation of organ support after brain death.


Protocols from 331 institutions in 25 different states and the District of Columbia were reviewed. There was no mention of how to handle a family’s objections in 77.9 % (258) of the protocols. Of those that allowed for accommodation, reasons to defer brain death declaration or prolong organ support after brain death declaration included: (1) religion; (2) moral objection; (3) nonspecific social reasons; or (4) awaiting arrival of family. Recommendations to handle these situations included: (1) seek counsel; (2) maintain organ support until cardiac cessation; (3) extubate against the family’s wishes; (4) obtain a second opinion; or (5) transfer care of the patient to another practitioner or facility. Protocols differed on indications and length of time to continue organ support, code status while support was continued, and time of death.


The majority of protocols reviewed did not mention how to handle circumstances in which families object to determination of brain death or discontinuation of organ support after brain death. The creation of guidelines on management of these complex situations may be helpful to prevent distress to families and hospital staff.

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Author Contributions

Ariane Lewis was responsible for conception and design, analysis and interpretation of data, drafting the manuscript, statistical analysis and final approval of the manuscript. Panayiotis Varelas was responsible for conception and design, critical revision of the manuscript, and final approval of the manuscript. David Greer was responsible for acquisition of data, critical revision of the manuscript, and final approval of the manuscript. Ariane Lewis and David Greer had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Ariane Lewis performed data analysis.


The authors received no funding support for this study.

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Correspondence to Ariane Lewis.

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Ariane Lewis has no financial disclosures or conflicts of interest. Panayiotis Varelas is a member of the advisory board of Gift of Life in Michigan. David Greer is the editor-in-chief of Seminars in Neurology. This manuscript represents valid work and neither this manuscript nor one with substantially similar content has been published or is being considered for publication elsewhere.

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Lewis, A., Varelas, P. & Greer, D. Prolonging Support After Brain Death: When Families Ask for More. Neurocrit Care 24, 481–487 (2016).

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  • Brain death
  • End-of-life
  • Ethics
  • Family
  • Guidelines