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BrainDeath:LegalObligationsandtheCourts
ChristopherM.BurkleThaddeusM.Pope
SeminNeurol.201535(2):174179.

AbstractandIntroduction
Abstract

Braindeath,ordeathdeterminedbyneurologiccriteria,hasbeenlegallyadoptedinallU.S.statesfordecades.Despiteitslongestablishedhistory,alackofclearunderstandinghasledto
disputesrequiringalegalforumforresolution.Recently,physiciansandhospitalsacrossthecountryhavebeenimpactedbyagrowingnumberofdisputesaboutbraindeath.Theauthors
offercliniciansahistoricalperspectiveontheevolutionofbraindeathasalegalcauseofdeathintheUnitedStates.Theythenreviewthemorecommonlegalcategoriesofdisputes
encountered,includingrepresentativecourtcasesforeach.Thisoverviewprovidesphysicianswithagenerallegalperspectiveonbraindeathsotheymaybetterappreciatethepertinent
issuesifandwhenlaterconfronted.
Introduction

Hereweprovidealegalhistoricaltimelineofbraindeath,ordeathdeterminedbyneurologiccriteria(DDNC),alongwithperspectivesonmajorcategoriesoflegaldisputesinthisarea.Our
commentslargelyreviewandexpandupontopicsthatwehavepreviouslyaddressedinearlierpublicationsonthetopic. [1,2]Thegoalofthisworkistooffercliniciansanoverviewonthelegal
aspectsofbraindeath,suchthattheyhaveagreaterunderstanding,ifandwhentheirpracticeisimpactedbythisemotionalandchallengingevent.

HistoryofDeterminingDeathbyNeurologicCriteria
Traditionally,thelegaldefinitionofdeathwasviewedasthecessationofcardiopulmonaryfunctionalone.Amongthoseincludedwithinthisdefinitionofdeathwereindividualssufferingan
acuteoverwhelmingbraininjuryleadingtoasystole.However,withadvancesincardiopulmonaryresuscitation,patientssufferingamajoracutebraininjuryandlossofallbrainstemfunction
wereincreasinglybeingsupportedinintensivecareunits(ICUs).Thisledtobothaninterestandneedtomoreaccuratelydeterminedeathbyneurologiccriteria. [3]In1968,aphysicianled
committeeatHarvardMedicalSchoolpublishedaseminalpaperentitled"ADefinitionofIrreversibleComa." [4]TheHarvardCommitteeconcludedthatpatientswhomeetcriteriafora
certaintypeofseverebraininjurymaybepronounceddeadbeforecardiopulmonarycessationoccurs. [4]
Duringthe1970s,statelegislaturesbeganamendingtheirstatutestolegallyrecognizethisadditional,alternativemethodfordeterminingdeath.KansaswasthefirststatetodefineDDNC
asalegaldeathbystatestatutein1970(see). [3]However,Kansasandotherstatesthatfollowedfailedtoformulatetheneurologicdeathstandardinaconsistentanduniformmanner,
therebycreatingpossiblefutureconfusionandconflict.
Table1.Timelineofkeylegaldevelopments

Year KeylegaldevelopmentsintheUSA

1970 Kansasisthefirststatetolegallyrecognizebraindeath.
1978 UniformBrainDeathAct
1981 UniformDeterminationofDeathAct
1987 NewYorkDepartmentofHealthregulationsrequirehospitalstoaccommodatereligiousandmoralobjections
1991 NewJerseyDeclarationofDeathActpermitsreligiousexemption.
2009 Californiastatuterequireshospitalstoaccommodateobjections.
Inresponsetotheneedforgreaterconsistency,thePresident'sCommissionfortheStudyofEthicalProblemsinMedicineandBiomedicalandBehavioralResearchproposedamodel
statutein1981(see). [5]Employingtheircooperativestudytitled"DefiningDeath"asatemplate,ThePresident'sCommissionproposedthatdeathcouldbemetbyeither:(1)"irreversible
cessationofcirculatoryandrespiratoryfunctions"or(2)"irreversiblecessationofallfunctionsoftheentirebrain,includingthebrainstem." [35]Thelatterqualificationwillbereferencedas
"braindeath"throughouttheremainderofthisreview.
Table1.Timelineofkeylegaldevelopments

Year KeylegaldevelopmentsintheUSA

1970 Kansasisthefirststatetolegallyrecognizebraindeath.
1978 UniformBrainDeathAct
1981 UniformDeterminationofDeathAct
1987 NewYorkDepartmentofHealthregulationsrequirehospitalstoaccommodatereligiousandmoralobjections
1991 NewJerseyDeclarationofDeathActpermitsreligiousexemption.
2009 Californiastatuterequireshospitalstoaccommodateobjections.
TheCommission'sproposalwasquicklyendorsedbytheAmericanMedicalAssociation(AMA),theAmericanBarAssociation(ABA),andtheNationalConferenceofCommissionerson
UniformStateLaws(NCCUSL). [1]TheNCCUSLadvancedthetwomodelcriteriaunderthename"UniformDeterminationofDeathAct"(UDDA)whileseekingitspassageinallstatesand
jurisdictionsacrosstheUnitedStates(see). [6]Today,36states,theDistrictofColumbia,andtheU.S.VirginIslandshaveadoptedtheUDDA. [7]Theremainingstateshaveenacted
substantiallysimilarstandardseitherthroughlegislationorthroughcourtdecision. [6]AlthoughnotallU.S.jurisdictionshaveadoptedtheliteralwordingoftheUDDA,allcontainsomelegal
acknowledgmentofabrainbasedstandardofdeath. [1,6,8,9]Inaddition,despitesomevariationintheadministrationofclinicaltesting,mostcountriesacknowledgeDDNC. [10]
Table1.Timelineofkeylegaldevelopments

Year KeylegaldevelopmentsintheUSA

1970 Kansasisthefirststatetolegallyrecognizebraindeath.
1978 UniformBrainDeathAct
1981 UniformDeterminationofDeathAct
1987 NewYorkDepartmentofHealthregulationsrequirehospitalstoaccommodatereligiousandmoralobjections
1991 NewJerseyDeclarationofDeathActpermitsreligiousexemption.
2009 Californiastatuterequireshospitalstoaccommodateobjections.

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Despiteitswidespreadadoption,DDNCishardlywithoutlegalandethicalcontroversyandcriticism.Ithasbeendescribedas"atoncewellsettledandpersistentlyunresolved." [11]Thelatest
reevaluationofthedefinitionofdeathfromafederaloversightperspectivewasfromtheU.S.President'sCouncilonBioethics. [9]Inits2008publishedreport,theCouncilcontinuedto
endorse"totalbrainfailure"asanappropriatecriterionfordeclaringdeath. [6]Further,itconcludedthatbraindeathremainsboth"biologicallyandphilosophicallydefensible." [6]
Someremaincritical,arguingthatbraindeathis"seriouslyproblematic"andthatthelegaldefinitionofdeathdoesnotcorrespondtoabiologicaldefinitionofdeath. [12]Butmost
acknowledgethat"currentpracticescanbejustifiedethicallyandlegally." [13]Inshort,despitesomeconceptualflaws,thesecriticsseebraindeathas"tooingrainedtoabandon." [14]
Indeed,therehasbeenrelativelylittlelegislativeorjudicialactiontoeliminateoramendbraindeath.Despiteongoingacademicdebate,thelawconcerningbraindeathhasremained
relativelystablefordecades.Recently,themainlegalissueshaveinsteadconcernedthedutytoaccommodatefamilyobjectionsandthemannerofconductingbraindeath.

GeneralAccommodationPrinciplesandStateLaws
Onceapatientisdetermineddead,physiologicalsupportistypicallydiscontinuedasthereisnolongeradutytotreat.Thisiswellestablishedbothinappellatecaselaw[15]andinmedical
practice. [16]Oncedead,thepatientisnolongerapatient [17]therefore,thehospitalisnolongerinatreatmentrelationshipwithapatient.Instead,itisactinginthecapacityofthecustodian
ofadeadbody. [18]Moreover,continuing"treatment"couldconstitutemistreatmentofthenewlydead. [19]Therefore,theDDNCactsasa"hardclinicalendpoint"wheretechnological
interventionsreachthelimitsofrequiredoracceptedmedicalpractice. [20]
Butthereremaintwosituationsinwhichhospitalscontinuephysiologicalsupportafterbraindeath.First,ifthepatientisanorgandonor,supportiscontinueduntildonation.Second,
measuresmightbeofferedtoaccommodatethefamily.Continuingphysiologicalsupportfororgandonationisgovernedbywellsettledlaw. [21]Incontrast,continuingphysiologicalsupport
asanaccommodationislesssettled.
Manyfacilitiesvoluntarilyofferashorttermaccommodationperiodsasacompassionatemeasuretohelpthefamilycopewiththepatient'sdeath, [22]whileinthreestates,thedutyto
accommodateismandatedbylaw. [23]StatutesinNewJersey,NewYork,andCaliforniaexplicitlyrequirehospitalsto"accommodate"familiesafterapatientisdeclareddeadbyneurologic
criteria(see).
Table1.Timelineofkeylegaldevelopments

Year KeylegaldevelopmentsintheUSA

1970 Kansasisthefirststatetolegallyrecognizebraindeath.
1978 UniformBrainDeathAct
1981 UniformDeterminationofDeathAct
1987 NewYorkDepartmentofHealthregulationsrequirehospitalstoaccommodatereligiousandmoralobjections
1991 NewJerseyDeclarationofDeathActpermitsreligiousexemption.
2009 Californiastatuterequireshospitalstoaccommodateobjections.
NewJersey

In1991,NewJerseyenactedtheNewJerseyDeclarationofDeathAct. [24]Asineveryotherstate,thisstatuteprovidesthatanindividualwhohas"sustainedirreversiblecessationofall
functionsoftheentirebrain,includingthebrainstem,shallbedeclareddead." [25]However,unlikeotherstates,theNewJerseystatuteallowsforacategoricalexception[26]forareligious
objectiontobraindeath.
TheNewJerseystatutestatesthat:
[t]hedeathofanindividualshallnotbedeclareduponthebasisofneurologicalcriteria.whenthelicensedphysicianauthorizedtodeclaredeath,hasreasontobelieve,onthebasis
oftheinformationintheindividual'savailablemedicalrecords,orinformationprovidedbyamemberoftheindividual'sfamilyoranyotherpersonknowledgeableabouttheindividual's
personalreligiousbeliefsthatsuchadeclarationwouldviolatethepersonalreligiousbeliefsoftheindividual.Inthesecases,deathshallbedeclaredsolelyuponthebasisofcardio
respiratorycriteria[27]
Summarizing,theNewJerseyDeclarationofDeathActprovidesthat"thedeathofanindividualshallnotbedeclareduponthebasisofneurologicalcriteriawhensuchadeclarationwould
violatethepersonalreligiousbeliefsoftheindividual." [27]Althoughthestatutedoesnotdefinewhatqualifiesasalegitimatereligiousbelief,itseemsthatupontheassertionofanyplausible
religiousclaim,deathshallbedeclared"solelyuponthebasisofcardiorespiratorycriteria."
NewYork

NewYorkjudiciallyrecognizebraindeathaslegaldeathin1984[28]andin1987,theNewYorkDepartmentofHealth(NYDOH)adoptedthisstandardintoitsadministrativeregulations. [29]
ButtheNYDOHdidmorethanformallyrecognizebraindeath,asitalsorequiredhospitalstoaccommodatereligiousormoralobjectionstobraindeath.
In2011,theNYDOHconfirmedthattheNewYorkaccommodationrequirementisnotacategoricalexceptionliketheNewJerseyaccommodationrequirement.Instead,NewYorkhospitals
mustmerely"establishwrittenproceduresforthereasonableaccommodationoftheindividual'sreligiousormoralobjectionstouseofthebraindeathstandard"whensuchanobjectionhas
beenexpressedbythepatientorsurrogate. [30]InfurthercontrasttoNewJersey,theNYDOHaccommodationrequirementextendsnotonlytoreligious,butalsotomoralobjections.
Althoughtherangeofobjectionsmaybebroader,thedutyofaccommodationislessdemanding.TheNYDOHallowshospitalssignificantdiscretionindesigningtheirownaccommodation
policies.
TheNewYorkstatutehasbeeninvolvedinatleasttwopriorcourtdecisions. [3133]Inone,thecourtfoundinfavorofthehospitalinadisagreementoverwhethertheAfricanAmerican,
bornagainChristianparentsofayoungchildhadbeenprovidedproperreligiousaccommodationasrequiredunderNewYorklaw. [33]
Inthesecondcase,thecourtheldthatthehospitalcouldterminateintensivecare"support"forayoungchildwhometthebraindeathguidelinessetoutintheNewYorkstatute. [31]The
parents,whowereJehovah'sWitnesses,arguedthattheNewYorkstatutewasunconstitutionalbothbecauseitinfringedonthebaby'srighttoliveandbecauseitfailedtoincludesa
mechanismforchallengingthehospital'sdeterminationofbraindeath.However,thecourtheldthatthestatutewasconstitutionalanddeterminedthatthehospitalwasincompliancewith
applicablestatestatutes.Threemonthslater,anappealwasdismissedwhenthehospitaldeterminedtheinfantwasnotdeadafterall.
Informulatingitsholding,thecourtacknowledgedearliercaselawinNewYorkwhenstatingthat"[i]fapersonisdead,thereisnolifetobedeprivedof,withorwithoutdueprocessoflaw.
Fromtimeimmemorial,physicianshavedeterminedwhenpersonsaredeadandhaveceasedgivingmedicaltreatment.Itisnotadenialofdueprocesstohavephysicians,ratherthan
parentsornextofkinorclosefriends,determinethatdeathhasoccurred." [31]Intheirfinaldecision,thecourtextendedtheorderrestrainingthehospitalfromdiscontinuinglifesupport
systemsfor7daystoallowthefamilytimetoseekoutaanotherfacilitywillingtotakethechild.
California

Californiafirstacknowledgedbraindeathin1974andagainin1982byadoptingtheUniformDeterminationofDeathAct. [34]Butin2009,anewCaliforniastatuteextendedobligationsof
hospitalswithrespecttopatientsdeclareddeadonthebasisofneurologiccriteriaalone. [35]TheCaliforniastatuterequiresthatgeneralacutecarehospitalsadoptapolicyforproviding
familywitha"reasonablybriefperiodofaccommodation"afterapatientisdeclareddeadbyreasonofirreversiblecessationofallfunctionsoftheentirebrain.Californiarequiresnotonly
accommodationofmoralorreligiousobjections,butalsoaccommodationofalltypesofobjections.

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Althoughbroadinthetypesofobjectionscovered(e.g.,religious,moral,psychological),theCaliforniadutyofaccommodationislimitedinseveralothermaterialrespects.First,duringthis
"reasonablybriefperiodofaccommodation,ahospitalisrequiredtocontinueonlypreviouslyorderedcardiopulmonarysupport." [35]"Noothermedicalinterventionsarerequired." [35]Second,
the"briefperiod"isnarrowlydefinedasonly"anamountoftimeaffordedtogatherfamilyornextofkinatthepatient'sbedside." [36]Inotherwords,theCaliforniadutyofaccommodationis
finite.
Ontheotherhand,thedutytoaccommodatemaybemoredemandingifthepatient'sfamilyvoicesany"specialreligiousorculturalpracticesandconcerns." [37]Inthatcase,thehospital
mustmake"reasonableeffortstoaccommodatethosereligiousandculturalpracticesandconcerns." [37]Becausethisdutyisnotlimitedtoa"reasonablybriefperiod,"itisprobablysimilarto
thedutytoaccommodateunderNewYorklaw.

CourtActivity
Asdescribedinthelastsection,mostlegaldevelopmentsconcerningbraindeathhavebeenlegislativeandregulatorytodate.Buttherehasalsobeensignificantjudicialactivity.Court
caseshavetakenfivebasicforms:(1)familiesseekingphysiologicalsupportafterbraindeath,(2)familiesseekingdamagesforintentionallyprematurebraindeath,(3)familiesseeking
damagesfornegligentlyprematurebraindeath,(4)familiesseekingdamagesforemotionaldistress,and(5)pregnancylimitationsonbraindeath.
FamiliesSeekingPhysiologicalSupportafterBrainDeath

Familiesregularlybringlawsuitsseekinginjunctionsmandatingcontinuedphysiologicalsupport.Butcourtsalmostnevergrantpermanentinjunctions. [38]Instead,morecommonly,courts
grantonlytemporaryrestrainingordersthatpreservethestatusquountilmoreevidencecanbegathered.Insomeofthesecases,thefamilyhasreligiousobjections, [22]orjustdistruststhe
diagnosis. [32]Tworecentcases,bothinvolvingchildren,serveasexamples.
JahiMcMath(OaklandChildren'sHospital,California).InDecember2013,a13yearoldOakland,Californiachild(JahiMcMath)sufferedfromrespiratorycomplicationsfollowinga
tonsillectomyandadenoidectomy.ThehospitalclaimedthatJahiMcMathwaslegallydeadaftertwoneurologicassessmentsbyitsmedicalstaff.Asthechildwasnolongerliving,the
hospitalmaintainedthatitwasnolongerobligatedtocontinueprovidingmedicalcareatthefamily'srequest.Thefamilyclaimedthattheirchildwasnotdeadbecauseshehadacontinually
beatingheartandwasmovinginresponsetotouch.Theydemandedthatthehospitalcontinuetoprovidemedicalcare,includingventilatorysupport,inhopesthatshemightstillrecover.
Some22daysaftertheoriginaldiagnosisofbraindeath,theAlamedaCountySuperiorCourtannouncedthatthefamilyandhospitalhadcometoapartialagreement. [23]Theagreement
specifiedthatanoutsidemedicalteamcouldremoveJahiMcMathfromthehospitalandthathermotherwouldtakefullresponsibilityforherbodyduringitsrelocationtoanotherfacility.In
earlyJanuary2014,theMcMathfamilyremovedJahi'sbodyfromthehospitaltoafacilityinNewJersey. [39]ThefamilyisreportedtobeseekingtorevokeJahi'sCaliforniadeathcertificate,
sothatJahiwillqualifyformedicalbenefits. [40]
IssacLopez(KosairChildren'sHospital,Kentucky).OnJune29,2014,2montholdIssacLopezpresentedtotheemergencydepartmentataLouisville,Kentuckyhospitalwithaskull
fracture,ribfractures,respiratoryfailure,cardiacarrest,andbloodandfluidpoolingaroundhisbrain. [41]Issac'sfatherwasarrestedforchildabuseafteradmittingtohavinghitIssac'shead
againstthebathtub.IssacwasadmittedtothepediatricintensivecareunitwheretheattendingphysiciandiagnosedIssacwithtotalbrainfailure.
Atthefamily'srequest,asecondexamtoconfirmbraindeathwasdeferredfor48hourstoallowextendedfamilymemberstoarriveatthehospital.Tworepeatexaminationsconfirmedtotal
brainfailure.Butthefamilydidnotacceptthediagnosis.Issac'smotherthenobtainedatemporaryrestrainingorder.(Inlightofthependingcriminalcharges,Issac'sfathersuffereda
materialconflictofinterestinmakingmedicaldecisionsforIssac.Hisobjectiontostoppingphysiologicalsupportwasimpactedbyhisdesiretoavoidhomicidecharges.)Thehospitalthen
fileditsownseparateactionaskingthecourttoallowtheremovalofphysiologicalsupportgiventhatIssacwasdead.Twoadditionalexaminations(onebythefamily'sindependentmedical
expert)alsoconfirmedtotalbrainfailure.Atthispoint,therewasnolongerafactualdisputethatIssac'sconditionmetthecriteriaforbraindeath.
Still,Issac'smotherandacourtappointedguardianarguedthatthehospitalcouldnotstopIssac'sphysiologicalsupportbecauseparentshaveaconstitutionalrighttomakemedical
decisionsfortheirchildren.TheyarguedthatbecauseIssac'sparentshadnothadthoserightsterminated,theypossessedsoledecisionmakingauthoritywithrespecttoIssac'smedicalcare.
Thecourtrejectedthispositionstatingthat"withdeath,noparentaldecisionmakingsurvives(savedecisionsregardingburial)."Instead,thecourtfoundthatbecausethecriteriaforbrain
deathweremet,Issacwas"legallydead" [42]andtherefore,thehospitalhad"nolegalobligationtoartificiallymaintainrespiration,circulationortorenderanyothermedicalinterventionor
treatment." [43]
CasesSeekingDamagesforIntentionallyPrematureBrainDeath

Onealarmingallegationbroughtbeforethecourtsisthatcliniciansintentionallyanddeliberatelyconfirmdeathbyneurologiccriteriabeforethosecriteriaareactuallymet.Thecasebelow
servesasanillustration.
GregoryJacobsv.CORE(Erie,Pennsylvania).In2007,ahighschoolstudentsustainedheadinjurieswhileonaschoolskitrip.Inafederallawsuitfiledagainstthehospitalandthearea
organprocurementorganization,theboy'sparentsallegedthattheywereaskedtoconsenttoorgandonationeventhoughdeathhadnotbeendeterminedandwasnotevenimminent.Their
claimincludedthathadhebeenproperlytreatedratherthan"killedforhisorgans,"hewouldhavehadasignificantchanceofrecovery.Claimsforbattery,fraudulentmisrepresentation,
negligentmisrepresentation,andmedicalmalpracticewereasserted. [44]Inlate2012,thepartiessettledtheseclaimsforover$1million. [45]
CasesSeekingDamagesforNegligentlyPrematureBrainDeath

Althoughcasesofintentionallyanddeliberatelyprematurebraindeatharethemostalarming,alsoconcerningarethosecasesallegingnegligentlyprematurebraindeath.Thecasebelow
servesasanexampleofthisconcern.
St.Joseph'sHospital(Syracuse,NewYork).In2009,cliniciansataSyracusehospitaldeclaredColleenBurnsdeadfollowingadrugoverdose.Despiteseveralsignsofresponsivenessto
stimuli,thehospitalcontinuedtoprepareherfororganprocurement.Then,justassurgerywasabouttocommence,Burnsopenedhereyesintheoperatingroom.Thesurgerywas
immediatelycanceledandBurnswasreleased2weekslater.In2013,theNewYorkDepartmentofHealthfinedthehospital$6,000forimproperlyimplementingbraindeathprotocols.In
addition,theCentersforMedicareandMedicaidServices(CMS)sanctionedthehospitalforfailingtoundertakean"intensiveandcriticalreviewoftheevent." [46]
CasesSeekingDamagesforEmotionalDistress

Inadditiontocourtcasesthatseekcontinuedphysiologicalsupportandthoserequestingdamagesforprematurebraindeath,therearestillothersseekingemotionaldistressdamages.In
thesecases,familiesallegethatclinicianswereinsensitiveoroutrageousinhowtheytreatedorcommunicatedwiththefamilyofthepatientafterbraindeath.Thecasebelowservesto
illustratethisconcern.
MorganWesthoff(OaklandChildren'sHospital,California).InJanuary2013,21montholdMorganWesthoffdiedatOaklandChildren'sHospitalafterallegedmalpracticeinrepairinga
bloodvesselbirthdefect.Morgan'sparentsdidnotdisputethebraindeathdiagnosis.Buttheydidstateconcernforthehospital'smanagementfollowingtheirdaughter'sdiagnosis.First,the
hospitalhadapparentlyliedaboutanautopsy,leavingtheWesthoffsin"hoursofcruelandunjustagony"astheywaitedwiththeirdaughter'sbodyforthecoronertoarrive.Second,the
familyfelt"betrayed,violated,andlost"whentheylearnednoautopsywaseverconducted.Third,thehospitalpressuredthefamilywith"multipleaggressiverequests"todonateMorgan's
organs.Fourth,thehospitalsentrepeatedfundraisingsolicitationsandsurveys.Alawsuitwasthenfiledfornegligentinflictionofemotionaldistress,intentionalinflictionofemotional
distress,andfraudulentmisrepresentation. [47]Ahearingbeforethecourtisstillpendingasofthedateofthiswriting.
PregnancyLimitationsonBrainDeath

Despiteageneraltrendinthelawallowingformaternalautonomysurroundingdecisionsabouttheirhealthalongwithprecedenceprovidingstepbystepguidanceastohowtodecideon
terminationofmedicaltreatment,manystatescontinuetomaintainpregnancyexclusionswithintheiradvancedirectivestatutes. [48]Currently,statesarecategorizedintofiveclassifications

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dependingontheirapproachtotheimpactofpregnancyonlifesustainingtreatment: [48]
1. Lawautomaticallyinvalidatestheadvancedirective(AD)ofawomanwhensheispregnant.
2. LawcontainsrestrictionssimilartotheUniformRightsoftheTerminallyIllAct(URTIA),whichrequiresthatapregnantwomanbeprovidedwith"lifesustainingtreatment"ifitis
"probable"thatthefetuswillreachthepointof"livebirth"regardlessofawoman'sexpresswishestothecontrary.
3. LawconsidersfetalviabilityindeterminingenforceabilityoftheAD.
4. LawallowsforwritingofspecifictreatmentsintheADthatthepregnantwomanwouldaccept.
5. LawissilentontheimpactofpregnancyontheAD.
OnerecentcaseillustratestheapplicationofanADstatutepregnancyclausetoawomanafterbraindeath.
Muozv.JohnPeterSmithHospital(FortWorth,Texas).OnNovember26,2013at2:00am,MarliseMuoz,a33yearoldwomanpregnantwithher14weekoldfetus,wasfound
unconsciousonherkitchenfloor,whereshehadapparentlycollapsedalmost1hourprior. [4951]ShewasrushedtoJohnPeterSmithHospitalinFortWorth,Texas,whereshewas
intubatedandventilatedandmanagedintheintensivecareunit.Shewassoonpronouncedbraindead.Accordingly,herfamily(includingherhusbandandherparents)requestedthatlife
supportmeasuresbediscontinued. [49]AlthoughMarlisehadnotleftanywrittendirectivesregardingendoflifecare,accordingtoherhusband,shehadpreviouslyverbalizedthat"shedidnot
wanttohavemachineskeepherbodyalive." [50]Officialsatthehospital,however,refusedtowithdrawlifesupport,citingaTexasstatelawrequiringthemtomaintainlifesustaining
treatmentforapregnantpatient.
OnJanuary24,2014,almost2monthsaftersufferingherfatalevent,StateDistrictJudgeR.H.Wallaceheldthatthestatuteconcerning"lifesustainingtreatment"didnotapplytoapatient
whowasdead.ThejudgeorderedthehospitaltoterminateMuoz'scardiopulmonarysupport. [52]Intheend,thehospitalacknowledgedthatMuozhadbeenbraindeadsinceNovember28,
2013andthatherfetuswasnotviable. [50,51]

Conclusions
Asreflectedbythesampleofcasesabove,althoughtheconceptofbraindeathhasbeenacceptedfordecades,confusionandconflictstillarise.Thesedisputesanduncertaintiesoften
requirelegaldetermination.Disagreementsonsuchanemotionallytryingtopicasbraindeathwilllikelynevergoaway.Familiesandclinicianswillcontinuetopetitionthecourtsfor
resolution.Itisimperativethathospitalsandpractitionersalikeappreciatethehistoryandnatureofthesedisputesinhopesthattheymaybetterconfrontthisissue,ifandwhenitimpacts
theirpracticewhilealsoassistingfamiliesintheirbetterunderstandingofbraindeath.
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Acknowledgments
TheauthorswishtothankMs.JanetHendersonforhertechnicalassistancewiththismanuscript.
SeminNeurol.201535(2):174179.2015ThiemeMedicalPublishers

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