MORE ABOUT THE DETERMINATION OF DEATH BY NEUROLOGIC CRITERIA

Lewis et al. published an important and timely necessary article about the determination of death by neurological criteria, revising the Uniform Determination of Death.The acceptance of brain death (BD) has been progressively accepted beginning at the late 1950s. Nonetheless, contentious brain-death cases have recently raised new controversies about the diagnosis of BD, such as the Jahi McMath case, extensively covered by the US and international press. Jahi McMath meant a terrible tragedy for her and her family. But further than this gloomy story, the case has also raised confusion and challenging qualms about a fundamental query: how we confirm whether a person is dead or alive? Since 1981, the Uniform Determination of Death Act (UDDA) has served as the legal foundation for the medical practice of determining death. But, although death by neurologic criteria is considered legal death throughout the United States, several recent lawsuits have quizzed the rightfulness the authority of the UDDA to declare death by neurological criteria. This issue explains the importance of Lewis’s et al. paper. In this article I want to present the historical procedure for issuing a law in Cuba for the determination and certification of death. Of course, it is impossible to compare our country with USA. Cuba is a small and developing country, in which a law encompasses a national scenery, in contrast with USA, a multistate nation.

The acceptance of brain death (BD) has been progressively accepted beginning at the late 1950 s . [2][3][4][5][6][7][8][9][10][11][12][13] Nonetheless, contentious brain-death cases have recently raised new controversies about the diagnosis of BD, such as the Jahi McMath case, extensively covered by the US and international press. [14][15][16][17][18][19][20][21][22][23][24] . Jahi McMath meant a terrible tragedy for her and her family. But further than this gloomy story, the case has also raised confusion and challenging qualms about a fundamental query: how we confirm whether a person is dead or alive? 20,23,[25][26][27][28] Since 1981, the Uniform Determination of Death Act (UDDA) has served as the legal foundation for the medical practice of determining death. 29,30 But, although death by neurologic criteria is considered legal death throughout the United States, several recent lawsuits have quizzed the rightfulness the authority of the UDDA to declare death by neurological criteria. 18,[31][32][33][34][35][36] This issue explains the importance of Lewis's et al. paper. 1 In this article I want to present the historical procedure for issuing a law in Cuba for the determination and certification of death. 20,24,[37][38][39][40][41][42][43] Of course, it is impossible to compare our country with USA. Cuba is a small and developing country, in which a law encompasses a national scenery, in contrast with USA, a multistate nation.

The Civil Code
The Cuban Civil Code has undergone several historical changes regarding the determination of death. 24,25,40,42,44 The Spanish Civil Code, established in Cuba since 1889, stated in Article 31:   Ministry of Public Health to legalize the determination and certification of death.

Law Within a Ministry
According to the Cuban Parliament, a resolution is a law that legalizes a working standard within any ministry and that could be signed and changed by the minister in function.  Fig 1). 43 The main body of the norm contained the following points: 40,43 :  Physicians diagnose death by documenting the "signs of death."  When the diagnosis of death is based on the irreversible loss of whole brain functions, medical specialists need to be accredited by the National Commission for the Determination and Certification of Death.
 Death is certified by the physician who diagnoses it. Physicians will register the moment of death upon completing the diagnostic procedure.
 The commission will annually review the diagnostic criteria of death and will propose changes or amendments, according to medical and technological advances in this area.

Diagnosis of Death
The National Commission accepted only one kind of death 39,40,45 : The irreversible loss of whole brain functions, including the brainstem and the cerebral hemispheres.
The Commission also recommended to consider my new definition of death, based on the patho-physiological mechanism for generation of consciousness: [46][47][48] Irreversible VI-Cadaveric spasm.
VII-Loss of muscle contractions.
The commission adopted the view that the irreversible loss of cardiocirculatory and respiratory functions can only cause death when ischemia and anoxia are prolonged enough to produce an irreversible los of functions of the whole brain. 40,[49][50][51] Physicians diagnose death by finding the "signs of death." Signs I and II correspond to the classic respiratory and cardiocirculatory functions, which can be applied in scenarios without an intensive care setting. Signs III to VIII are related to forensic circumstances. Sign IX corresponds to BD diagnosis The description of the way to assess the signs of death, including BD diagnosis, according to our Commission is outside the scope of this article, and can be found elsewhere. . 38,40,[49][50][51][52] The Commission also stated that any legal code of death should be completely separate from any norm governing organ transplants. In fact, in our legal norm, the word "transplant" is not cited. 43

Final remarks
Lewis et al. 1 also clearly discussed the question about pituitary/hypothalamic function preservation in suspected brain-dead cases. 54,55 In the case of Jahi McMath, the family's legal position assured that she was alive because in large part on continued hormonal function manifested by menstruation. 18,[21][22][23] On the contrary, I assured that Jahi McMath was not braindead, because ancillary tests performed 9 months after initial brain insult, showed conservation of intracranial structures, EEG activity, and autonomic reactivity to "Mother Talks" stimulus. I concluded that Jahi McMath represented a new state of disorder of consciousness, non-previously described, that I have termed: "responsive unawake syndrome" (RUS). 20,24,56 Nonetheless, the preservation of hormonal function in BD deserves further attention. [57][58][59] It is necessary to finally remark that, although there is only one kind of human death, based on the irreversible loss of functions of the whole brain, there are several ways of diagnosing death, according to the scenario where death occurs.