David M. Greer, Hilary H. Wang, Jennifer D. Robinson, Panayiotis N. Varelas, Galen V. Henderson, Eelco F. M. Wijdicks. Variability of Brain Death Policies in the United States. JAMA Neurol. Published online December 28, 2015. doi:10.1001/jamaneurol.2015.3943.Abstract
Importance Brain death is the irreversible cessation of function of the entire brain, and it is a medically and legally accepted mechanism of death in the United States and worldwide. Significant variability may exist in individual institutional policies regarding the determination of brain death. It is imperative that brain death be diagnosed accurately in every patient. The American Academy of Neurology (AAN) issued new guidelines in 2010 on the determination of brain death.
Objective To evaluate if institutions have adopted the new AAN guidelines on the determination of brain death, leading to policy changes.
Design, Setting, and Participants Fifty-two organ procurement organizations provided US hospital policies pertaining to the criteria for determining brain death. Organizations were instructed to procure protocols specific to brain death (ie, not cardiac death or organ donation procedures). Data analysis was conducted from June 26, 2012, to July 1, 2015.
Main Outcomes and Measures Policies were evaluated for summary statistics across the following 5 categories of data: who is qualified to perform the determination of brain death, what are the necessary prerequisites for testing, details of the clinical examination, details of apnea testing, and details of ancillary testing. We compared these data with the standards in the 2010 AAN update on practice parameters for brain death.
Results A total of 508 unique hospital policies were obtained, representing the majority of hospitals in the United States that would be eligible and equipped to evaluate brain death in a patient. Of these, 492 provided adequate data for analysis. Although improvement with AAN practice parameters was readily apparent, there remained significant variability across all 5 categories of data, such as excluding the absence of hypotension (276 of 491 policies [56.2%]) and hypothermia (181 of 228 policies [79.4%]), specifying all aspects of the clinical examination and apnea testing, and specifying appropriate ancillary tests and how they were to be performed. Of the 492 policies, 163 (33.1%) required specific expertise in neurology or neurosurgery for the health care professional who determines brain death, and 212 (43.1%) stipulated that an attending physician determine brain death; 150 policies did not mention who could perform such determination.
Conclusions and Relevance Hospital policies in the United States for the determination of brain death are still widely variable and not fully congruent with contemporary practice parameters. Hospitals should be encouraged to implement the 2010 AAN guidelines to ensure 100% accurate and appropriate determination of brain death.
The rules for judging when a patient is brain dead vary widely from hospital to hospital, despite the existence of national standards created to ensure accuracy, a new study has found.
The American Academy of Neurology adopted a set of updated guidelines in 2010 for judging whether a person has lost all brain function and is being kept alive solely through hospital machinery, said lead researcher Dr. David Greer, a professor of neurology at the Yale School of Medicine, in New Haven, Conn.
There are no legitimate reports of any patient ever being declared brain dead when they weren't, Greer said, but such judgments need to be made with "100 percent certainty."
"That's why we want to provide a very high level of accountability for this, and that's why we created the guidelines to be so specific, so straightforward and cookbook," Greer said. "Basically, you might call it 'Brain Death For Dummies.' You should be able to take this checklist to the bedside, follow it point by point and be able to get through it."
But hospitals have been slow to adopt the brain death standards in their policies, Greer and colleagues found in a national review.
They reviewed 508 hospital policies regarding brain death, representing hospitals and health systems in all 50 states. The results were published online Dec. 28 in the journal JAMA Neurology. To rule a person brain dead, physicians must make two judgments, Greer said.
They have to prove there's no brain function at all, even to regulate automatic processes in the body. "Even the most basic things such as taking a breath constitutes brain function," he said.
They must also rule out any chance that the person might recover brain function. For example, doctors have to make sure the person isn't suffering from a condition that resembles brain death, Greer said.
"If there's any chance that, by continuing to treat the patient or by eliminating some unknown factor, the patient might retain some brain function, then you don't declare them," he said.
But the rules for both judgments vary widely between hospitals, and often do not stick to the guidelines, researchers found...
Dr. James Bernat, a neurologist with Dartmouth's Geisel School of Medicine in Hanover, N.H., said he was surprised to learn that about one in 10 hospital policies did not require doctors to make sure that a patient can no longer breathe on his or her own before declaring brain death -- otherwise known as an "apnea test."
"That is an absolute requirement," Bernat said. "No one should ever do a brain death determination without an apnea test. Determining apnea is essential."...
"However, there are core requirements that should not be debatable whatsoever," he said. "The core things absolutely have to be there. If there are things stipulated by the state on top of that, then that's fine."
The review researchers are concerned that organ donations could drop off if potential donors become fearful that the proper steps aren't being followed to make sure brain death has occurred, Greer said.
"That's why we're all working together, to make sure this is done right 100 percent of the time," he said. "If the public were to lose faith in what we're doing on the medical side, then that would have disastrous implications for organ donation."
Wahlster S, Wijdicks EF, Patel PV, Greer DM, Hemphill JC 3rd, Carone M, Mateen FJ. Brain death declaration: Practices and perceptions worldwide. Neurology. 2015 May 5;84(18):1870-9.ReplyDelete
To assess the practices and perceptions of brain death determination worldwide and analyze the extent and nature of variations among countries.
An electronic survey was distributed globally to physicians with expertise in neurocritical care, neurology, or related disciplines who would encounter patients at risk of brain death.
Most countries (n = 91, response rate 76%) reported a legal provision (n = 63, 70%) and an institutional protocol (n = 70, 77%) for brain death. Institutional protocols were less common in lower-income countries (2/9 of low [22%], 9/18 lower-middle [50%], 22/26 upper-middle [85%], and 37/38 high-income countries [97%], p < 0.001). Countries with an organized transplant network were more likely to have a brain death provision compared with countries without one (53/64 [83%] vs 6/25 [24%], p < 0.001). Among institutions with a formalized brain death protocol, marked variability occurred in requisite examination findings (n = 37, 53% of respondents deviated from the American Academy of Neurology criteria), apnea testing, necessity and type of ancillary testing (most commonly required test: EEG [n = 37, 53%]), time to declaration, number and qualifications of physicians present, and criteria in children (distinct pediatric criteria: n = 38, 56%).
Substantial differences in perceptions and practices of brain death exist worldwide. The identification of discrepancies, improvement of gaps in medical education, and formalization of protocols in lower-income countries provide first pragmatic steps to reconciling these variations. Whether a harmonized, uniform standard for brain death worldwide can be achieved remains questionable.
The narrow, inscrutable zone between undeniably still here and unequivocally gone includes a range of states that look like life but may not be: a beating heart, a functioning digestive system, even moving fingers and toes. Death is less a moment then a process, a gradual drift out of existence as essential functions switch off, be it rapidly or one by one.ReplyDelete
It was exactly midnight when Colleen Burns was wheeled into the operating room at St. Joseph's Hospital Health Center in Syracuse, N.Y. She had been deep in a coma for several days after overdosing on a toxic cocktail of drugs. Scans of electrical activity in her brain were poor, and oxygen didn't seem to be flowing. Burns was brain dead, her family was told; if they wanted to donate her organs, now was the time to do it.
But there, under the bright lights of the prep room in the OR, Burns opened her eyes. The 41-year-old wasn't brain dead. She wasn't even unconscious anymore. And doctors had been minutes away from cutting into her to remove her organs.
This is the nightmare scenario, the one that sends doctors and neurologists into cold sweats. It's the reason that, in 2010, the American Academy of Neurology issued new guidelines for hospitals for determining brain death — the condition that legally demarcates life from whatever lies beyond. Those standards, according to Yale University neurologist David Greer, who worked on them, are meant to ensure that no patient is declared dead unless they really are beyond all hope of recovery.
"This is truly one of those matters of life and death, and we want to make sure this is done right every single time," he told NPR.