Practice variability in brain death determination

Abstract

Objective: To characterize the present state of brain death (BD) determination in actual practice relative to contemporary American Academy of Neurology (AAN) guidelines. Methods:We reviewed the charts of all adult (16 years and older) BD organ donors during 2011 from 68 heterogeneous hospitals in the Midwest United States. Data were collected across 5 categories: guideline performance, preclinical testing, clinical examination, apnea testing, and use of ancillary tests. Practice within categories and overall adherence to AAN guidelines were assessed.Results: Two hundred twenty-six BD organ donors were included. Practice exceeded recommendations in guideline performance but varied widely and deviated from AAN guidelines in all other categories. One hundred two (45.1%) had complete documentation of brainstem areflexia and absent motor response. One hundred sixty-six (73.5%) had completed apnea testing. Of the 60 without completed apnea testing, 56 (93.3%) had ancillary tests consistent with BD. Overall, 101 (44.7%) strictly and 84 (37.2%) loosely adhered to contemporary AAN guidelines.Conclusions: There is wide variability in the documentation of BD determination, likely reflecting similar variability in practice. This is a call for improved documentation, better uniformity of policies, and comprehensive and strategically targeted educational initiatives to ensure consistently contemporary approaches to BD determination in every patient. In 1981, the Uniform Determination of Death Act defined brain death (BD) as the "irreversible cessation of all functions of the entire brain, including the brain stem" with the same legal and medical legitimacy as the traditional cardiopulmonary standard, but only asserted that the determination be made "in accordance with accepted medical standards."1 Time has led to expanding awareness and acceptance of BD worldwide.2 The American Academy of Neurology (AAN) published and revised practice parameters in 1995 and 2010, respectively. 3,4 It has been shown that official hospital policies for determining BD at top-rated neurology departments vary widely and often deviate from AAN guidelines in multiple domains of the process. 5 The absence of clear and uniform expectations could hypothetically predispose to misdiagnosis or, conversely, deter unfamiliar physicians from pursuing the diagnosis altogether. Furthermore, the variability in official policies may perpetuate confusion about BD, create ambivalence about the importance of BD determination, 6 and hinder the manner in which it is explained to grieving families.The lack of uniformity among institutional policies does not necessarily reflect variability in approaches to BD determination in practice. To date, there is no systematic study that has scrutinized approaches to BD determination in actual practice.Our study examined the approaches to BD determination in adults (16 years and older) at a cross-section of regional academic and nonacademic medical centers in the Midwestern United

Practice variability in brain death determination: A call to action

“…1 The data are not sufficient to draw this conclusion. Age at onset studies conducted in a single disease group cannot indicate associations with risk factors because the age at onset depends on the age distributions of the groups from which the participants are selected in the source population.…”

“…Noam Y. Stadlan, Skokie, IL: Shappell et al 1 highlighted the problems concerning determinations of death. If documentation reflects reality, some patients were declared dead with neither an apnea test nor confirmatory testing.…”

Radionuclide Evaluation of Brain Death in the Post-McMath Era

“…A recent examination of 508 major U.S. hospitals demonstrated wide variability in brain death policies, which were not fully congruent with contemporary practice parameters (26). A chart review of 226 brain-dead organ donors at 68 heterogeneous hospitals in the Midwest United States revealed that documentation was often incomplete, likely reflecting actual variability in practice (58). Adherence to contemporary AAN guidelines was followed strictly in only 45% of patient records and loosely in 37%.…”

Current controversies: Physicians vs Pharma

“…Authors Respond: Daryl Story, MD, Stephen Winter, MD: In an era where there is still wide variability in the process for determining brain death, 7 we welcome the comments our report has produced.…”