Simulation-Based Training Improves Fellows’ Competence in Brain Death Discussion and Declaration

Abstract

Background: Despite well-defined American Academy of Neurology guidelines for death by whole brain criteria (brain death), there is marked variability in national practice, which some have attributed to lack of formal education. Further, communication with surrogates and families about brain death is integral to brain death declaration. As such, we developed a targeted brain death curriculum combining didactics and simulation-based education to improve examination and subsequent communication skills with families.Methods: Multidisciplinary critical care fellows participated in (1) didactic and case-based curriculum, (2) brain death simulated examination (SimMan3G mannequin), and (3) a standardized family scenario with delivery of a brain death diagnosis to a surrogate "family member". Fellows completed a precurriculum and postcurriculum multiple choice knowledge test and survey (Likert 1 to 10 scale) evaluating measures regarding diagnosis and communication of brain death. t Test and 2-tailed Wilcoxon signed rank test were used for statistical analysis (P < 0.05).Results: Thirteen critical care fellows participated in the curriculum. Most fellows [80% (N = 12)] had only participated in 0 to 5 brain death declarations before this intervention. There was significant improvement across all measures: self-rated knowledge (P = 0.004), perceived knowledge relative to peers (P = 0.002), confidence (P = 0.001), and comfort (P = 0.001) with performing a brain death exam, and comfort with family discussion (P = 0.01). Objective test scores improved from 56 to 73% after simulation (P = 0.004). All fellows found the curriculum beneficial. Conclusion:Trainees may lack sufficient exposure to brain death education. Didactics with simulation-based education can improve objective knowledge and subjective measures of comfort with brain death declaration and surrogate communication.

Curriculum Innovations: How Real Is Real Enough?

“…Our study suggests that novice trainees gain both confidence and medical knowledge in the management of neurocritical care concepts through a simulation course, regardless of whether a standardized patient or manikin-video platform is used. Prior studies in neurology have used manikin-based curricula, 4,6,7,9,10 standardized patient-based curricula, 3 or a hybrid of the 2, 5,8 but this study provided a direct comparison between the 2 platforms.…”

“…There is mounting evidence that simulation training can improve performance in acute ischemic stroke, 3,4 increase trainee knowledge and comfort with brain death testing, [5][6][7][8] and improve adherence (or demonstrate nonadherence) to the epilepsy guidelines for status epilepticus. 9,10 Yet, despite a growing body of evidence that supports simulation training, there remains uncertainty about how best to create an authentic simulated experience for neurology trainees, given that neurologic findings may be difficult to replicate with a manikin.…”

“…9,10 Pioneering studies have used manikin-based curriculum, 4,6,7,9,10 standardized patient-based curriculum, 3 or a hybrid of the 2. 5,8 However, within neurology, it is not known whether knowledge and/or confidence differentially increase when the simulated environment uses a standardized patient or a manikin simulator to portray a conscious patient.…”

The 2023 American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine Pediatric and Adult Brain Death/Death by Neurologic Criteria Determination Consensus Guidelines: What the Critical Care Team Needs to Know*

“…Although many of these courses (e.g., the Neurocritical Care Society's Brain Death Determination Course) require completion of written examinations, there is no universal evaluation or certification process (15). Simulation-based courses can provide valuable handson training and experience with examination techniques, and standardized patients can be used to educate about communication strategies related to BD/DNC (16)(17)(18)(19)(20). Trainees may not perform BD/DNC evaluations independently and must be directly supervised by an attending clinician.…”

Impact of Simulation on Critical Care Fellows’ Electroencephalography Learning

“…Simulation can provide a reproducible learning platform when patient variability would be a confounding factor. Simulation is increasingly being used in education, including in brain death declaration [ 8 ]. Trainees can also have the opportunity to practice on simulators prior to instituting actual patient care, including just-in-time simulation training [ 9 ].…”