Simulation-Based Training in Brain Death Determination

MacDougall, Benjamin J.; Robinson, Jennifer D.; Kappus, Liana; Sudikoff, Stephanie N.; Greer, David M.

doi:10.1007/s12028-014-9975-x

Cited by 59 publications

(52 citation statements)

References 9 publications

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“…20 These results were mirrored in a test on DNC given to practicing neurologists, who were able to correctly answer only 54% of questions. 21 It is important for medical students to receive a solid education on this topic and for neurologists and other clinicians who are responsible for declaration of DNC to receive continuing education throughout their careers. Our findings suggest that this education should be focused on both the process of declaration of DNC and the ideal way to handle families who request continuation of organ support after DNC.…”

Section: Solo Practice 21 20mentioning

confidence: 99%

Organ support after death by neurologic criteria

et al. 2016

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Objective: We sought to evaluate how neurologists approach situations in which families request prolonged organ support after declaration of death by neurologic criteria (DNC). Methods:We surveyed 938 members of the American Academy of Neurology (AAN) who treat critically ill patients, including 50% who practice in states with accommodation exceptions (states that require religious or moral beliefs to be taken into consideration when declaring death or discontinuing organ support: California, Illinois, New Jersey, New York), and 50% who practice in nonaccommodation states.Results: The survey was completed by 201/938 individuals (21% response rate), 96 of whom were from accommodation states and 105 of whom were from nonaccommodation states. Both groups reported encountering situations in which families requested continuation of organ support after DNC (48% from accommodation states and 46% from nonaccommodation states). In a hypothetical scenario where a request is made to continue organ support after DNC (outside of organ donation), 48% of respondents indicated they would continue support due to fear of litigation. In reply to an open-ended question, respondents requested that the AAN generate guidelines and advocate to codify laws regarding organ support after DNC, and to improve public and physician education on DNC.Conclusions: Our findings suggest that it is relatively common for neurologists who treat critically ill patients to encounter families who object to discontinuation of organ support after DNC at some point during their career. It would be beneficial for physicians, families, and society to rely on clear medicolegal guidelines on management of this situation. Death by neurologic criteria (DNC) is legally accepted throughout the United States as equivalent to cardiopulmonary death.1 The American Academy of Neurology (AAN) advises that organ support be discontinued after declaration of DNC unless donation is planned, 2 but families sometimes request continuation of support. [3][4][5][6][7][8][9] Four states have legal accommodation exceptions.10-13 New Jersey's statute states that DNC cannot be declared in violation of a patient's religious beliefs.11 In California and New York, hospitals are instructed to make reasonable efforts to accommodate religious or moral objections to DNC. 10,12 In Illinois, hospitals are told to take religious beliefs into account when determining time of death. 13The questions of what constitutes reasonable accommodation and how these situations should be handled in states that do not have accommodation exceptions have left physicians, nurses, administrators, and ethics committees flustered. 3,[7][8][9] Although there are case reports 3-9 on management of objection to DNC, there are no universal legal or medical society guidelines to dictate behavior in these challenging cases. As a result, the frequency of objection to DNC and the manner in which individual centers handle From the

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Section: Solo Practice 21 20mentioning

confidence: 99%

Organ support after death by neurologic criteria

et al. 2016

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“…18,20 Another barrier to performance of accurate determinations is the fact that qualifications for examiners and physician awareness of the intricacies of brain death determination vary. 18,21 Frequent education and reeducation is warranted. This can be accomplished through simulation sessions.…”

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confidence: 99%

“…This can be accomplished through simulation sessions. 21 In addition, a credentialing program for physicians involved in brain death determination could help ensure that evaluations are performed consistently and accurately.…”

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An interdisciplinary response to contemporary concerns about brain death determination

et al. 2018

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In response to a number of recent lawsuits related to brain death determination, the American Academy of Neurology Ethics, Law, and Humanities Committee convened a multisociety quality improvement summit in October 2016 to address, and potentially correct, aspects of brain death determination within the purview of medical practice that may have contributed to these lawsuits. This article, which has been endorsed by multiple societies that are stakeholders in brain death determination, summarizes the discussion at this summit, wherein we (1) reaffirmed the validity of determination of death by neurologic criteria and the use of the American Academy of Neurology practice guideline to determine brain death in adults; (2) discussed the development of systems to ensure that brain death determination is consistent and accurate; (3) reviewed strategies to respond to objections to determination of death by neurologic criteria; and (4) outlined goals to improve public trust in brain death determination.

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“…Important parts of the clinical exam, such as the gag reflex, were not defined in six countries and the apnea test details in four. The number of clinical exams varied from 1 to 3 and the time interval between exams from no minimum to 12 h. The list can go on, but the reader, like the authors, can easily conclude one of two things: that an international consensus on BD determination is imperative and that some clinical competency requirement [5] or check lists (like those used in the operating room or the one provided by the AAN [2]) may put further order into an already chaotic situation.One step in the right direction is the paper by MacDougall et al [6]. The authors describe a BD didactic course and simulation exercise that they developed at Yale.…”

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confidence: 99%

“…One step in the right direction is the paper by MacDougall et al [6]. The authors describe a BD didactic course and simulation exercise that they developed at Yale.…”

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confidence: 99%

Brain Death Determination: Still a Lot to Learn, Still a Lot to Do…

Varelas

2014

Neurocrit Care

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Human life is book-ended by two major events, birth and death. Although all are born the same way, since the invention of ventilators and ICUs humans can die either by cardiorespiratory arrest or by irreversible cessation of all brain functions [the so-called death by neurological criteria or ''brain death (BD) '']. Diagnosing the former is an easy process requiring an electrocardiogram or a stethoscope. Diagnosing the latter, however, is a complex process that requires experience. There is wide-spread variability across countries or across states and hospitals in the US on how patients are pronounced BD [1]. There are also many unanswered questions regarding the BD process and, because of the lack of high-level evidence, continuous challenge of its core notions by a substantial minority of physicians. In fact, few years ago, when the American Academy of Neurology BD Guidelines were revised, and a panel of experts attempted to answer five basic questions, they concluded that in 4/5 questions the level of evidence was U (data inadequate or conflicting) and in 1/4 level C (possibly effective, ineffective, or harmful for the given condition in the specified population) [2]. Therefore, any attempts to conduct quality research and answer questions pertaining to BD are more than welcomed. In this issue of Neurocritical Care, our readers will find four studies that try to address four different BD problems.In the first paper Citerio et al. [3], examined the variability in BD determination in 28 European countries that responded to a survey. Across the Atlantic, variability occurs in State laws, hospital policies, bedside performance of physicians, and documentation of BD [1,4]. Therefore, it is no surprise to report that variability also exists across European countries. Basic prerequisites such as normal core temperature or blood pressure were not required in one and ten countries, respectively. Clinical exam alone was sufficient in 50 % of countries and in the rest some ancillary test was required. Important parts of the clinical exam, such as the gag reflex, were not defined in six countries and the apnea test details in four. The number of clinical exams varied from 1 to 3 and the time interval between exams from no minimum to 12 h. The list can go on, but the reader, like the authors, can easily conclude one of two things: that an international consensus on BD determination is imperative and that some clinical competency requirement [5] or check lists (like those used in the operating room or the one provided by the AAN [2]) may put further order into an already chaotic situation.One step in the right direction is the paper by MacDougall et al. [6]. The authors describe a BD didactic course and simulation exercise that they developed at Yale. A set of questions was administered before the didactic session and after the simulation. The authors report that there was a significant improvement in responses, which initially were correct in only 41.5 % of the time. Interestingly, even neurointensivists (who ostensibly a...

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Simulation-Based Training in Brain Death Determination

Cited by 59 publications

References 9 publications

Organ support after death by neurologic criteria

Organ support after death by neurologic criteria

An interdisciplinary response to contemporary concerns about brain death determination

Brain Death Determination: Still a Lot to Learn, Still a Lot to Do…

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