Variability of Brain Death Policies in the United States

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.

An interdisciplinary response to contemporary concerns about brain death determination

“…11,18,19 Protocols have varying descriptions of prerequisites, ancillary testing, and apnea testing. 18 Despite significant improvements in compliance with AAN guidelines in recent years, institutional protocols still deviate from the AAN practice guideline.…”

“…11,18,19 Protocols have varying descriptions of prerequisites, ancillary testing, and apnea testing. 18 Despite significant improvements in compliance with AAN guidelines in recent years, institutional protocols still deviate from the AAN practice guideline. 19 Reasons for these variances should be explored and education should be provided to promote standardization in order to avoid false-positive or false-negative brain death determinations.…”

“…One method to generate consistency is for an appropriate regulatory authority such as the Joint Commission to review hospital protocols, similar to that which occurs during stroke center certification. 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.…”

“…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.…”

Radionuclide Evaluation of Brain Death in the Post-McMath Era

“…Reviews of the current medical literature periodically appear (13)(14)(15)(16), and updated guidelines have been issued by professional societies (17)(18)(19)(20)(21). Despite these resources, surveys have repeatedly shown that many physicians exhibit a poor understanding of the underlying concepts (22,23) and that even carefully formulated practice guidelines are inconsistently adopted (7,(24)(25)(26), indicating a persistent gap in knowledge and training (27,28). The topic of brain death has entered into the public's consciousness, albeit in a distorted manner (29,30); physicians must therefore contend with families' erroneous notions, which are based, at least in part, on inaccurate or sensational media reports (31).…”