Practice variability in brain death determination: a call to action

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.

Figures

Figure 1. Specialty of physician of record determining brain death

Other: trauma surgeon (5), emergency (3), anesthesiologist (1), family practitioner (1), geriatrician (1), transitional year (1), vascular surgeon (1). For subjects with more than one diagnosing physician, the specialties of both physicians were included (n = 250).

Figure 2. Apnea testing and performance of ancillary studies in select subjects

Figure 3. Flowchart evaluating overall adherence to AAN guidelines

*Clinical features include absence of pupillary, corneal, oculocephalic, oculovestibular, gag, and cough reflexes and motor response to pain. AAN = American Academy of Neurology.