LOS ANGELES—The timely and certain determination of brain death is essential, especially when organ transplantation is being considered. However, a recent analysis[1] of brain death declarations made at a large general hospital indicated that physicians are not following the brain death documentation guidelines that were published by the American Academy of Neurology (AAN) in 1995.[2]

“The biggest problem with documentation appears to be the documentation itself,” said Michael Y. Wang, MD, clinical instructor in neurological surgery at the University of Southern California in Los Angeles. “There is frequently a knowledge deficit as well, but many [hospital staff] are fully aware of the criteria and simply either forget or assume that components of the exam are obvious.”

The study involved 58 patients from Los Angeles County General Hospital who were declared brain dead in 1999. Using patient charts, the researchers identified all notes related to the brain death determination. They recorded the number of such notes, the content of the notes, and the time elapsed between notes. The use of confirmatory tests, such as electroencephalography and radionuclide studies, was also determined. Adverse physiological events that occurred after the first note but before the declaration of brain death were identified.

DOCUMENT INCONSISTENT

A total of 121 brain death notes were written: 57 by neurosurgeons, 25 by trauma surgeons, eight by general surgeons, seven by neurologists, 10 by internists, and 14 by physicians on other services.

Of the 11 components accepted by the AAN for use in a complete brain death examination (see Table 1), single-step neurological tests were documented most frequently. For example, pupillary reflexes were documented in 86% of the notes and gag reflexes in 78%. Multistep tests were used less often. Although 76% of the notes contained information about apnea testing, only 28% included caloric testing results. About two thirds of the notes listed temperature and blood pressure readings, but only about one quarter contained toxicology results. No confirmatory tests were performed.

Neurosurgeons were more likely than other physicians to include most of the AAN’s components for brain death determination (median, nine vs six components, respectively). However, neurosurgeons were less likely to record oxygen saturation, toxicology screening, and caloric testing results.

In seven cases, only one set of examination notes was found, and in another case, two brain death examinations were performed simultaneously. In the remaining cases, the time between examinations varied considerably, from less than two hours (in five cases) to more than eight hours (in 17 cases). The time delay between brain death examinations was originally intended to reduce the chances of diagnostic error, but concerns have been raised that prolonged intervals adversely affect donor organs. In this study, the requirement of a second round of examinations had no effect on the viability of donor organs.

A POLICY IS NEEDED

Incomplete assessments of brain function often occur when there is no uncertainty regarding brain death, the researchers acknowledge. However, specific neurological tests should be performed to exclude other possible causes of impaired consciousness.

In the United States, brain death is diagnosed by the “irreversible cessation of all brain function.”[1] There is another approach that is somewhat controversial—the “neocortical” approach, in which brain death is diagnosed by the loss of higher brain function only.[1]

Dr. Wang noted that the AAN’s criteria “are validated by numerous large studies. We … found that they were not being strictly adhered to.” In response to these findings, the study hospital is implementing a standardized checklist for brain death documentation. Neurologist participation will be required in all cases, and physicians and nurses will be educated about the accepted standards for brain death declaration.

“We believe that in the US, the same criteria can be used at all adult hospitals, with certain exceptions being made in pediatric cases,” said Dr. Wang. He and his colleagues are conducting a postintervention follow-up study to determine if educating hospital staff will promote uniformity of documentation.

—Gale Jurasek

References
1. Wang MY, Wallace P, Gruen JP. Brain death documentation: analysis and issues. Neurosurgery. 2002;51:731-736.

2. Wijdicks EFM. Determining brain death in adults. Neurology. 1995;45:1003-1011.

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