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Original Investigation |

Variability of Brain Death Policies in the United States

David M. Greer, MD, MA1; Hilary H. Wang, BA1; Jennifer D. Robinson, APRN1; Panayiotis N. Varelas, MD, PhD2; Galen V. Henderson, MD3; Eelco F. M. Wijdicks, MD, PhD4
[+] Author Affiliations
1Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
2Department of Neurology, Henry Ford Hospital, Detroit, Michigan
3Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
4Department of Neurology, Mayo Clinic, Rochester, Minnesota
JAMA Neurol. 2016;73(2):213-218. doi:10.1001/jamaneurol.2015.3943.
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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.

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Figure 1.
Type of Health Care Professional Performing Brain Death Determination

Types and qualifications of health care professionals performing determination of brain death, with larger circles representing more of that type of health care professionals.

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Figure 2.
Prerequisites for Clinical Testing

The prerequisites prior to performing determination of clinical brain death are shown here, with their relative percentages as found in the policies.

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Figure 3.
Specifics of Clinical Examination Requirements

The details of the clinical examination as stipulated in the policies are represented here.

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Figure 4.
Specifics of Apnea Testing Requirements

Specific criteria for determination of brain death pertaining to the apnea test are shown here.

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Figure 5.
Specifics of Ancillary Testing

A, When to perform ancillary testing. B, Which ancillary tests to perform. Specifics mentioned are shaded in the darker shade.

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