Brain Death Guidelines Vary at Top US Neurological Hospitals

Susan Jeffrey

January 31, 2008

January 31, 2008 — A new survey shows wide variation in brain death guidelines among leading neurological institutions in the United States, differences that may have implications for the determination of death and initiation of transplant procedures, the researchers say.

Under the Uniform Determination of Death Act, guidelines for brain death determination can be developed at the institutional level, leading to potential variability in practice, David M. Greer, MD, from Massachusetts General Hospital, in Boston, and colleagues report. Although there are guidelines on brain death determination from the American Academy of Neurology (AAN), they are not binding at the local level.

Results of this survey, published in the January 22 issue of Neurology, now suggest that substantial variation is in fact present even among top US hospitals.

"It was very concerning that there was a huge mismatch between what is set forth in the practice parameters from the AAN and what is actually being stipulated at local hospitals," Dr. Greer told Medscape Neurology & Neurosurgery when their findings were first presented in October 2007 at the 132nd Annual Meeting of the American Neurological Association.

Although it is possible that actual performance at these hospitals is better than what is suggested by the protocols, he noted, "We have no evidence of that."

Top 50 Hospitals

For the study, the authors requested the guidelines for determination of death by brain criteria from the US News and World Report top 50 neurology/neurosurgery institutions in 2006. There was an 82% response rate to their request, from 41 institutions, but 3 did not have official guidelines, leaving protocols from 38 hospitals for evaluation.

The guidelines were evaluated for 5 categories of data: guideline performance, preclinical testing, clinical examination, apnea testing, and ancillary tests. They compared the guidelines directly with the AAN guidelines for consistencies and differences.

"Major differences were present among institutions for all 5 categories," the authors write. "Variability existed in the guidelines' requirements for performance of the evaluation, prerequisites before testing, specifics of the brain-stem examination and apnea testing, and what types of ancillary tests could be performed, including what pitfalls and limitations might exist."

For example, with regard to preclinical testing, it was surprising to find that the cause of brain death was not stipulated in a large number of guidelines, they note. "Of concern was the variability in the apnea testing, an area with the greatest possibility for inaccuracies, indeterminate testing, and potentially even danger to the patient," they note. "This included variability of temperature, drawing of an [arterial blood gas sample] ABG prior to testing, the proper baseline [partial pressure carbon dioxide] pCO2, and technique for performing the test. Although a final pCO2 level was commonly stated (most often 60 mm Hg), specific guidelines in a situation of chronic CO2 retention, clinical instability, or inconclusive testing were commonly lacking. A surprising number (13%) of guidelines did not specify that spontaneous respirations be absent during the apnea test."

In the category of guideline performance, there was a "surprisingly low rate of involvement of neurologists or neurosurgeons in the determination." Further, the requirement that an attending physician be involved was "conspicuously uncommon."

"Given a technique with some complexity as well as potential medical-legal implications, we find it surprising that more institutions did not require a higher level or more specific area of expertise," they write.

Their findings suggest that stricter AAN guidelines may be order, they conclude. "Given the fact that the guidelines put forth by the AAN are now 13 years old, perhaps now is the time that they be rewritten, with an emphasis on a higher degree of specific detail in areas where there is greater variability of practice. Furthermore, perhaps now there should be standards by which individual institutions area held more accountable for their closeness to, or variability from, national guidelines."

Coauthors on the study were Panayoitis Varelas, MD, PhD, and Shamael Haque, DO, from Henry Ford Hospital, in Detroit, Michigan, and Eelco Wijdicks, MD, PhD, from the Mayo Clinic, in Rochester, Minnesota.

A "Disturbing Pattern of Nonuniformity"

In an editorial accompanying the paper, James L. Bernat, MD, from Dartmouth-Hitchcock Medical Center, in Lebanon, New Hampshire, points out that Greer and colleagues have shown that "physicians declaring brain death in leading neurology departments in the United States practice with a disturbing pattern of nonuniformity."

Some of these variations are inconsequential, he notes, but some could make a serious difference in outcomes. "Practices that do not require demonstrating an anatomic lesion sufficient to explain the clinical findings, do not rigorously exclude potentially reversible metabolic and toxic factors, do not properly test brain-stem function, or do not require proper apnea testing are consequential because they could yield an incorrect determination of death," he writes.

Although brain death has to be determined correctly to maintain confidence in high-quality medical care and the organ-procurement enterprise, he writes, in addition to accuracy, "it is desirable to achieve a uniformity of practice using the optimal guidelines."

"I suggest that the AAN, the American Neurological Association, and Child Neurology Society jointly empanel a task force to draft evidence-based guidelines, including specific recommendations for conducting the clinical and confirmatory tests for brain death," Dr. Bernat continues. "Once these guidelines have been accepted and published, neurologists should act as envoys to ensure that they become incorporated into hospital policies throughout the country and help implement them locally."

This task force could also update the guidelines at intervals to accommodate emerging technologies as they are validated, such as noninvasive neuroimaging tests measuring the absence of intracranial blood flow, he writes. "The most daunting global problem of establishing worldwide uniformity of brain death guidelines is a task for the World Federation of Neurology."

Dr. Greer reports receiving speaker honoraria from Boehringer-Ingelheim Pharmaceuticals Inc. Disclosures for coauthors appear in the paper.

Neurology. 2008;70;284-289 Abstract, 252-253. Abstract

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