Second Brain Death Exam Increases Anguish, Decreases Organ Donation

Susan Jeffrey

December 15, 2010

December 15, 2010 — A new study suggests a single examination is sufficient to determine brain death in 100% of patients, calling into question the need for a second neurologic examination.

Results showed that of more than 1,300 adults and children who were declared dead at a first examination in any of 100 New York hospitals, none regained brainstem function at the subsequent examination.

Furthermore, the state-recommended 6 hours between examinations was more like 19 hours in practice, needlessly increasing family anguish and ICU costs, and decreasing both the number of organs suitable for donation and the willingness of families to donate them.

Lead author on the study is Dana Lustbader, MD, from the New York University School of Medicine and North Shore University Hospital in Manhasset.

"This paper, coupled with the American Academy of Neurology (AAN) brain death guidelines, is really a game-changer, and it really must force all hospitals, nationally and internationally, to look at brain death policies and revise them to a single exam," Dr. Lustbader told Medscape Medical News. "There's simply no reason for a second exam, and now we see how harmful a second exam can be."

Their findings are published online December 15 and will appear in the January 11, 2011, issue of Neurology.

2 Examinations Mandated

The AAN guidelines, published in June of this year, already require only 1 examination (Neurology. 2010; 74:1911-1918). "Some people may object, but we found that 1 exam was sufficient," guideline coauthor Gary Gronseth, MD, from the University of Kansas, Kansas City, told Medscape Medical News at that time.

The New York State Department of Health convened an expert panel in 2005 that published recommendations calling for a single apnea test and 2 clinical brain death examinations separated by an arbitrary 6-hour observation period, a recommendation that is now a requirement in all New York hospitals, the study authors write.

"We wanted to see how close were we to the 6-hour interval (between exams) and what if any was the impact of a delay in brain death diagnosis on organ donation rates," Dr. Lustbader said.

To look at this question, they reviewed data on 1229 adult and 82 pediatric patients pronounced dead in hospitals serviced by the New York Organ Donor Network between June 1, 2007, and December 31, 2009. They reviewed the interval between examinations and related it to the day of the week, hospital size, and organ donation.

"We were stunned to find that the average interval between the 2 examinations was 19 hours," she said. "This was just shocking to us because, not only does this reduce organ donation rate, but it's horrendous for families to have this additional anguish and uncertainty while they're going through this prolonged process."

The median interval was 18.5 hours but ranged from 3 to 50 hours. Consent for organ donation decreased from 57% to 45%, and refusal of organ donation increased from 23% to 36% as the interval between examinations increased.

Moreover, a total of 166 patients, or 12%, had cardiac arrest between examinations, "so the opportunity for organ donation goes to zero for those patients," she said.

They found a significant correlation between hospital size and the interval between examinations, with a 19.9-hour interval seen in hospitals up to 750 beds vs 16 hours for hospitals with more than 750 beds (P = .0015).

Finally, they also found an effect by day of the week, with a lower frequency of brain death examinations and a longer interval between examinations seen on the weekends compared with during the week. "This either suggests weekend procrastination or avoidance in brain death diagnosis or reduced availability of qualified examiners to do the exam," Dr. Lustbader noted.

Since finding these results, the study authors met with and made a recommendation to the New York State Task Force on Life and the Law to revise their 2005 brain death guidelines to conform to the new AAN 2010 brain death guidelines supporting 1 examination, she added.

"We believe they will revise their guidelines in support of a single brain death examination."

'Significant Harm' in Delay

In an editorial accompanying the publication, Gene Sung, MD, MPH, from the University of Southern California, Los Angeles, and David Greer, MD, from Yale University School of Medicine, New Haven, Connecticut, write that although the intent of the state-mandated time interval is "reasonable" — to allow assessment of stability of measures over time — implementation was not always "feasible, given the realities of intensive care."

These new data are "crucial" to help standardize approaches to the determination of brain death.

"There is significant harm in the delay of proper brain death diagnosis from a moral and ethical standpoint, not to mention the extra economic costs of prolonged hospital stay and resources," they write.

Organ viability also decreases the longer the patient is brain dead, secondary to hormonal, hemodynamic, and inflammatory changes that may particularly affect kidneys and livers, they note.

"This study helps build the case for a single competent brain death examination or ancillary study when the examination cannot be performed," they conclude.

Dr. Lustbader is a consultant for the American Board of Internal Medicine and serves on the Test Writing Committee for Palliative Medicine. Disclosures for coauthors appear in the article. Dr. Sung serves as an associate editor for Neurocritical Care and serves on speakers' bureaus for Boehringer Ingelheim, Sanofi-Aventis, and EKR Therapeutics Inc. Dr. Greer receives royalties from the publication of Acute Ischemic Stroke: An Evidence-Based Approach (Wiley and Sons, 2007), has served on the speaker's bureau and received research support from Boehringer Ingelheim, and has served as a consultant in medicolegal cases.

Neurology. Published online December 15, 2010.

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