David M.Greer, Massachusetts General Hospital, ACC 739A, 55 Fruit Street, Boston, MA, 02114[email protected]
Panayiotis N. Varelas, Shamael Haque, Eelco F.M. Wijdicks
Submitted March 12, 2008
We appreciate the comments of Drs. Powell, Zisfein and Halperin regarding the work done in the state of New York to assess and correct the problem of variability of brain death determination in that state. Their findings appear quite similar to what we found on a nationwide level, and we are pleased to hear that the New York State Department of Health took the problem so seriously, making efforts to provide guidelines that allow more specificity in terms of who can do the determination and what exactly is to be tested.
There are several important aspects of the “key points” mentioned that bear discussion. First, two clinical examinations are not something that is universally required, and it is feasible that one examination by a physician who is competent in the testing would be sufficient. On the other hand, erring on the side of certainty by having more examiners potentially may be helpful, but may not always be possible, depending on the staffing issues of the individual hospital.
Second, we agree that the level of intoxicants should not be at a level that might influence the clinical examination, but that defining exactly what this level is for each medication becomes quite murky.
Third, we would advocate that an ancillary test must be performed in certain clinical situations, and not be optional. These would include a patient too unstable for an apnea test, or one with significant facial trauma precluding the performance of an adequate examination.
Finally, we agree that in this age of limited resources, including the human resources of neurologists and neurosurgeons, having other physicians (e.g. intensivists) who are capable of accurately diagnosis brain death would be helpful in many hospitals.
We agree that there does not need to be absolute uniformity of guidelines for all hospitals, but certain key elements such as the prerequisites for testing, the details of the clinical examination, and the details of the apnea testing should be uniformly agreed upon on a national level, and deviations from these principles not be taken lightly.
Disclosure: Dr. Greer reports receiving speaker honoraria from Boehringer-Ingelheim Pharmaceuticals, Inc. Drs. Varelas reports being a speaker for UCB-Pharma and a consultant for Codman, and an advisor for the Medicines Company. Drs. Haque and Wijdicks report no conflicts of interest.
We appreciate the comments of Drs. Powell, Zisfein and Halperin regarding the work done in the state of New York to assess and correct the problem of variability of brain death determination in that state. Their findings appear quite similar to what we found on a nationwide level, and we are pleased to hear that the New York State Department of Health took the problem so seriously, making efforts to provide guidelines that allow more specificity in terms of who can do the determination and what exactly is to be tested.
There are several important aspects of the “key points” mentioned that bear discussion. First, two clinical examinations are not something that is universally required, and it is feasible that one examination by a physician who is competent in the testing would be sufficient. On the other hand, erring on the side of certainty by having more examiners potentially may be helpful, but may not always be possible, depending on the staffing issues of the individual hospital.
Second, we agree that the level of intoxicants should not be at a level that might influence the clinical examination, but that defining exactly what this level is for each medication becomes quite murky.
Third, we would advocate that an ancillary test must be performed in certain clinical situations, and not be optional. These would include a patient too unstable for an apnea test, or one with significant facial trauma precluding the performance of an adequate examination.
Finally, we agree that in this age of limited resources, including the human resources of neurologists and neurosurgeons, having other physicians (e.g. intensivists) who are capable of accurately diagnosis brain death would be helpful in many hospitals.
We agree that there does not need to be absolute uniformity of guidelines for all hospitals, but certain key elements such as the prerequisites for testing, the details of the clinical examination, and the details of the apnea testing should be uniformly agreed upon on a national level, and deviations from these principles not be taken lightly.
Disclosure: Dr. Greer reports receiving speaker honoraria from Boehringer-Ingelheim Pharmaceuticals, Inc. Drs. Varelas reports being a speaker for UCB-Pharma and a consultant for Codman, and an advisor for the Medicines Company. Drs. Haque and Wijdicks report no conflicts of interest.