Variability of brain death determination guidelines in leading US neurologic institutions
TiaPowell, New York State Task Force on Life & the Law, 90 Church Street, 15th Floor, New York, NY 10007tpp03@health.state.ny.us
James Zisfein, John Halperin
Submitted March 12, 2008
We appreciate the article by Greer et al. [1] Similar concerns led to a major review of brain death determinations in New York State and the release of updated guidelines for such determinations.
Brain death policies from facilities across New York were collected by the New York Organ Donor Network and revealed numerous significant differences across institutions and deviations from accepted guidelines. Variations included: the number of different professionals required, interval between determinations, role of ancillary testing, and timing of apnea tests. Some institutional policies had requirements that could delay or even prevent the diagnosis of brain death, such as waiting periods of 24 hours or more. The New York State Department of Health (NYSDOH) was concerned by this degree and type of variability.
In November 2004, NYSDOH convened a Brain Death Guideline Panel composed of external experts in conjunction with the New York State Task Force on Life & the Law, the state-level bioethics committee. This panel reviewed existing standards (including the 1995 AAN report [2]) and applicable state law and derived guidelines for the determination of brain death disseminated throughout New York State in December, 2005. [3]
Some key points are: (1) two clinical exams that document the absence of brain functions during a six-hour observation period, with a single apnea test at the end of that period, is adequate for diagnosis of brain death in most cases; (2) levels of intoxicants need not be zero but simply in a range not expected to “interfere significantly” with consciousness; (3) a confirmatory test (e.g., cerebral blood flow determination) is not routinely required but can be used when the diagnosis of brain death is uncertain on clinical grounds; and (4) physicians who diagnose brain death must be privileged for that task but there is no specific requirement for a neurologist or neurosurgeon; only one privileged physician is needed to make the diagnosis.
We do not believe that all hospital policies on brain death must be identical. However, variability should be based on local issues such as availability of ancillary tests and procedures for conflict resolution. On the basic principles of how brain death is diagnosed, we agree with Bernat that uniformity is a desirable goal. [4]
References
1. Greer DM, Varelas PN, Haque S, Wijdicks E. Variability of brain death determination guidelines in leading US neurologic institutions. Neurology 2008;70:284-289.
2. Practice parameters for determining brain death in adults (summary statement). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 1995;45:1012–1014.
3. New York State Guidelines for Determining Brain Death, December 2005. http://www.health.state.ny.us/professionals/hospital_administrator/determination_of_brain_death/
4. Bernat JL. How can we achieve uniformity in brain death determinations? Neurology 2008; 70: 252-253.
Disclosure: The authors report no conflicts of interest.
We appreciate the article by Greer et al. [1] Similar concerns led to a major review of brain death determinations in New York State and the release of updated guidelines for such determinations.
Brain death policies from facilities across New York were collected by the New York Organ Donor Network and revealed numerous significant differences across institutions and deviations from accepted guidelines. Variations included: the number of different professionals required, interval between determinations, role of ancillary testing, and timing of apnea tests. Some institutional policies had requirements that could delay or even prevent the diagnosis of brain death, such as waiting periods of 24 hours or more. The New York State Department of Health (NYSDOH) was concerned by this degree and type of variability.
In November 2004, NYSDOH convened a Brain Death Guideline Panel composed of external experts in conjunction with the New York State Task Force on Life & the Law, the state-level bioethics committee. This panel reviewed existing standards (including the 1995 AAN report [2]) and applicable state law and derived guidelines for the determination of brain death disseminated throughout New York State in December, 2005. [3]
Some key points are: (1) two clinical exams that document the absence of brain functions during a six-hour observation period, with a single apnea test at the end of that period, is adequate for diagnosis of brain death in most cases; (2) levels of intoxicants need not be zero but simply in a range not expected to “interfere significantly” with consciousness; (3) a confirmatory test (e.g., cerebral blood flow determination) is not routinely required but can be used when the diagnosis of brain death is uncertain on clinical grounds; and (4) physicians who diagnose brain death must be privileged for that task but there is no specific requirement for a neurologist or neurosurgeon; only one privileged physician is needed to make the diagnosis.
We do not believe that all hospital policies on brain death must be identical. However, variability should be based on local issues such as availability of ancillary tests and procedures for conflict resolution. On the basic principles of how brain death is diagnosed, we agree with Bernat that uniformity is a desirable goal. [4]
References
1. Greer DM, Varelas PN, Haque S, Wijdicks E. Variability of brain death determination guidelines in leading US neurologic institutions. Neurology 2008;70:284-289.
2. Practice parameters for determining brain death in adults (summary statement). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 1995;45:1012–1014.
3. New York State Guidelines for Determining Brain Death, December 2005. http://www.health.state.ny.us/professionals/hospital_administrator/determination_of_brain_death/
4. Bernat JL. How can we achieve uniformity in brain death determinations? Neurology 2008; 70: 252-253.
Disclosure: The authors report no conflicts of interest.