What’s New in the Patient Safety World

February 2019

Call for Uniform Braindeath Criteria

 

 

The American Academy of Neurology (AAN), the American Neurological Association (ANA), and the Child Neurology Society (CNS) have issued a position statement calling for laws to require a uniform definition of brain death (Russell 2019). They endorse legislation modeled after a Nevada statute, which specifically defers to current adult and pediatric Brain Death Guidelines and any future updates.

 

This is an issue near and dear to our hearts. Dr. Truax, along with Dr. Rick Munschauer, co-authored New York State’s first braindeath determination criteria in the mid-1990’s. These arose out of very practical considerations. At the University of Buffalo we had a consortium of teaching hospitals. Our neurology residents rotated through 6 hospitals. Unfortunately, they encountered different policies and approaches to braindeath determination at each hospital. That led us to convene local stakeholders to develop a uniform policy and approach for all our consortium hospitals.

 

Shortly after we had developed our local consortium guidelines, the New York State Department of Health convened a group of representatives from all over New York to address this issue. Dr. Fred Plum chaired the group’s sessions. We ended up adopting statewide the Buffalo criteria with a few modifications. These were the first official guidelines in New York. Dr. Truax subsequently served as the Department of Health’s spokesperson on the criteria for the next 10 years.

 

While the need for uniformity was the most compelling reason for development of such criteria, there were other important considerations as well. Prior to that work, most neurologists and neurosurgeons informally used the “Harvard criteria”, which had been developed years earlier. The Harvard criteria, in addition to demonstration of cessation of all brainstem and cortical function, required 2 EEG’s done 24 hours apart that demonstrated no evidence of electrocortical activity. They also required 2 neurological exams (24 hours apart) and that 2 neurologists or neurosurgeons be involved in confirmation of braindeath.

 

That led to several problems. One was that it had implications for organ donation and organ procurement (the long delay sometimes led to lack of viability of organs that might have been donated). The other major issue was that not all hospitals had ready availability of EEG’s and many, particularly small rural hospitals, did not have access to 2 neurologists or even any neurologists or neurosurgeons.

 

So, the criteria we developed included the usual bedside clinical determination of absence of both cortical and brainstem function and demonstration of lack of respiration when there was an adequate physiologic stimulus that should have caused respiration (we developed recommendations as to how to appropriately perform and interpret the apnea test). And we allowed use of a test demonstrating lack of intracerebral blood flow as a confirmatory test that might be particularly useful in those cases where adequate assessment of brainstem function was not possible (eg. in a patient with severe facial trauma). Of course, the criteria also required that factors such as hypothermia or presence of CNS depressant drugs be excluded. In practice, the criteria reduced the minimum period required for determination of braindeath from 24 hours down to 6 hours.

 

There was also another confounding factor. Though New York State already had a statute that stated braindeath equated to death (i.e. that once someone was declared braindead, they were officially dead), there were certain religious or cultural groups that did not accept the concept of braindeath. Hence, we required that all hospitals have in place a special accommodations for families of such religions. Usually this meant allowing families some time to spend with the patient after declaration of braindeath before the patient was actually removed from ventilatory support. Hospitals were required to specify what other treatments (IV fluids, feedings, antibiotics, vasopresors, etc.) would be suspended during that period.

 

New York State modified the braindeath determination criteria somewhat in the mid-2000’s and the AAN (American Academy of Neurology) published its updated braindeath determination criteria in 2010.

 

The new position paper states “The brain death standards for adults and children that are now widely accepted and used are the AANs 2010 Evidence-Based Guideline Update: Determining Brain Death in Adults (Wijdicks 2010) and the 2011 Guidelines for the Determination of Brain Death in Infants and Children (Nakagawa 2011), issued by the Pediatric Section of the Society of Critical Care Medicine, the Sections of Neurology and Critical Care, the American Academy of Pediatrics and the Child Neurology Society.”

 

The current call for legislation is for all states to develop statutes that adopt the above criteria. To date, apparently only Nevada has formally adopted those criteria and gudelines.

 

AAN acknowledges that braindeath determination is a basically a clinical determination and that the primary role of any ancillary testing is to serve as a surrogate when portions of the clinical exam cannot otherwise be performed (for example, as above, due to severe facial trauma). AAN also reaffirms that, while accommodating for religious or cultural beliefs, there is no ethical obligation to provide medical treatment to a deceased person. The AAN position paper has a good discussion about how to handle such accommodations. It also makes recommendations for transfer of care when a physician has objections to the braindeath determination concept based on religious or moral conscience.

 

AAN also encourages the development of programs that train and credential physicians who determine brain death and that public and professional education be provided regarding brain death and its determination. We mentioned before that some small, rural hospitals may not have a neurologist or neurosurgeon on staff to make braindeath determnations. But each hospital can have other physicians trained to do braindeath determinations. We do recommend that each hospital not only adopt the criteria but specify which physicians will be credentialled and privileged to do those determinations and what criteria will be required for that credentialing.

 

We concur with the AAN position paper that it is desirable that all states adopt legislation that would make the determination and process for braindeath determination uniform throughout the US.

 

 

References:

 

 

Russell JA, Epstein LG, Greer DM, et al. on behalf of the Brain Death Working Group. Brain death, the determination of brain death, and member guidance for brain death accommodation requests. AAN position statement. Neurology 2019; Published ahead of print January 02, 2019

http://n.neurology.org/content/neurology/early/2019/01/02/WNL.0000000000006750.full.pdf

 

 

Wijdicks EF, Varelas PN, Gronseth GS, Greer DM. Evidence-based guideline update: determining brain death in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2010 ; 74(23): 1911-1918 First published June 7, 2010

http://n.neurology.org/content/74/23/1911.long

 

 

Nakagawa TA, Ashwal S, Mathur M, Mysore M, the Society of Critical Care Medicine, Section on Critical Care and Section on Neurology of the American Academy of Pediatrics, and the Child Neurology Society. Guidelines for the Determination of Brain Death in Infants and Children: An Update of the 1987 Task Force Recommendations. Pediatrics 2011; 128(3):

http://pediatrics.aappublications.org/content/128/3/e720

(reaffirmed April 2015) Pediatrics 2015; 135(4): 31105

http://pediatrics.aappublications.org/content/135/4/e1105

 

 

 

 

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