Dead is dead. Right?

From JAMA Neurology, “Variability of Brain Death Policies in the United States“:

Importance  Brain death is the irreversible cessation of function of the entire brain, and it is a medically and legally accepted mechanism of death in the United States and worldwide. Significant variability may exist in individual institutional policies regarding the determination of brain death. It is imperative that brain death be diagnosed accurately in every patient. The American Academy of Neurology (AAN) issued new guidelines in 2010 on the determination of brain death.

Objective  To evaluate if institutions have adopted the new AAN guidelines on the determination of brain death, leading to policy changes.

Design, Setting, and Participants  Fifty-two organ procurement organizations provided US hospital policies pertaining to the criteria for determining brain death. Organizations were instructed to procure protocols specific to brain death (ie, not cardiac death or organ donation procedures). Data analysis was conducted from June 26, 2012, to July 1, 2015.

Main Outcomes and Measures  Policies were evaluated for summary statistics across the following 5 categories of data: who is qualified to perform the determination of brain death, what are the necessary prerequisites for testing, details of the clinical examination, details of apnea testing, and details of ancillary testing. We compared these data with the standards in the 2010 AAN update on practice parameters for brain death.

Procurement organizations want to be able to deliver life-saving organs to people as soon as possible after death. But – obviously – they only want to remove them from brain-dead individuals. It’s important, therefore, to have some sort of rules as to what constitutes “brain dead”.

The American Academy of Neurology (AAN) put some out in 2010. There’s even a checklist where all boxes must be checked. In this study, researchers compared hospital protocols obtained from 52 procurement organizations against the guidelines to see if they have been adopted.

They found 508 unique hospital policies (pretty much all the places that could evaluate brain death), and 492 of them provided data. That’s a stunning response rate, by the way. There were, however, significant discrepancies between what hospitals do and what the AAN recommends. For instance, only 56% of hospitals documented the absence of hypotension, and only 79% documented the absence of hypothermia. Only a third of policies required a neurologist or neurosurgeon (or someone with neuro expertise) to determine brain death. About 30% of policies didn’t specify who can make the final determination at all.

The media is covering this in typical fashion, with all the screaming that would make you think that alive people have been pronounced dead because of shoddy practice. It’s important to note that this isn’t the case. I don’t know of any “false-positive” determinations of brain death because people did not adhere to the guidelines.

My gaming-group group text (which is seriously one of the most qualified, educated, and thought-provoking feeds that only eight people get to access) was on fire about this article this morning. On the one hand, you can’t be 100% sure about anything in medicine, so even perfect adherence could yield a false positive, and none has arisen. There also is never perfect agreement on “who” gets to set the rules (see my recent Upshot column on this). The AAN has set their stake in the ground, but others have tried, many of them locally.

On the other hand, we should be able to agree on at least a floor here. A minimal set of criteria by which brain death is assured. Others can add to it and make it a higher bar to clear. Making sure everyone is doing the minimum should be our goal, not making sure everyone does the maximum.

This is also obviously a tricky subject. Some people are uncomfortable even discussing “brain death” while the body can be kept alive. We should recognize that no guideline will ever be sufficient for them.

In other words, once again, medicine is complicated and rarely cut and dry. Regardless of what the headlines say.



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