| Departments — Benchmarks | Spring 2008 |
|
Not Even Death Is Certain The members of the research team designed their study after they became curious about what they viewed as major discrepancies among such policies in certain hospitals. So they set out to gather and compare protocols on brain death determination from 50 hospitals listed high in U.S. News and World Report’s 2006 ranking of neurology and neurosurgery centers. The team was led by David Greer, an assistant professor of neurology at Massachusetts General Hospital, and included researchers at the Mayo Clinic in Rochester, Minnesota, and the Henry Ford Hospital in Detroit, Michigan. Their interest, and indeed that of medicine in general, in the issue of brain death has its roots in questions raised in the late 1950s by two French physicians. Their published descriptions of 23 patients in unending comas spawned the concept and gave rise to a definition: the irreversible loss of all brain function while systemic organs remain artificially supported. Equating brain death with standard concepts of death came in a 1981 Presidential Commission on ethical problems in medicine. It stated that brain death was the legal equivalent of such long-accepted measures of death as cessation of heart and lung function. Currently, most states have enacted what is known as the Uniform Determination of Death Act, which specifies that determinations of brain death be made according to accepted medical standards, be they national, regional, or local. In an effort to create a norm for such guidelines, in 1995 the AAN published practice parameters based on an evidence-based review of the literature and best practices. Dead Reckoning The researchers used five categories of the AAN practice parameters as points of comparison: guideline performance, preclinical testing, clinical examination, apnea testing, and ancillary tests. Among the 41 responding institutions, three had no policy at all. For the remaining 38 hospitals, the researchers found a surprisingly low percentage (42 percent) required either a neurologist or a neurosurgeon be present during the determination. Of these, only 35 percent required an attending neurologist or neurosurgeon be present. Nearly three-quarters of responding hospitals required multiple examinations—3 percent sought more than two—while allowable time between examinations varied from 1 to 24 hours, with 6 hours being the most common. More than 95 percent of the responders required preclinical tests but differed widely in what tests they recommended: establishing an underlying cause (63 percent); ensuring the absence of sedatives and paralytics (55 percent); verifying the absence of acid-base disorders (45 percent); or ensuring the absence of endocrine disorders (42 percent). Although apnea testing was missing from one group’s guidelines for clinical examinations, guidelines that did include it stipulated a variety of techniques for such testing. Lowest acceptable temperature, for instance, was specified in only 26 percent of the guidelines; 66 percent required an arterial blood gas prior to testing; and 76 percent stated preoxygenation was mandatory, although the method for doing this was unclear in 69 percent. As for information related to ancillary testing, 66 percent of the guidelines specified when it was necessary. And although specific tests were often mentioned, such as EEGs (84 percent), the details of how the tests were to be administered were less common—only 33 percent mentioned EEG specifics. Grave Differences Although Greer and his team were encouraged by the rate of response from hospitals they contacted, they were disturbed by the variation they In pointing to the ethical as well as the medical–legal implications of such variability, the team underscored how wide-ranging guidelines can have unfortunate consequences, such as the administration of inappropriate treatment to patients who have been labeled brain dead. Noting that the AAN’s practice parameters are more than a decade old, the researchers suggest a revision may be in order and that the results of their study could be used to inform such an effort. They also propose the development of web-based checklists or other new tools that could aid physicians who must make brain death determinations. Ann Marie Menting is associate editor of the Harvard Medical Alumni Bulletin Photo caption: David Greer (story end) Photo: © iStockphoto.com/Joseph Jean Rolland Dube (story top) |
weighed in on the subject, a report in the January 22 issue of Neurology found many of the nation’s top-ranked neurology and neurosurgery centers differ considerably in how they apply the AAN’s guidelines. And the researchers found some institutions had no guidelines at all.
discovered. “We were surprised to find such significant differences among these hospitals in terms of their guidelines for brain death determination,” says lead author Greer. “We anticipated more consistency with the AAN’s practice parameters.”
|