Understanding Brain Death:
for laypersons, experts & everyone in between
This webcast is a collaborative effort between the
Society of Critical Care Medicine’s Emergency Medicine
Section and Project Dispatch. Funding for this project is
provided by a grant from the Agency for Healthcare
Research & Quality.
Any views presented by the speakers in this webcast are
those of the presenters.
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Today’s presentation will also include an interactive
audience poll. Answer by clicking the bubble next to
your choice.
Presenters for Today’s Webcast
David B. Seder, MD, FCCM
Director, Neurocritical Care
Maine Medical Center
Portland, Maine
Isaac Tawil MD, FCCM
Associate Professor: Critical Care/ Emergency Medicine
Neurosciences ICU Medical Director
University of New Mexico School of Medicine
New Mexico Donor Services: Associate Medical Director
Albuquerque, New Mexico
Understanding Brain Death:
for laypersons, experts & everyone in between
Isaac Tawil MD, FCCM
Associate Professor: Critical Care/ Emergency Medicine
Neurosciences ICU Medical Director
University of New Mexico School of Medicine
New Mexico Donor Services: Associate Medical Director
Disclosures?
Learning Objectives
• Review current level of understanding among Laypersons
& Brain Death Experts
• Discuss educational interventions
• Medical student education
• Family Presence during brain death evaluation
• Review Fundamentals of Brain Death Evaluation
• Identify further areas of study
Brain Death… Death By Neurologic Criteria
A Short Story
18 y.o. s/p MVC
– Devastating TBI
– GCS 1T1, no evidence of brainstem reflexes
– Appears to be dead by neurologic criteria
Questions that encounter prompted
1. Do families in this situation understand the concept
of death by neurologic criteria?
2. Has a family presence strategy during brain death
evaluation ever been studied or shown to improve
understanding?
Layperson/ Family Understanding of
Death by Neurologic Criteria is POOR
As many as 1/3 of relatives of patients diagnosed
with brain death DO NOT UNDERSTAND that DEATH
has OCCURRED!
– Do people accept brain death as death? Tessmer et al. Prog Transplant 2007
– What does a prognosis of brain death mean to family members approached
about organ donation. Long T et al. Prog Transplant 2008
– A survey of families of brain dead patients. Pearson IY et al. Anaesth. Int.
Care 1995
– Explaining brain death; A critical feature of the donation process. Franz H. et
al. J Transplant Coord. 1997
Patient’s Families often consent to organ
donation on patient’s behalf without a clear
understanding of Death By Neurologic Criteria…
Next of kin who decided against organ
donation had far less understanding of brain
death than did those who were in favor of
donation…
Expert Understanding: Physicians
Brain death & Organ retrieval; A cross sectional survey
of knowledge and concepts among health
professionals. Youngner et al. JAMA 1989
63% of MDs correctly defined brain death as irreversible loss of
brain function. 35%provided correct definition and correctly
interpreted a brain death scenario
Expert Understanding: Med Students *
•
Essman C et al. Assessing medical student knowledge, attitudes, and behaviors
regarding organ donation. Transplant Proc. 2006
- Ohio students; faired worse than random layperson sample
•
Connie FO et al. Knowledge, acceptance and perception towards brainstem death
among medical students in Hong Kong. A questionnaire survey on brainstem
death. Med Teach 2008
– < Half made distinction between BD & PVS
•
Alfonso RC et al. Future Doctors and Brain death: What is the Prognosis? Transplant
Proc 2004
- Canadian students
•
Garcia CD et al. Educational program of organ donation and transplantation at
medical school. Transplant Proc 2008.
- Brazilian students
• *A validated assessment tool was not used
To address these gaps in medical education:
To start we had to develop a tool to truly measure level of
understanding…
Validated:
– “internal consistency”
– “test-retest validity”
– “discriminatory capacity” (experts versus laypersons)
Then we used the tool to measure
understanding among the UNM SOM
student body
What about that second question?
Has a family presence strategy during brain
death evaluation ever been studied or shown to
improve understanding?
Share your practice with this poll:
Is family presence offered during brain death
evaluation in your ICU?
Always
Sometimes (~ 50%)
Rarely (<25%)
Never
Family Presence During
Resuscitations & Procedures
Family Presence During Brain Death
Evaluation
• Editorial
• Observational
• Failed trial
• Survey study
• PRCT 2009- 2011
• Enrolled immediate family members of patients suspected to
be dead by neurologic criteria
• Group randomized to Presence vs. Absence
• Outcomes
1.
2.
Understanding Brain death survey scores
Measures of psychological distress at 1 mo. f/u
Family Presence Study Protocol
Consent Family Member for
Randomization
Contact With Family Care Coordinator –
Complete First Survey
Family Member Not Present
For Brain Death Exam
Family Member Present
For Brain Death Exam
Complete Second Survey
Discussion Regarding
Organ Donation
Complete Third Survey
One to Three Months Later
Results
•
•
•
•
Randomized 58 family members during 17 BDEs
Present; N = 38
Absent; N = 20
Families unwilling to be randomized = 12
–(8 insisted on presence, 4 insisted on absence)
• Follow up; N= 41 (71%)
Understanding Brain Death Scores
Follow –up Psychological Evaluation:
No difference between groups
Other Results:
• # Achieving Expert Scores (5)
– 66% of Present group
– 20% of Absent group
• 95% of those “Present” reported that being present
helped them understand Brain Death.
• 84% reported that they would recommend
“Presence” to other family members.
Keys to Successful Family Presence
Educational Intervention
• Should be family preference
• Clinician/ Chaperone dedicated to family education
• Clinician performing the exam experienced &
prepared for family presence
• Limited # of family members (educational efficacy & space)
• Sensitivity to educational barriers & cultural
differences
Conclusions
Beyond the evidence….
So we need to continue to improve
Brain death Education at all levels!
And in that spirit…
Brain Death Determination:
Prerequisites
• Clinical or neuroimaging evidence of an acute CNS catastrophe
that is compatible with the clinical diagnosis of brain death
• Exclusion of complicating medical conditions that may confound
clinical assessment: No severe electrolyte, acid base, endocrine,
or hemodynamic disturbances.
• No drug intoxication or poisoning (including hospital administered
sedatives or paralytics)
• Core temperature > 36o C
Brain Death Determination: once
prerequisites are met, move on to
assessing the 3 Cardinal findings in
Brain Death…
• Coma or Unresponsiveness
• Absence of brainstem reflexes
• Apnea testing without a respiratory response
Cardinal Finding #1:
Coma / unresponsiveness
• Prove absence of response to noxious stimuli. This includes
the absence of a motor response to painful stimuli such as
nail-bed or supra-orbital pressure.
• Spinal reflexes may remain intact and do not rule out the
diagnosis of brain death.
Cardinal finding #2:
Absence of Brainstem reflexes
1.
2.
3.
4.
5.
Pupilary light reflex:
Corneal reflex:
Gag & cough reflex:
Oculocephalic (doll’s eyes) reflex:
Vestibulo-ocular (cold calorics) reflex:
tests cranial nerves II & III
tests cranial nerves V &VII
tests cranial nerves IX & X
cranial nerves III, VI, VIII
cranial nerves III, VI, VIII
Cardinal finding #3:
Apnea
•
•
Once all previous criteria have been met, the physician
must perform the apnea test.
The patient must be relatively stable to tolerate this
challenge. Pre-requisites include:
•
•
•
•
•
Core body temp >36o C (>34o in pediatrics)
Systolic blood press >100 (vasopressors acceptable)
Euvolemia/ positive fluid balance
PaO2 and PCO2 within normal range for patient
Normal pH, not requiring high FiO2 or mean airway pressure
Apnea Test
• Set ventilator to obtain a PCO2 within normal limits for the
patient and pre-oxygenate for 10 minutes.
• The patient is disconnected from the ventilator while
oxygenation of the lungs is continued passively. The
patient’s PCO2 is allowed to rise to 60 mm Hg or 20 mm Hg
above their baseline and a diagnosis of brain stem death is
supported if there is no respiratory effort.
Ancillary Studies
• Additional studies are not required unless the clinical
exam is equivocal, apnea test cannot be completed or a
full exam cannot be performed.
• Ancillary tests include cerebral angiography (the gold
standard), Nuclear imaging studies, TCDs, CTA, MRA, and
EEG monitoring.
Is there one way everyone performs
the brain death evaluation?
Greer DM et al. Neurology 2008
Guideline performance
Pre- Requisites for testing
The clinical exam
Apnea testing
2010 Guidelines Update
– In adults, no published cases of return of neurologic
function where 1995 AAN guidelines followed
– Complex motor movements and false ventilator
triggering occur in those who are brain dead
– No strong evidence to guide a minimal observation
period, or serial exams
– Insufficient evidence to guide apnea testing technique
– Insufficient evidence to guide new ancillary testing
What we do know?
All families should be offered the opportunity to
be present during the brain death evaluation
and we must see our job as being educators and
not just clinicians.
“It is no longer acceptable for doctors and nurses to
have the benefit of witnessing confirmation of death
whilst expecting the relatives to accept brainstem death
in the face of so much apparent life”
M. Doran, The Presence of family during brainstem death testing.
Crit care Nursing 2004
Questions / Comments?
David B. Seder, MD, FCCM
Director, Neurocritical Care
Maine Medical Center
Portland, Maine
Isaac Tawil MD, FCCM
Associate Professor: Critical Care/ Emergency Medicine
Neurosciences ICU Medical Director
University of New Mexico School of Medicine
New Mexico Donor Services: Associate Medical Director
Albuquerque, New Mexico