An evaluation of brainstem death documentation: the importance of full documentation

Abstract

With the introduction of the concept of brainstem death as acceptable proof that life has ended, rather than cessation of the beating heart, the process of determining brain death has to be rigorous to ensure maintenance of confidence in the definition. A recent study from South Thames in the UK revealed that only 44% of brainstem death documentation was complete at the time of referral to the transplant coordinator. The aim of our study was to see whether our documentation of brainstem death in paediatric practice complied with the UK Royal College's guidelines and to determine whether any changes are required to be instituted. We studied retrospectively the case notes of children who underwent brainstem testing over a 3-year period (1994-1997) at two tertiary referral children's hospitals. The results of the audit were disseminated and a reaudit was performed over a 3-year period (1998-2001). A proforma was completed in 61% of cases and in only 54% of cases was the ideal standard of two tests by two doctors documented. Of the 26 sets of case notes studied, the cause of coma was not stated in 85% of cases and exclusion of other causes was stated in 54%. For the reaudit, 32 sets of case notes were studied and the proforma was completed in 100% of cases. In 91% of cases, the cause of coma was stated and in 94%, exclusion of other causes was documented. In 94% of cases two tests were performed by two doctors. Documentation of adherence to the Royal Colleges, guidelines on brainstem death testing improved significantly between the two study periods as a consequence of major changes in practice within the PICU. With the appointment of dedicated intensive care consultants, care became largely consultant intensivist led and emphasis was placed on the documentation and completion of a single validated brainstem death proforma. It is essential to improve and maintain the quality of brainstem death test documentation in order to ensure the integrity of the process.