Editors' note: Variability in reported physician practices for brain death determination

Abstract

In “Variability in reported physician practices for brain death determination,” Braksick et al. reported that a survey of physicians at 3 academic medical centers demonstrated variability in performance of brain death evaluations. For example, many respondents reported that they perform ancillary tests for indications outside those described in the 2010 AAN Practice Parameter, including institutional mandates, protection from liability, and following the observation that a patient breathes during apnea testing. In their comments, Sethi and Machado reinforce their finding that ancillary tests are often ordered for indications outside the AAN Practice Parameter recommendations and note that it is imperative to remember that (1) brain death is a clinical determination and (2) ancillary tests can have both false positives and false negatives. Machado also suggests that the AAN criteria be revised to require an ancillary test to reduce variability in brain death policies. Braksick et al. disagree with this proposal, noting that the value of ancillary tests is “extremely questionable.” Furthermore, with respect to Machado's argument that implementing universal mandatory ancillary testing would reduce variability in brain death policies, in light of the fact that he also noted that only 6.5% of policies mandate ancillary testing, it would clearly be more reasonable for these policies to change to conform to the current AAN Practice Parameter than for the other 93.5% of protocols to start mandating ancillary testing. To reinforce awareness about the indications for ancillary testing, Braksick et al. advocate for formal education about brain death determination for all clinicians performing brain death evaluations. They, unfortunately, found that 76% of respondents did not receive formal training on performance of this evaluation. Accordingly, to decrease variability in brain death determination, the Neurocritical Care Society has recently released a training module on brain death.[1][1] Machado further comments that he recently proposed a new disorder of consciousness, based on the case of Jahi McMath, which exists when a patient meets clinical criteria for brain death but has ancillary tests that conflict with the clinical findings. Further discussion of this interesting case and the questions it generated can be found elsewhere.[2][2] In “Variability in reported physician practices for brain death determination,” Braksick et al. reported that a survey of physicians at 3 academic medical centers demonstrated variability in performance of brain death evaluations. For example, many respondents reported that they perform ancillary tests for indications outside those described in the 2010 AAN Practice Parameter, including institutional mandates, protection from liability, and following the observation that a patient breathes during apnea testing. In their comments, Sethi and Machado reinforce their finding that ancillary tests are often ordered for indications outside the AAN Practice Parameter recommendations and note that it is imperative to remember that (1) brain death is a clinical determination and (2) ancillary tests can have both false positives and false negatives. Machado also suggests that the AAN criteria be revised to require an ancillary test to reduce variability in brain death policies. Braksick et al. disagree with this proposal, noting that the value of ancillary tests is “extremely questionable.” Furthermore, with respect to Machado's argument that implementing universal mandatory ancillary testing would reduce variability in brain death policies, in light of the fact that he also noted that only 6.5% of policies mandate ancillary testing, it would clearly be more reasonable for these policies to change to conform to the current AAN Practice Parameter than for the other 93.5% of protocols to start mandating ancillary testing. To reinforce awareness about the indications for ancillary testing, Braksick et al. advocate for formal education about brain death determination for all clinicians performing brain death evaluations. They, unfortunately, found that 76% of respondents did not receive formal training on performance of this evaluation. Accordingly, to decrease variability in brain death determination, the Neurocritical Care Society has recently released a training module on brain death.1 Machado further comments that he recently proposed a new disorder of consciousness, based on the case of Jahi McMath, which exists when a patient meets clinical criteria for brain death but has ancillary tests that conflict with the clinical findings. Further discussion of this interesting case and the questions it generated can be found elsewhere.2 [1]: #ref-1 [2]: #ref-2