Absent Brainstem Reflexes Research Articles

Brain Death: Assessment, Controversy, and Confounding Factors

When brain injury is refractory to aggressive management and is considered nonsurvivable, with loss of consciousness and brain stem reflexes, a brain death protocol may be initiated to determine death according to neurological criteria. Clinical evaluation typically entails 2 consecutive formal neurological examinations to document total loss of consciousness and absence of brain stem reflexes and then apnea testing to evaluate carbon dioxide unresponsiveness within the brain stem. Confounding factors such as use of therapeutic hypothermia, high-dose metabolic suppression, and movements associated with complex spinal reflexes, fasciculations, or cardiogenic ventilator autotriggering may delay initiation or completion of brain death protocols. Neurodiagnostic studies such as 4-vessel cerebral angiography can rapidly document absence of blood flow to the brain and decrease intervals between onset of terminal brain stem herniation and formal declaration of death by neurological criteria. Intracranial pathophysiology leading to brain death must be considered along with clinical assessment, patterns of vital signs, and relevant diagnostic studies.

End-of-Life and Brain Death in Acute Coma and Disorders of Consciousness

Consulting neurologists are often asked to evaluate patients in acute nontraumatic coma. The authors review prognostication of functional outcomes, determining brain death, and managing end-of-life care. Prognostication of outcome after cardiac arrest in comatose patients is a frequently encountered scenario with high-stakes implications. However, current guidelines are limited by a failure to address the use of therapeutic hypothermia and thus may lead to overly pessimistic outcome prediction. Pupillary light responses and corneal reflexes remain highly predictive clinical signs of a poor prognosis. Motor responses have a high false-positive rate for predicting a poor outcome, especially in patients treated with therapeutic hypothermia. Ancillary testing with electroencephalography, somatosensory evoked potentials, serum neuron-specific enolase, and neuroimaging is often useful in predicting outcomes. Brain death is a clinical condition of irreversible coma of known cause with absent brainstem reflexes and apnea. An understanding of the value of confirmatory testing and the potential for confounding factors is essential in making a correct diagnosis. As coma carries a high mortality rate, neurologists must be capable of guiding goals of care, discussing end-of-life issues, and understanding organ-procurement procedures.

Non confirmatory electroencephalography in patients meeting clinical criteria for brain death: Scenario and impact on organ donation

ObjectiveTo describe the causes and outcome of adult patients with preserved electroencephalographic activity despite clinical findings suggesting brain death (BD), and its impact on organ donation. MethodsRetrospective study of the clinical and electroencephalography (EEG) data of all adult patients admitted to our hospital between January 2001 and December 2011 in whom a comprehensive clinical diagnosis of BD was reached following absence of brainstem reflexes and confirmatory apnea tests, were obtained. All patients with clinical findings suggesting BD and an EEG showing brain activity were selected for the analysis. We calculated the brain death interval (BDI) as the time between the first complete clinical examination and confirmatory ancillary test, or the time between the first and second complete clinical examination for BD, in order to analyze the impact on family consent for organ donation. ResultsA complete clinical examination and EEG were diagnostic in 289 patients. In 279 (96.5%), the first EEG showed electrocerebral inactivity corroborating the clinical findings of BD. The mean BDI in this group was 4.2±5.8h (median; 1.8[1.0–3.5]). This value was significantly lower than in the group in which only two full clinical evaluations were performed (p<0.0001). In 10 out 289 (3.5%), the first EEG showed at least some brain activity. The mean BDI in this group was 27.2±13.8h (median; 22.9 [19.1−31.2]). In two cases, a third EEG was necessary before obtaining electrocerebral inactivity. A BDI>6h, was positively associated with a family refusal for organ donation (p=0.02). ConclusionsThe rate of EEGs with electrocerebral activity despite clinical findings suggesting BD was only 3.5%. It occurred most frequently with severe brainstem damage. Although in this small percentage of patients, BD diagnosis was notably delayed, in the great majority of cases the use of EEG shortened the BDI. In our series, a BD diagnosis delay >6h negatively affected consent for organ donation. SignificanceThe use of EEG can decrease the time interval for brain death diagnosis.

The incidence of potential missed organ donors in intensive care units and emergency rooms: a retrospective cohort

There is a shortage of organ donors in Canada. The number of potential organ donors that are not referred to organ procurement organizations in Canada is unknown. We conducted a retrospective cohort study of all deaths in ICUs and emergency rooms not referred to the Human Organ Procurement and Exchange Program in four hospitals between 1 January 2008 and 31 December 2010. The primary outcome was the number of normal and expanded criteria heart-beating donors and circulatory death (DCD) donors. Of 2,931 deaths, 64 patients were identified as having a high probability for progression to heart-beating donation (Glasgow Coma Score of 3 and three or more absent brainstem reflexes) and 130 patients were assessed for possible DCD donation. The number of potential abdominal and lung heart-beating donors ranged from 3.2 to 7.5 and 0.5 to 2.7 per million population. The number of potential DCD abdominal and lung donors ranged from 3.9 to 6.5 and 2.7 to 4.3 per million population. Potential heart-beating abdominal (p=0.04) and lung (p=0.06) donors increased after legislation mandating donation discussion. Non-pupillary brainstem reflexes were documented in fewer than 60% of records. Life-sustaining treatment was withdrawn in 19 of 46 (41.3%) cardiac arrest patients not requiring high doses of vasoactive drugs within 24h. The number of heart-beating or DCD organ donors represented by missed referrals may represent up to 7.5 donors per million population. Improved documentation of brainstem reflexes and encouraging referral of patients suffering cardiac arrest to ICU specialists may improve donor numbers.

Apnea Testing During Brain Death Assessment: A Review of Clinical Practice and Published Literature

The diagnosis of brain death is a complex process. Strong knowledge of neurophysiology and an understanding of brain death etiology must be used to confidently determine brain death. The key findings in brain death are unresponsiveness, and absence of brainstem reflexes in the setting of a devastating neurological injury. These findings are coupled with a series of confirmatory tests, and the diagnosis of brain death is established based on consensus recommendations. The drive to breathe in the setting of an intense ventilatory stimulus (ie, respiratory acidosis) is a critical marker of brainstem function. As a consequence, apnea testing is an important component of brain death assessment. This procedure requires close monitoring of a patient as all ventilator support is temporarily removed and Paco2 levels are allowed to rise. A "positive" test is defined by a total absence of respiratory efforts under these conditions. While apnea testing is not new, it still lacks consensus standardization regarding the actual procedure, monitored parameters, and evidence-based safety measures that may be used to prevent complications. The purpose of this report is to provide an overview of apnea testing and discuss issues related to the administration and safety of the procedure.

Assessment of unconsciousness in pigs during exposure to nitrogen and carbon dioxide mixtures

The aim of this study was to assess unconsciousness in pigs during and after the exposure to gas mixtures of 70% nitrogen (N2) and 30% carbon dioxide (CO2) (70N30C), 80% N2 and 20% CO2 (80N20C) and 85% N2 and 15% CO2 (85N15C) compared with 90% CO2 in air (90C) by means of the Index of Consciousness®(IoC), their behaviour and the absence of brain stem reflexes. The experiment included three trials of 24 pigs divided into four groups according to the number of treatments. Half of the group was exposed for a short time and the other half for a long time (3 and 5 min for the N2/CO2 mixtures exposure and 2 and 3 min in 90C exposure, respectively). During exposure, the IoC and the electroencephalography suppression rate (ESR) were assessed, as well as the time to onset and percentage of gasping, loss of balance, vocalizations, muscular excitation and gagging. At the end of the exposure, the corneal reflex, rhythmic breathing and sensitivity to pain were each assessed at 10 s intervals for 5 min. Brain activity decreased significantly (P < 0.05) 37.60 s after the start of the exposure to 90% CO2, which was significantly earlier than in 70N30C, 80N20C and 85N15C exposure, (45.18 s, 46.92 s and 43.27 s, respectively). Before brain activity decreased, all pigs experienced gasping and loss of balance and a 98% muscular excitation. The duration of the muscular excitation was longer in animals exposed to 70N30C, 80N20C and 85N15C than 90C (P < 0.01). After a long exposure time, all animals exposed to 90C died, whereas the 30.4% of animals exposed to N2/CO2 gas mixtures survived. Pigs exposed to 85N15C recovered corneal reflex and sensitivity to pain significantly earlier than when exposed to 90C. Exposure to 90C causes a higher aversive reaction but a quicker loss of consciousness than N2/CO2 gas mixtures. Exposure to N2/CO2 gas mixtures causes a lower percentage of deaths and an earlier recovery of the brain stem activity than 90C, whereas the time to recover the cortical activity is similar. In conclusion, the inhalation of N2/CO2 gas mixtures reduces the aversion compared with high concentrations of CO2; however, the period of exposure for inducing unconsciousness may be longer in N2/CO2 gas mixtures, and the signs of recovery appear earlier, compared to CO2.

Neurogenic Stunned Myocardium and Cardiac Transplantation: A Case Report

We present the case of a 46-year-old woman referred to our center for urgent heart transplantation assessment, initially diagnosed as having cardiogenic shock of uncertain etiology. Some hours before she had suffered syncope without regaining consciousness. When she arrived at our hospital, the objective examination revealed bilateral unreactive mydriasis and absent brain-stem reflexes, and echocardiography showed global left ventricle wall hypokinesis sparing the apex. An urgent computed tomography (CT) imaging of the head was performed, which showed a massive subarachnoid hemorrhage and extensive cerebral edema. In the following hours, she fulfilled the criteria of brain-stem death and indeed became a multiorgan donor. The heart was rejected for transplantation because of the existence of left ventricle wall motion abnormalities associated with neurogenic stunned myocardium. Neurogenic stunned myocardium is a stress-related cardiomyopathy that occurs after an acute brain injury. It is especially frequent in subarachnoid hemorrhage, where it reaches an incidence of up to 40% of patients. It is characterized by acute electrocardiographic changes and regional hypokinesis of the left ventricle wall not consistent with the coronary artery distribution, and is thought to be a transient condition. For this reason it should not constitute an absolute contraindication to cardiac donation in young donors with no previous cardiac disease. In our hospital during the last year one third of the potential heart donors had regional left ventricle wall motion abnormalities compatible with neurogenic stunned myocardium. With the aim of improving the number of cardiac donors, several strategies have been described to try to demonstrate the reversibility of this entity, such as dobutamine stress echocardiography.

Teaching Neuro Images : Reverberating TCD flow pattern in brain death

A 70-year-old man presented after being found unresponsive at home. Emergent head CT showed bilateral intracranial hemorrhages causing significant mass effect ([figure][1], A). Neurologic examination demonstrated absent brainstem reflexes and no response to noxious stimulation. Apnea testing could

Pitfalls in Brain Death Diagnosis: A Case Report

Although there are distinct guidelines in nearly all countries, a reliable secure assessment of brain death in cases with open head injury can be challenging. We present a case of a 32-year-old man with severe head injury after intracranial penetration of a grindstone fragment. As the injury led to destruction of nearly the whole greater wing of the right sphenoid bone and parts of the right orbit, the examination of brainstem reflexes and the confirmation of brain death was unfeasible. On day 2, all clinical criteria of brain death (coma, absence of brainstem reflexes, apnea) were fulfilled. In addition, there was an extinction of brainstem auditory (BAEP) and cerebral (N20) components of median nerve somatosensory evoked potentials, while electroencephalogram (EEG) activity was still present. In the following days, a persisting EEG activity was obtained. Thus, an irreversible loss of whole brain functions could not be proved. As the patient had agreed to organ donation in case of brain death several years ago, ancillary methods to test the cessation of cerebral blood flow were mandatory. However, in this patient these methods turned out either to be doubtful or unavailable. For example, values of transcranial Doppler ultrasonography are not reliable in cases with open head injury. Due to a progressive septic state, time was running out to get the radiopharmaceutical agent for a cerebral scintigraphy (delivery time about 7 days, as the radiopharmaceutical agent was not in stock). Referring to the actual German guidelines, we had no legitimating indication for a cerebral angiography. Finally, the patient died of sepsis. We discuss the widening of the German guidelines in assessing brain death with the fast and low-risk method of cerebral computed tomography-angiography (CTA) to confirm diagnosis of brain death.

Transient perioperative brainstem paralysis secondary to a local anesthetic

Local anesthesia is widely used, in isolation or in conjunction with general anesthesia. The authors describe 2 adolescent patients presenting with absent brainstem reflexes and delayed awakening following elective foramen magnum decompression for Chiari Type I malformation. In both cases, neurological deficits were closely associated with the administration of a levobupivacaine field block following wound closure. In the absence of any structural or biochemical abnormalities, and with spontaneous recovery approximating the anesthetic half-life, the authors' observations are consistent with transient brainstem paralysis caused by perioperative local anesthetic infiltration.

Imprecise definitions of starting points in retrospectively reviewing potential organ donors causes confusion: call for a reproducible method like ‘imminent brain death’

Low donor supply and the high demand for transplantable organs is an international problem. The efficiency of organ procurement is often expressed by donor conversion rates (DCRs). These rates differ among countries, but a uniform starting point for defining a potential heart-beating donor is lacking. Imprecise definitions cause confusion; therefore, we call for a reproducible method like imminent brain death (IBD), which contains criteria in detail to determine potential heart-beating donors. Medical charts of 4814 patients who died on an ICU in Dutch university hospitals between January 2007 and December 2009 were reviewed for potential heart-beating donors. We compared two starting points: 'Severe Brain Damage' (SBD) (old definition) and IBD (new definition), which differ in the number of absent brainstem reflexes. Of the potential donors defined by IBD 45.6% fulfilled the formal brain death criteria, compared with 33.6% in the larger SBD group. This results in a higher DCR in the IBD group (40% vs. 29.5%). We illustrated important differences in DCRs when using two different definitions, even within one country. To allow comparison among countries and hospitals, one universal definition of a potential heart-beating donor should be used. Therefore, we propose the use of IBD.

Clinical Reasoning: A 41-year-old comatose man with absent brainstem reflexes

A 41-year-old obese man was stopped by the police for driving erratically. He was confused, dysarthric, ataxic, and vomited repeatedly before collapsing and becoming rapidly obtunded, eventually requiring rapid sequence intubation (RSI). He arrived at the emergency department (ED) with a Glasgow Coma Scale score of 3, hypothermia (35.3°C), and hypotension (78/38 mm Hg), with a heart rate of 80. He was treated with warm IV fluid boluses and warming blanket. He was examined by the attending and resident neurologists approximately 2.5 hours from the time of RSI. He was mechanically ventilated but had received no sedation since intubation. Nothing was known about his medical history and no collateral information was available. He did not respond to naloxone or thiamine. Clinical examination was performed with a temperature of 36°C and a blood pressure of 120/80 mm Hg. He remained mechanically ventilated without spontaneous respirations. No meningismus, external signs of trauma, needle puncture marks, or tongue or buccal lacerations were observed. Spontaneous movements were absent. He did not open his eyes, grimace, withdraw, or posture to noxious stimuli (nailbed and supraorbital pressure). Neuromuscular blockade was excluded with a train of 4 twitches with maximal ulnar nerve stimulation. His pupils were fixed at 2 mm and unreactive to light. Corneal and oculocephalic (vertical and horizontal) reflexes were absent. Irrigation of each ear canal with ice water produced no eye deviation. No gag or cough reflexes were elicited with posterior pharyngeal stimulation and tracheal suctioning respectively. His extremities were flaccid and areflexic. Babinski sign was absent. No gaze deviation, nystagmoid eye movements, facial twitching, or jerking movements were observed. Cardiovascular, lung, and abdominal examinations were unremarkable. ### Questions for consideration: 1. How do you approach a comatose patient? 2. What are the differential diagnoses? GO TO SECTION 2 The comatose patient who presents to the ED is a challenge. …

Baclofen overdose mimicking brain death

Context. Brain death guidelines should be used with caution in patients with drug intoxication. It is often suggested that physicians use five half-lives of a drug when observing a patient with an overdose. We report two cases of baclofen intoxication where brain death was entertained as an explanation for prolonged coma, with arousal seen days later, suggesting that routine use of a 5-half-life observation period is insufficient with baclofen intoxication. Case presentation. A 40-year-old woman was found unresponsive by her family. Baclofen was found to be the responsible overdose. The patient had absent brain stem reflexes and was intubated and in the ICU for several days. Although EEG and Apnea test were inconclusive, the patient was thought to be brain dead and organ procurement was arranged. On hospital day 5, the patient started having purposeful movements. The patient had progressive arousal and was eventually transferred without neurologic sequelae to psychiatry. The second patient also had a massive baclofen overdose, had absence of almost all brain stem reflexes and was also intubated and in the ICU. Brain death was felt to be imminent, but the patient began to awake on hospital day 7. Discussion. Our two cases suggest that baclofen intoxication may result in very prolonged and profound coma and may, in fact, mimic brain death. Conclusion. The determination of brain death in the comatose overdose patient must proceed with caution. An adequate period of time to allow drug clearance must be allowed.

Predictors of outcome in World Federation of Neurologic Surgeons grade V aneurysmal subarachnoid hemorrhage patients*

Only a small percentage of World Federation of Neurologic Surgeons grade V aneurysmal subarachnoid hemorrhage patients have a favorable outcome. The influence of clinical parameters on outcome was assessed. Retrospective evaluation of consecutive patients admitted from 2000-2007 with grade V subarachnoid hemorrhage at two institutions by evaluating, over time, the motor value of the Glasgow Coma Scale, effects of external ventricular drainage and rebleeding on outcome. Six-month outcome was assessed with the extended Glasgow Outcome Scale; favorable outcome was defined as good recovery or moderately disabled. Of 126 patients, 28 had absent brainstem reflexes, without improvement after external ventricular drainage. Rebleeding occurred in 26 patients, resulting in treatment withdrawal in 14. Only one patient had a favorable outcome after rebleeding. Of the 84 remaining patients, 61 improved at day 2 after subarachnoid hemorrhage to Glasgow Coma Scale motor value ≥4; 24 of these (39%) had a favorable outcome. All 23 patients with a Glasgow Coma Scale motor value ≤3 had an unfavorable outcome or died. Patients younger than 65 yrs of age had a better outcome (p < .03). Hydrocephalus was present in 71 of 84 patients. Favorable outcome was similar for patients with a positive external ventricular drainage response (8 of 28) as compared to no response to external ventricular drainage (12 of 43). The high rebleeding rate and subsequent poor outcome in World Federation of Neurologic Surgeons grade V patients warrants early treatment to secure the ruptured aneurysm. Favorable outcome was seen in 39% of patients with a Glasgow Coma Scale motor value ≥4 at day 2. In this study, patients with Glasgow Coma Scale motor value ≤3 at day 2 all had a very poor prognosis.

Long-term Angiographic and Clinical Outcomes in Completely Versus Incompletely Coiled Ruptured Intracranial Aneurysms

Long-term Angiographic and Clinical Outcomes in Completely Versus Incompletely Coiled Ruptured Intracranial Aneurysms

Should ancillary brain blood flow analyses play a larger role in the neurological determination of death?

We present two patients who regained spontaneous respiration following clinical neurological determination of death (NDD) while ancillary radiological imaging demonstrated brain blood flow. A 26-yr-old male with chronic otitis media presented with a Glasgow Coma Scale (GCS) score of 3 and fixed 7-mm pupils. Computed tomography demonstrated right-sided mastoiditis and a temporal lobe abscess associated with uncal herniation. The patient was diagnosed brain dead seven-hr later when motor responses and brainstem reflexes were absent and his apnea test was positive. Approximately 28-hr after NDD, during post-declaration organ resuscitation, the patient regained spontaneous respiration and magnetic resonance imaging revealed brain blood flow. Spontaneous respirations persisted for five-days before cardiovascular collapse occurred. In the second case, a 50-yr-old female presented with a GCS score of 3 and fixed 6-mm pupils following a traumatic brain injury and a five-minute cardiac arrest. The patient was deemed clinically brain dead six-hr later when physical examination revealed absent motor responses and brainstem reflexes and her apnea test was positive. As confirmation of brain death, a cerebral radionuclide angiogram was performed, which surprisingly revealed intracranial arterial flow. During organ resuscitation, 11-hr after NDD, the patient regained spontaneous respiration. She expired hours after family decision to withdraw treatment. For both patients, several unrecognized confounding factors for NDD were present. These cases illustrate the difficulties encountered by experienced clinicians in determining brain death using clinical criteria alone, and they suggest that more routine use of ancillary brain blood flow analyses should be recommended.

Challenges in diagnosing brain death

Recognizing that the nature of the practice of clinical medicine involves areas of uncertainty, death is one diagnosis that doctors must not be allowed to miss. The concept of brain death, which originates from the Harvard Criteria, has allowed development of cadaveric organ transplantation programs. Over the years, the definition of brain death and the criteria for the neurological determination of death (NDD) have been updated. The Universal Determination of Death Act provides a definition of death but leaves the determination process to accepted medical standards (national, provincial, or even local), which can entail a high variability. In April 2003, in response to a perceived need in the general medical and critical care community, the Canadian Council for Donation and Transplantation (CCDT) held a national forum to revisit the process of declaring brain death and to propose updated recommendations. These are the current guidelines used by organ donation and transplantation organizations across Canada. The CCDT recommendations have the virtue of having brought uniformity to the process of NDD. Still, several of its recommendations are somewhat vague and open the door to clinical judgement and interpretation, a situation that is highly undesirable when facing potential organ donation. In this issue of the Journal, Roberts et al. report two cases where experienced physicians faced challenges in the clinical NDD. In both cases, it appears that several of the criteria for NDD were either misinterpreted or overlooked. Although they are usually not reported in the medical literature, similar incidents occur more than occasionally. This is somewhat disturbing. The existence of cadaveric organ donation and transplantation programs relies on the Dead Donor Rule that dictates that a patient’s death must be confirmed before any attempt at organ preservation or harvesting for the purpose of transplantation. Before a patient is dead, ethical principles mandate that medical care must be directed toward the sole and only benefit of this patient, even in a situation that could be perceived as ‘‘almost dead’’. Brain death is a complex concept that is very difficult for the general public to understand. Patients and their families place their trust in their treating physician. In organ donation, they trust that physicians will strictly abide by the Dead Donor Rule. Therefore, the process for NDD must be watertight. The CCDT recommendations define neurological death as the irreversible loss of all brain stem functions. The minimum criteria for clinical NDD are: 1) an established etiology capable of causing neurological death in the absence of reversible conditions capable of mimicking neurological death; 2) a deep unresponsive coma with bilateral absence of motor responses (excluding spinal reflexes); 3) absent brain stem reflexes, as defined by absent gag and cough reflexes, and the bilateral absence of corneal responses, pupillary responses to light (with pupils at mid-size or greater), and vestibulo-ocular responses; 4) absent respiratory effort based on the apnea test; and 5) absence of any confounding factors. Minimum means that at least all of these criteria must be met for clinical NDD. Confusion may arise regarding the first criterion. An etiology ‘‘capable of causing’’ neurological death is not the same as ‘‘sufficient to account for’’ the absence of clinical signs of brain function. For example, brain trauma is an M. R. Lessard, MD (&) J. G. Brochu, MD Department of Anesthesia and Critical Care, Centre hospitalier affilie universitaire de Quebec, Universite Laval, 1401, 18e rue, Quebec, QC G1J 1Z4, Canada e-mail: martin.lessard@anr.ulaval.ca

Severe Guillain-Barré syndrome following head trauma

Fulminant forms of Guillain-Barré syndrome (GBS) present as acute onset tetraparesis and areflexia with absent brainstem reflexes, simulating brain death. Head trauma as an antecedent to fulminant GBS has been infrequently reported, and recognizing an association between GBS and head trauma may be crucial for patient management. Consequently, we report a patient with fulminant GBS with mixed demyelinating and axonal features preceded by a closed head injury, and discuss the possible pathophysiological mechanisms.

Acute aortic dissection mimicking basilar artery occlusion in a patient presenting with sudden coma

A 77-year-old female suddenly became comatose. Examination at the emergency room revealed stable vital signs and bilateral positive plantar reflexes but absent brainstem reflexes. Basilar artery occlusion was initially diagnosed and recombinant tissue plasminogen activator was administered. However, her blood pressure dropped after thrombolysis. A chest CT scan showed aortic dissection extending to the bilateral common carotid arteries. Her follow-up brain CT scan disclosed infarctions over bilateral carotid territories without brainstem involvement. Aortic dissection should be listed as a possible diagnosis in a patient who presents with a sudden coma mimicking basilar artery occlusion. Detailed clinical examination and discussion might lead to the correct diagnosis and avoid inadvertent thrombolysis in the emergency room.

Authors' response to letter re: The Rapid Assessment of Hospital Procurement Barriers in Donation: Assessing Hospitals for Change

Laura A. Siminoff, Heather M. Marshall TrainoTo the Editor:In their letter to the editor (this issue), Ve-rheijde, Potts, Rady, and Shewmon (2010)equate implementation of the Rapid Assess-ment of hospital Procurement barriers inDonation (RAPiD) with compromising the ba-sic principle upon which the U.S. organdonation system is founded—voluntariness.Specifically, the authors contend that theRAPiD infringes upon healthcare providers’right to ‘‘opt out’’ of or ‘‘conscientiously ob-ject’’ to engaging in ‘‘health serviceprogram[s] or research activit[ies]’’ that are‘‘contrary to his [or her] religious beliefs ormoral convictions’’ (Public Health Service Act42 USC ‰ 300a-7 (d)) (Office of the Law Re-vision Counsel U.S. House of Representatives,1973). The authors seem to overlook the factthat health practitioners’ employment withinany healthcare organization constitutes partic-ipation in neither a ‘‘health service program’’nor a ‘‘research activity.’’ Employees in health-care organizations, such as hospitals, arecontractually obligated to adhere to the poli-cies and procedures of that organization,whether codes of dress or conduct, or policiesrelated to the identification and referral of do-nor-eligible patients to regional organprocurement organizations (OPO). Moreover,these policies are in response to federal andstate regulations.Hospitals’ organ donation policies are theproduct of national regulatory efforts to in-crease the supply of transplantable organs. Inthe late 1970s, it became apparent that thoseon the transplant waiting list far exceeded thenumber of organs available. Some arguedAmericans wanted to donate and that the or-gan shortage reflected a failure on the part ofhospital staff to approach families and ask fordonation. These assumptions resulted in a se-ries of new state and federal laws intended toincrease the supply of transplantable organs.These laws, commonly called ‘‘required re-quest,’’ were designed to encourage healthcareprofessionals to speak with families about or-gan donation (Caplan, Siminoff, Arnold, V however, this didnot happen. After an initial modest increase,donations leveled off to no more than 5,000donors per year. One problem was that at least50% of all requests for organ donation to fam-ilies of brain dead patients were met withdenial (Siminoff, Arnold, Caplan, Virnig, S Cohen, 1992; Kappel, Whitlock, Parks-Thomas, Hong, & Freedman, 1993). ‘‘Re-quired notification’’ was enacted in 2001 toattempt to address this concern. This policyobligates hospitals to report all deaths to a localOPO to determine patient eligibility for organdonation. The purpose of routine notificationis to try to increase OPO involvement in thepatient identification process so as to improvethe request process (Health Care FinancingAdministration, 1998). Siminoff, Gordon, Hew-lett, and Arnold (2001) and Evanisko et al.,(1998) have demonstrated that OPO staff arebest qualified to discuss this option with fam-ilies.Thus, healthcare organizations are federallymandated to report all potential donor-eligiblepatients to regional OPOs in a timely manner.A timely referral is made within 1hr of a pa-tient meeting the clinical triggers for referral,that is the absence of brain stem reflexes, aGlascow Coma Score45 or the considerationof withdrawal of care (Ehrle, 2006). Hospitalpolicies concerning the identification and re-Vol. 32 No. 3 May/June 2010 45