A new study finds that policies on defining brain death vary from hospital to hospital and could result in serious errors.
Since 2010, neurologists have had a clear set of standards and procedures to distinguish a brain-dead patient from one who might emerge from an apparent coma.
But when profoundly unresponsive patients are rushed to hospitals around the nation, the physicians who make the crucial call are not always steeped in the diagnostic fine points of brain death and the means of identifying it with complete confidence.
State laws governing the diagnosis of brain death vary widely. Some states allow any physician to make the diagnosis, while others dictate the level of specialty a physician making the call must have. Some require that a second physician confirm the diagnosis or that a given period of time elapse. Others make no such demands.
Given these situations, hospital policies can be invaluable guides for physicians, hospital administrators and patients’ families. In the absence of consistent physician expertise or legal requirements, hospital protocols can translate a scientific consensus into a step-by-step checklist. That would help ensure that no one who is not brain-dead is denied further care or considered a potential organ donor and that the deceased and their families would have every opportunity to donate organs.
With the stakes so high, you would probably assume that medical institutions across the country have taken the scientific consensus — a set of guidelines issued by the American Academy of Neurology in 2010 — and adopted hospital protocols to ensure that brain death gets diagnosed the right way every time.
But they haven’t, says a study published last week in JAMA Neurology.
Despite the existence of a number of conditions that can mimic the symptoms of brain death, the study said, not all hospitals had protocols between 2012 and 2015 that required a physician to rule out those “masking conditions.” Others adopted cumbersome procedures that might delay the harvesting of a deceased patient’s organs. Rules that could help diagnose brain death varied widely from hospital to hospital, the study found.
Patients who have been rescued from freezing water or snow may be hypothermic and satisfy many of the criteria for brain death, but they often recover when warmed. Regardless, only 36 percent of hospitals surveyed required physicians to ensure that a patient’s core body temperature reached near-normal levels before declaring the person brain-dead.
Similarly, ingestion of certain drugs sometimes causes the loss of primitive reflexes seen in those with no remaining brain activity. But only about 32 percent of hospitals surveyed required drug testing to rule out toxic drug levels. While an absence of spontaneous respiration is one clear criterion for diagnosing brain death, fewer than two-thirds of hospital protocols included detailed standards for testing that capability in an injured patient, the study found.
The match between hospital protocols and the 2010 guidelines “should be 100 percent,” said David Magnus, a Stanford University medical ethicist. “So this is disconcerting,” he said.
Martin Monti, an expert on coma and other disorders of consciousness at UCLA, said that for diagnosing brain death, “the science is there.”
Declaring someone brain-dead who is not would be a horrific error, Monti said. But measures that delay a correct diagnosis and reduce the availability of transplantable organs are also unacceptable, in that they may deny a potential beneficiary a chance at life.