Improving uniformity in brain death determination policies over time

Abstract

Objective: To demonstrate that progress has been made in unifying brain death determination guidelines in the last decade by directly comparing the policies of the US News and World Report's top 50 ranked neurologic institutions from 2006 and 2015.

Methods: We solicited official hospital guidelines in 2015 from these top 50 institutions, generated summary statistics of their criteria as benchmarked against the American Academy of Neurology Practice Parameters (AANPP) and the comparison 2006 cohort in 5 key categories, and statistically compared the 2 cohorts' compliance with the AANPP.

Results: From 2008 to 2015, hospital policies exhibited significant improvement (p = 0.005) in compliance with official guidelines, particularly with respect to criteria related to apnea testing (p = 0.009) and appropriate ancillary testing (p = 0.0006). However, variability remains in other portions of the policies, both those with specific recommendation from the AANPP (e.g., specifics for ancillary tests) and those without firm guidance (e.g., the level of involvement of neurologists, neurosurgeons, or physicians with education/training specific to brain death in the determination process).

Conclusions: While the 2010 AANPP update seems to be concordant with progress in achieving greater uniformity in guidelines at the top 50 neurologic institutions, more needs to be done. Whether further interventions come as grassroots initiatives that leverage technological advances in promoting adoption of new guidelines or as top-down regulatory rulings to mandate speedier approval processes, this study shows that solely relying on voluntary updates to professional society guidelines is not enough.

Figure 1. Year of most recent policy update/revision

The majority of institutions (74%) have updated their policies at a date after the June 2010 update to the American Academy of Neurology Practice Parameters (AANPP), while 16% did not and 10% made no mention of revision date, suggesting that most institutions had an opportunity to review the official guidelines before adopting their current policies, but 26% did not.

Figure 2. Prerequisites to testing

(A) The vast majority of 2015 policies (96%) required the perquisites listed by the American Academy of Neurology Practice Parameters, but the policies contained high variability in details (e.g., [B] the definition of hypothermia).

Figure 3. Clinical examination compliance with AANPP, 2015 vs 2008

(A) Consistent compliance to the majority of the clinical examination is shown, with additional specificity for pupil size in 45% of policies. (B) Areas of notably poor adherence in 2008 and 2015. AANPP = American Academy of Neurology Practice Parameters.

Figure 4. Apnea testing compliance with AANPP, 2015 vs 2008

Apnea testing criteria showed a notably higher proportion of policies requiring arterial blood gas (ABG) measurement before beginning apnea testing (86% vs 66%) and a Pco₂ rise of 20 mm Hg above baseline for the test to qualify as positive (71% vs 39%). Overall compliance to the American Academy of Neurology Practice Parameters (AANPP) guidelines was greater in 2015 than in 2008 (p < 0.04).

Figure 5. Policies in 2015, similar to 2008, continue to name ancillary tests much more frequently than describing their specific details (e.g., 86% look for EEG as an ancillary test, only 49% stipulate specifics)

Radionuclide scintigraphy appears in a notably greater proportion of 2015 policies (88%) than 2008 policies (66%) and with greater details (43% scintigraphy specifics in 2015 vs 21% in 2008). Unproved tests (shaded gray) continue to be endorsed by a minority of policies.