Gaps in Understanding About Brain Death in Various Health Care Professionals and Families

We read with great interest the recently published article titled “A Qualitative Identification of Gaps in Understanding About Brain Death Among Trainees, Health Care Personnel and Families at an Academic Medical Center” by Chen et al. The authors have identified the gaps in understanding of fundamental principles of brain death among relevant sectors of healthcare professionals in an academic health care center in California.¹ However, we wish to add certain additional points.

The authors have concluded that only a minority proportion of professionals among all subgroups starting from advanced practice providers (APPs) to registered nurses expressed subjective mastery over principles of brain death declaration. But the basis on which they have reached such a conclusion is not firmly evident from the results described by the authors. They have merely described the curiosity of health care professionals with various designations regarding certain perspectives of the brain death declaration. This might be confounded by several factors such as differences in interests and perspectives, baseline knowledge of these professionals, and their exposure to a number of clinical circumstances where clinical assessment and testing for declaration of brain death were performed. But for determining the impact of these factors on the individual responses the authors could have mentioned their descriptive answers to all the questions in appendix A of the article. The authors have mentioned they allowed write-in answers. The article would be more informative to readers if the authors would analyze these write-in answers across various subgroups starting from medical students and registered nurses to critical care and neurosciences attendings and critical care APPs and add a brief comprehensive overview regarding the difference in knowledge about the definition of brain death, its mimics, apnea testing, and other ancillary testing. This would have also guided the regulating authorities in planning continuing medical education programs to address the weak areas for various subgroups.

Secondly, the authors have adopted a uniform questionnaire across health care professionals of diverse experience and expertise. Thus, some of the questions relevant for a certain group like registered nurses might be too simple and irrelevant for physicians declaring brain death in patients for many years. It would have been more informative and objective if the authors would have customized to add few more questions about the general understanding of brain death for registered nurses and few questions addressing more complicated and conflicting issues regarding brain death. In a similar but more objective survey performed on neurologists in the USA, Joffe et al found that they lack a consensus about what constitutes brain death, the role of the electroencephalogram, evoked potential and brain stem neuroendocrine function in confounding the declaration of brain death.² Similarly, a narrative review by Moghaddam et al including 44 articles assessing the knowledge of nurses concluded that there persists a significant confusion regarding basic concept of brain death, nursing care of these patients, planning for organ and tissue donation in these patients and legal regulations about the brain death.³ Many of these aspects were not addressed in the brief questionnaire used by the authors. Moreover, the authors could have used an objective score describing knowledge, aptitude, and practice parameters of nurses and physicians. Similar scores have already been used by Chakradhar et al and Prabahram et al in previous studies addressing issues related to organ and tissue donation and the questionnaire used by Mohod et al to determine the awareness regarding diagnostic testing for brain death declaration.^4-6

Another notable issue was that some of the questions in the questionnaire for families of brain death patients are too scientific to be asked by caregivers such as “How apnea test is performed?” or “What happens if the clinical examination is inconclusive or apnea test can’t be performed?” Rather they should have added some questions regarding provisions and opportunities for organ and tissue donation in such patients and whether they can discontinue the life support system after brain death declaration was made, which many clinicians come across while the counseling family of such patients.

Lastly, some of the questions used in appendix A are impromptu for other questions such as the question “How do you perform apnea testing” will help predict the participants regarding the answer for “What is the gold standard testing” and the question “What ancillary tests exist” will provide indirect answers for the question “What happens if the clinical exam is inconclusive or apnea test cannot be completed.” Probably for this reason none of the groups inquired about apnea testing, other ancillary tests, and some other questions also and this could have confounded the results of this study.