Prevention of False-Positive Determinations of Death by Neurologic Criteria Requires Education, Regulation, and Revision of Hospital Policies

In a 2016 summit on interdisciplinary concerns related to determination of death by neurologic criteria (DNC), the American Academy of Neurology (AAN) and other stakeholder organizations acknowledged variability in institutional policies on determination of DNC and emphasized the importance for all determinations of DNC to be performed in accordance with accepted medical standards.¹ This is imperative because false-positive determinations of death undermine the credibility of the medical profession.

In this issue of Neurology® Clinical Practice, Lele et al. described a quality improvement initiative in which LifeCenter Northwest, the organ procurement organization (OPO) for Alaska, Montana, North Idaho, and Washington, evaluated the documentation of determinations of DNC to confirm that it reflected adherence to the 2010 AAN standards before consideration of organ donation.^2,3 OPO coordinators escalated concerns about 58% of referrals (375/645) for organ donation after determination of DNC from 2016 to 2020 to supervising neurointensivists who served as the on-call medical directors for the OPO. The supervising neurointensivists were concerned about the determination process for 120 of these referrals (32% of cases referred to them and 19% of total cases). These concerns were related to the performance of apnea testing (n = 97), documentation of the clinical examination (n = 67), and confirmation of the prerequisites (n = 49). Concerns were more common when the description of the clinical examination and apnea testing in the institutional policy deviated from the 2010 AAN practice parameter (p = 0.049 and p = 0.02, respectively) and less common in hospitals with a dedicated neurocritical care unit/service (p < 0.001).

Previous studies have also demonstrated incomplete or incorrect documentation of determinations of DNC.⁴ Of course, errors in documentation may not be indicative of deviations in practice. However, in a survey of 68 US physicians involved in the determination of DNC, Braksick et al.⁵ identified practice deviations from the accepted medical standards. Of the 42 attending physicians who completed the survey, 19 (45%) did not report completion of all components of the clinical examination including assessment of responsiveness to voice, responsiveness to central pain, responsiveness to peripheral pain, pupillary reflex, corneal reflex, oculocephalic reflex, oculovestibular reflex, gag reflex, cough reflex, and absence of spontaneous respirations.

The 2010 AAN practice parameter and the World Brain Death Project, an international consensus statement on the determination of DNC, emphasized the importance of thorough documentation of determinations of DNC and advised the use of a standardized checklist.^3,4 A note summarizing the determination of DNC should include the etiology of coma, confirmation of the absence of confounders, details of the clinical examination, the arterial blood gas results after apnea testing, the indication for and results of ancillary testing (if performed), and the time of death.⁴

The 2010 AAN practice parameter did not address the qualifications to perform a determination of DNC, but a review of 492 institutional policies on DNC from hospitals in the United States demonstrated variability in the type of clinician allowed to complete a determination.⁶ A paucity of hospitals only allowed neurology or neurosurgery attendings to perform determinations of DNC. The World Brain Death Project recommended that determinations of DNC should be performed by clinicians who (1) have completed training, (2) are licensed to practice medicine independently, (3) are trained in determination of DNC and counseling families at the end of life, and (4) have experience in the management of devastating brain injury.⁷ Although this recommendation did not restrict determination of DNC to specialists with a particular background, the findings of Lele et al.² demonstrated that concerns about documentation of determinations of DNC are less common in hospitals with a dedicated neurocritical care unit/service. Relatedly, it has previously been suggested that outcomes for patients with severe brain injury are better when they are cared for in a dedicated neurocritical care unit.⁸

Lele et al.² also reported that a review of informal free text notes by OPO coordinators demonstrated that the treating physician often asked their input on the determination process (n = 64) and sometimes seemed to be unfamiliar with their institutional policy on determination of DNC (n = 23). In their aforementioned survey on determination of DNC, Braksick et al.⁵ similarly found that 15% of all respondents did not feel competent performing a determination of DNC. In addition, a quarter of all respondents (24%) reported that they had no formal training in determination of DNC.

At the 2016 summit, the AAN and other stakeholder organizations in the determination of DNC acknowledged the need to develop and promote educational initiatives and credentialing programs for clinicians involved in the determination of DNC.¹ The World Brain Death Project also recommended that education about DNC should be incorporated into all training programs for clinicians who manage patients with devastating brain injuries.⁷ To facilitate or augment education about DNC, the Neurocritical Care Society created a web-based didactic course that was endorsed by the AAN.⁹ The course offers self-assessment continuing medical education credit and addresses (1) components of the evaluation, (2) prerequisites, (3) the clinical examination, (4) apnea testing, (5) ancillary testing, (6) documentation, and (7) communication. It also includes a 20-question multiple-choice examination, completion of which could potentially be required for credentialing in the future, akin to the Advanced Cardiovascular Life Support certification courses.

LifeCenter Northwest should be applauded for designing a process to ensure that determinations of DNC for all patients being considered for organ donation are performed in accordance with accepted medical standards.² However, it is the responsibility of clinicians to (1) only perform evaluations for the determination of DNC if they are appropriately trained and comfortable with the evaluation process and (2) to follow accepted medical standards on the determination of DNC. Furthermore, it is the responsibility of each hospital to ensure their institutional policy on the determination of DNC conforms to accepted medical standards. Finally, it would be ideal to establish regulatory oversight of the determination of DNC, similar to the certification of stroke centers.¹

Study Funding

No targeted funding reported.

Disclosure

A. Lewis reports no disclosures relevant to the manuscript. Full disclosure form information provided by the author is available with the full text of this article at Neurology.org/cp.