Are hospitals doing everything they should to make sure they don't make mistakes when declaring patients brain-dead? A provocative study finds that hospital policies for determining brain death are surprisingly inconsistent and that many have failed to fully implement guidelines designed to minimize errors.
"This is truly one of those matters of life and death, and we want to make sure this is done right every single time," says David Greer, a neurologist at the Yale University School of Medicine who led the study.
Greer helped write a detailed set of guidelines in 2010 that the American Academy of Neurology recommended every hospital follow when declaring patients brain-dead.
"The worst-case scenario would be if we were to pronounce somebody brain-dead and then they recovered some neurological function," Greer says. "That would be horrific if that were the case."
To see how well the guidelines have been adopted, Greer and his colleagues analyzed policies at 492 hospitals and health care systems across the country. While most have adopted the guidelines, the researchers report Monday in the journal JAMA Neurology that there are significant differences in how the key parts of the guidelines have been accepted.
More than 20 percent of the policies don't require doctors to check that patients' temperatures are high enough to make the assessment, as the guidelines call for. "If somebody has a low temperature then their brain function can actually be suppressed based on that," Greer says.
Almost half of policies don't require doctors to ensure patients' blood pressure is adequate for assessment of brain function. And some say doctors can skip tests that the guidelines recommend.
In addition, most of the policies don't require that a neurologist, neurosurgeon or even a fully trained doctor make the call. "In some hospitals they actually allowed for a nurse practitioner or a physician assistant to do it," Greer says.
Based on the findings, Greer says compliance needs to improve. "There are very few things in medicine that should be black and white, but this is certainly one of them," he says. "There really are no excuses at this point for hospitals not to be able to do this 100 percent of the time."
In a statement sent by email, Dr. John Combes, chief medical officer at the American Hospital Association, said that hospitals "work hard to reflect various national-based guidelines, as well as state and local regulations, as well as consulting multi-disciplinary advisory committees, in this very complicated arena." He added that the study "shows improvement associated with certain national guidelines" and also "serves as a reminder for hospitals and health systems to review these important policies."
Yale's Greer isn't alone in criticizing hospitals' lapses in implementing the guidelines.
Boston University bioethicist Michael Grodin calls the findings "unconscionable."
Dartmouth College neurologist James Bernat, a leading authority on brain death, says, "It's disturbing that despite all of the educational intervention to try to bring doctors up to the national standards that there remains such great variability."
The lack of uniformity could erode public trust, which could make people reluctant to become organ donors or donate their loved ones' organs. "If one hospital is using a testing method that's different from another hospital, people might wonder: 'Are they really dead?'" says Leslie Whetstine, a bioethicist at Walsh University in Ohio.