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Update of clinical practice guidelines for brain death determination in an academic heath center.


Brain death (BD) is determined after a patient has sustained some form of a catastrophic neurologic injury that results in an irreversible loss of cerebral and brain steam function. Variability is caused by the small number of patients who progress to BD annually causing a lack of opportunity for physicians and healthcare staff to stay competent in performing the examination. Background: The current University of Cincinnati Medical Center policy on BD had not been updated since publication of the 2010 American Academy of Neurology guidelines on this subject. The diagnosis of BD in the medical community is an acceptable medical diagnosis, but the examination is difficult to perform, and explaining this diagnosis to a family can be challenging related to the emotions involved with discussing end of life. The goal of updating the current policy was to decrease variability in testing through consistency of practice among clinicians performing the examination. Methods: An integrative review of the evidence-based literature was conducted to identify articles discussing both BD confirmation and secondary confirmatory testing. Using this integrative review, results from hospital-based chart reviews, and targeted provider surveys, a policy update was completed. The bedside medical clinicians were provided this policy with evidence-based guidelines regarding performance of the clinical examination and confirmatory testing needed to diagnose BD and then communicate this diagnosis to the family. Results: The current hospital policy lacked two important components of any BD policy: (a) the apnea test techniques and (b) guidance regarding secondary confirmatory testing. Both components were added during revision of the policy. Implementation of the new policy occurred through computer-based training that incorporated both didactic education of the updates and a video demonstration of a BD examination. Discussion: A better defined policy for determining BD is essential. In addition, the implementation and quality assurance elements of the policy are necessary for efficiency and clinical decision making. By updating the policy within the University of Cincinnati Medical Center, the clinicians have been equipped with the latest evidence to perform the clinical examination for diagnosis of BD and then appropriately communicate this diagnosis to the family.

Keywords: brain death, brain death confirmatory test, brain death examination, la coma depasse, organ donation, permanent unconsciousness


Few diagnoses affect a patient and family more than that of brain death (BD). BD, or death by neurological criteria, is determined after a patient has sustained some form of catastrophic neurological injury resulting in irreversible loss of cerebral and brain stem function. The U.S. Government Information on Organ and Tissue Donation and Transplantation (2012) reports that only l%-2 % of all annual deaths in the United States are classified as BDs. Examples of some primary neurologic conditions that may result in BD include severe traumatic head injury, aneurysmal subarachnoid hemorrhage, large ischemic or hemorrhagic stroke, brain tumor, or cerebral edema due to infections or metabolic encephalopathies (i.e., hypoxia, fulminant hepatic failure, hypertensive crisis). However, establishing this diagnosis can be challenging to the medical community because of the etiology of a neurologic injury. The patient often is hemodynamically stable with nonnal vital signs, but a computed tomographic (CT) scan may show diffuse, brain edema, or a cerebral CT angiography (CTA) will show absence of intracerebral blood flow. The determination of BD was established by a set of guidelines researched and published by the American Academy of Neurology (AAN) and relies heavily on a clinical examination performed by a physician.


BD was first described by Mollaret and Goulan, in 1959, as an irreversible coma (la coma depasse). They described 23 comatose patients who had lost all brain stem reflexes and shown a flat electroencephalogram (EEG; Greer, Varelas, Haque, & Wijdicks, 2008). Since 1959, when the diagnosis of la coma depasse was first accepted in the medical community, there have been no published reports of patients who had recovery of neurologic function after BD has been determined based on appropriate clinical testing (Wijdicks, Varelas, Gronseth, & Greer, 2010).

In 1968, an ad hoc committee at Harvard Medical School reexamined the definition for determination of BD. The guidelines published by the Harvard ad hoc committee defined BD as "unresponsiveness and lack of receptivity, the absence of movement and breathing, the absence of brain-stem reflexes, and coma whose cause has been identified" (Wijdicks, 2001, p. 1215). In 1976, the international community published a statement from the United Kingdom stating "brain function: without it, no life exists" (Wijdicks, 2001, p. 1216).

The United States President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research pushed forward a legislative act calling for a standard protocol for the determination of BD. This legislation became known as the Uniform Death Act (UDA) and was passed by the President's Commission in 1981. The UDA established that the definition of death was more than just cessation of function of the heart and lungs but also irreversible loss of function of the entire brain including the brain stem while systemic organs were still supported by artificial means. This action had profound ethical and legal impact on the medical community. The UDA forced the community to begin to diagnose death as more than just stoppage of heart and lung function but also as cessation of whole brain function. Because of the UDA, many states followed with their own legislation to address the issue of determination of death. The state of Ohio passed State Legislative Code 2108.30 in November 1981, in which an individual is determined to be dead if he has sustained irreversible cessation of either circulatory and respiratory functions or all functions of the brain in accordance with acceptable medical standards (Greer et al., 2008). This legislation forced the medical community and, specifically, hospitals within the state of Ohio to create policies defining the medical standards around the determination of BD.

To help with this process, practice parameters were published by the AAN in 1994. These practice parameters provided guidelines for the medical community to follow when determining BD. Standardization of the clinical examination provided the medical community with a unified approach for the determination of BD. This process was again revisited in 2007 and in 2010 by the AAN, who published revisions to the 1994 guidelines stressing the importance of adhering to three distinct steps in determination of cessation of whole brain function enabling the physician to accurately document and declare BD (Drazkowski, 2007; Wijdicks et al., 2010).

Despite this diagnosis being an acceptable declaration of death among the medical community and a clear set of guidelines published by the AAN for physicians to follow, the risk for variability continues to be shown in the literature. This variability is caused by the small number of patients who progress to BD annually (1%-2% of the total deaths in the United States). The available literature has shown that a diagnosis of BD has discrepancies, variability, limitations, and pitfalls among clinicians, specifically related to guideline adherence regarding evaluation of brainstem function and the apnea test as well as the indications and options for secondary confirmatory testing (Greer et al., 2008). The risk for variability in a clinical BD examination among healthcare providers is increased by a lack of opportunity to perform the examination.

Studies have shown that the comfort level of a physician in performing a clinical BD examination is weak and supports the need for a well-defined policy within the hospital. Burns and Login (2002) specifically outlined two critical lessons that clinicians need to learn: (a) the need for a rigorous understanding of how to diagnose BD and (b) the distinction between grave prognosis and BD. Other studies have shown that physician groups most comfortable in performing the examination are neurologists and neurosurgeons, and often, they only conduct 25-30 examinations per year, leaving room for other physicians within the organization to perform even fewer examinations resulting in less confidence in performing the examination. Joff, Anton, Duff, and deCaen (2012) and Chin, Kwek, and Lew (2007) sent out questionnaires exploring how clinicians felt about BD. Chin et al. found that a well-written detailed protocol regarding how to perform a BD examination provided both inexperienced and experienced clinicians with confidence when performing the examination. Results from the questionnaire distributed by Joff et al. showed that some neurologists felt BD is a state of permanent unconsciousness and equal to cardiac death.

Multiple studies have examined the actual performance of the BD examination in hospitals (Chen et al., 2008; Chin et al., 2007; Joff et al., 2012; Levesque et al., 2006; Varelas et al., 2011; Vivien et al., 2006; Wijdicks, Rabinstein, Manno, & Atkinson, 2008). Wijdicks et al. (2008) found that BD examinations were done most often by neurointensivists or neurosurgeons, and these examinations more accurately followed the AAN guidelines for testing, including performance of the apnea test. Varelas et al. (2011) found that there was no difference in the incidence of laboratory work on patients, consent rates, or organ recovery/transplantation when physicians performed two separate examinations versus performing a single examination. Currently, the 2010 AAN guidelines do not require two separate BD examinations.

The BD examination is composed of several components including determination of brain stem function, an apnea test, and secondary confirmatory testing. The apnea test is the most essential component of the BD examination. If done incorrectly, it can lead the patient to decompensation and the complete cessation of circulation. Researchers have assessed different methods of providing and monitoring oxygenation during the apnea test. The use of continuous positive airway pressure during the apnea test helped maintain higher levels of arterial oxygen saturation (Levesque et al., 2006). Transcutaneous carbon dioxide partial pressure (PtcC[O.sub.2]) monitoring has also been found to shorten the duration of the apnea test by providing a more accurate timing for measuring the arterial carbon dioxide partial pressure (PaC[O.sub.2]; Vivien et al., 2006). Both the studies have potential to decrease the occurrence of complications such as hypoxemia or hypotension during apnea testing.

A final area of study centers on appropriate confirmatory tests that may be done to provide additional diagnostic information for assessing absence of brain function if the patient is unable to tolerate any part of the clinical examination. Combes, Chomel, Ricolfi, Athis, and Freysz (2007) compared CTA with cerebral angiography and found that CTA could act as a radiological tool to confirm BD. An observational study was completed to determine accuracy of CTA compared with EEG as a confirmatory test after BD was determined (Quesnel et al., 2007). This study concluded that CTA could not be recommended as a means of BD confirmation; therefore, the healthcare team should continue to utilize EEGs as their confirmatory test after a clinical diagnosis of BD has occurred (Quesnel et al., 2007). Assessment of the use of CTA and CT perfusion in determining cerebral circulatoiy arrest was considered a confirmatory test after diagnosis of BD by a clinical examination (Escudero et al., 2009). An additional prospective multicenter study validated the sensitivity of a simplified 4-point CTA versus the normal 7-point CTA currently used to confirm BD (Frampas et al., 2009). Several years later, Berenguer, Davis, and Howington (2010) conducted a prospective nonrandomized trial comparing whether CTA is an equivalent confirmatory test for BD as a nuclear medicine perfusion test (NMPT). They found a strong positive correlation (r = .66) between the use of CTA and NMPT to confirm BD. This study found that CTA may be the new norm as a confirmatory test because it is quicker (30 minutes) than NMPT (1 hour), which can help to bring more timely closure to families waiting for news of their loved one.

The creation of a well-defined hospital BD policy that follows AAN guidelines for performing a BD examination, along with a checklist for the clinicians that provides step-by-step instructions for examination performance and indications for confirmatory testing, should achieve the goal of decreasing variability in the process of detennining BD.


Despite the diagnosis of BD being an acceptable declaration of death among the medical community since 1968, University of Cincinnati Medical Center (UCMC)'s first policy was not written until 1984, and the current policy was last updated in February 2007. After extensive side-by-side review of the UCMC policy and the 2012 AAN BD guidelines by the chief nursing officer, the current policy was found to be outdated and not reflective of the published criteria.

Before updating the BD policy, four actions were undertaken. First, an integrative review of the evidencebased literature was conducted to identify articles on both BD confirmation and secondary confirmatory testing literature. The search included review of the CINAHL, PubMed, MedLine, and Cochrane Library databases. Key words used in the search included brain death, brain death examination, brain death confirmatory test, permanent unconsciousness, la coma depasse, organ donation, donation, and a combination of the words listed. Inclusion criteria for this review were adult brain-dead patients, BD determined by a medical physician, and both national and international studies. The only exclusion criteria were articles referencing pediatrics (children aged 0-18 years).

Second, a retrospective chart review was performed to determine the adequacy of documentation of the BD examination. The chart review was conducted by a neuroscience critical care nurse using a checklist created to reflect all the guidelines needed for documentation of BD. Third, a workforce needs assessment was conducted through the use of targeted focused groups of 18 critical care physicians and 54 bedside critical care nurses at UCMC. The questions were developed from concepts in the literature that are important to the study and targeted how the physicians and staff felt about performance, documentation, and conversation with the patient's family around BD. Finally, a critical review was undertaken of the current UCMC policy regarding BD to identify discrepancies with current guidelines and gaps in information.


The literature review identified 23 articles that met inclusion criteria. The focus of these articles was on historical reviews of the development of BD policies (5 articles), issues regarding performance of the examination (6 articles), and evaluations of confirmatory test methods (10 articles). Of note, there were no well-designed meta-analysis or systematic reviews identified. Several themes were present in the literature. Most notably, the risk for variability continues to be shown and caused by the small number of patients who progress to BD annually (1%-2% of the total deaths in the United States). The available literature has shown that a diagnosis of BD has discrepancies, variability, limitations, and pitfalls among clinicians, specifically related to guideline adherence regarding evaluation of brainstem function and the apnea test as well as the indications and options for secondary confirmatory testing (Greer et al., 2008). Studies also showed that the comfort level of a physician in performing a clinical BD examination is weak because it relates to competencies and emotional involvement (Chin et al., 2007; Joff et al., 2012).

The retrospective chart review revealed that there was inadequate documentation of BD criteria. The sample included all brain-dead solid organ donors who met criteria for lung donation at UCMC from January 1, 2008, through December 31,2010, which totaled a review of 68 donor charts. Upon chart review, variability existed with documentation and the BD procedure. For example, 13 charts (n = 68) were missing the BD determination form; therefore, there was no standard documentation. Of those that included the determination form (n = 55), the review revealed 22 charts with skipped steps or revealed improperly performed tests. In order for documentation to be complete, examinations were to be completed by two physicians documenting, at minimum, time of death and brainstem reflex. Charts were required to be signed by both physicians at the time of examination. Inadequacies in documentation (n = 68) included a lack of time-of-death documentation by both physicians (MD 1 = 100%, MD 2 = 35%), brainstem reflex yes/no boxes not checked (MD 1 = 16%, MD 2 = 38%), and a lack of both physicians' signature every time (MD 1 = 100%, MD 2 = 77%).

The needs assessment survey was sent to 30 physicians and 100 critical care nurses. The response rate was 60% for physicians and 54% for nurses with an overall response rate of 55% (72/130). The three main perceptions were identified concerning the BD examination during the needs assessment: (a) variability in the examination (63%, n = 72), (b) a lack of defined competencies for the BD examination (100%, n = 72), and (c) lack of defined core physicians responsible for the BD examination (50%, n = 72). In addition, the bedside nursing staff expressed a desire to only have a neurocritical care intensivist, neurologist, neurosurgeon, or trauma surgeon perform the examination. Reasons cited for this preference included (a) increased comfort level regarding knowledge base and expertise with the examination, (b) decreased variability in performing the examination, and (c) better ability to communicate openly and honestly with the patient's family.

The critical review of the UCMC policy regarding BD found that it was last updated in February 2007. This policy lacked two main components that would assist providers performing the examination: (a) guidance regarding perfonnance of the apnea examination and (b) recommendations regarding indications for secondary confirmatory test. The review showed a need for an update to reflect both the 2010 national guidelines endorsed by the AAN and additional evidence-based literature. The key changes to the old policy from 2007 to 2013 are outlined in the Table 1.

The apnea examination portion of the current policy was weak, with limited explanation on how to complete the examination. Performed incorrectly, the apnea portion of the examination can cause complications such as hypoxemia or hypotension to the patient during the examination, causing instability. The new BD policy outlines a step-by-step process the clinician must follow to complete the apnea test properly. The other essential component not mentioned in the 2007 policy was the confinnation of BD by a secondary confirmatory test. A confirmatory test is performed when the patient is unable to tolerate a specific component of the clinical examination to provide additional diagnostic information to assess absence of function. The new policy provides a definition around when to complete a secondary confirmatory test and the four acceptable testing options (EEG, conventional angiography, nuclear flow study, and transcranial doppler ultrasonography), as identified in the updated 2010 AAN BD guidelines. The process for execution of the new policy is outlined in Figure 1.


The comprehensive literature review showed an understanding of the problems facing BD examinations and the perceptions surrounding them by clinicians. Perception often becomes reality and may taint the view of those involved. The studies utilized in the update of the policy helped UCMC consider the heightened emotions and ethical concerns surrounding a diagnosis of BD. In addition, it provided valuable information regarding an ongoing opportunity to decrease examination variability by limiting the number of physicians credentialed to perform the examination. This provides an opportunity for UCMC to improve newly developed policy/guidelines by limiting the number of physicians credentialed to perform the examination from 350 down to 75 including neurosurgeons, neurologists, neurocritical care, and trauma surgeons. The evidence provided from the literature review will provide a basis for implementation and background to the staff assisting with the examination and help to reassure families who ultimately have to understand the results of the examination.


The retrospective chart review suggested that UCMC may benefit from the addition of a new clinical position in conjunction with any updated policy. The position required someone with expertise in BD criteria who would be key to addressing variability among clinicians around both the clinical examination and the secondary confirmatory examination. UCMC decided to call this additional position the "in-house donation coordinator" (IHC). The IHC is responsible for promotion, facilitation, and ongoing implementation of an effective BD examination along with assisting in the organ and tissue donation process. Initially, UCMC utilized a critical care nurse in the position but quickly realized that a respiratory therapist was a better fit for the IHC position. The respiratory therapist was favored because of their knowledge and expertise in lung/ ventilator management. The final UCMC care model is two respiratory therapists sharing coverage of the IHC duties. This arrangement has improved and fostered effective communication among the interdisciplinary healthcare team members during the examination. It has also promoted a positive experience for both the healthcare team and the patient's family and will continue to help to reduce conflict between care providers, including the bedside nurse, respiratory therapist, and clinicians. This position has enhanced care by educating the interdisciplinary team concerning the BD examination and donation process. It has also helped decrease UCMC's variability in the performance of the BD examination. Ultimately, positive relationships between members of the healthcare team will affect the perception of the patient's family and allow them to accept a declaration of BD and, ultimately, organ donation as the right decision for their loved one.

The needs assessment quickly identified many opportunities for improvement including inclusion of competencies for all care providers involved in a BD examination, examination of potential drivers and gaps around implementation, and understanding of the clinicians' current ability to adopt and consistently perform a BD examination through utilization of the updated policy. Numerous studies have identified variability as a potential limitation or have referenced the lack of understanding among care providers related to performing the actual examination. The retrospective chart review confirmed that variability was problematic at UCMC. This lack of documentation led to additional questions regarding concerns about a lack of competency and comfort levels in performing and documenting the examination. The results from the targeted surveys of physicians and bedside nurses at UCMC validated these findings that variability existed among physicians who perform the examination. It is believed that variability will continue to be a concern because of the small number of patients who progress to BD annually and the lack of opportunity to perform the BD examination. Opportunity does not exist for staff to practice this examination regularly; however, revision of the policy and procedure along with continuing competency assessment may allow for decreased variability in the examination as well as improved documentation.

The assessment also showed a need to review and update the current infrastructure to decrease the number of physicians who can actually perform and declare a patient BD. Currently, all 350 credentialed inpatient physicians are able to declare a patient BD. The assessment showed a lack of competency and comfort among the physicians, which, as previously mentioned, can lead to variability. Our results showed that the bedside nursing staff preferred that the BD examination be performed by a specific group of providers because of perceptions that they had more expertise with the examination and surrounding issues relative to communication of the results. If UCMC were to narrow the number of physicians qualified to perform the clinical examination to the approximately 60 neuroscience physicians and 12 trauma surgeons, variability among physicians would likely decrease and provide greater comfort to the clinical staff assisting with the examination.

Finally, the needs assessment showed that, to understand the patient population, physicians should have competency in providing care to patients sustaining primary neurologic diseases including aneurysmal subarachnoid hemorrhage, traumatic brain injury, large stroke, or secondary insult because of brain swelling. There are additional medical and/or surgical primary disease diagnoses that can result in irreversible loss of whole brain function and lead to a determination of BD, such as hypoxic-ischemic brain insults and fulminant hepatic failure. On average, UCMC reports between 350 and 400 cases of patients meeting the criteria of potential imminent death to LifeCenter, the hospital's organ and tissue procurement agency. The criteria of potential imminent death include a documented brain injury, ventilator dependency, and a Glasgow Coma Scale of less than 5. UCMC declares that, on average, 45-50 of those 400 potential patients become brain-dead patients each year.

Implementation of the updated new BD examination policy will occur through an online computer-based educational module. The educational module will utilize a PowerPoint presentation that will include a video demonstration of a BD examination being performed. The participants of the educational module will be the 350 credentialed physicians, 500 critical care nurses, and 25 respiratory therapists who work within one of the five critical care units at UCMC. Each participant of the module will take a short pretest, watch the PowerPoint and video, and then take a posttest evaluating comprehension and understanding of the policy.

The policy change/update will be implemented in all of the ICUs (surgical, neuroscience, burns, medical, and cardiac ICUs) within UCMC. It is felt that the new policy will decrease the variability that currently exists among providers as identified during the workforce needs assessment. The policy revisions should help prevent the wrong diagnostic test from being ordered by the physician when time matters most as well as saving valuable healthcare dollars.

Many gaps still exist related to BD in both the clinical examination and recommendations for confirmatory testing when the patient is unable to complete the clinical examination. There are a moderate number of research articles discussing BD that identify potential gaps and areas for added research. The first gap identified in the research was the clinical performance of the BD examination. Another gap identified was the small sample size for the studies. There is a consistent recommendation for further research involving multicenter designs to obtain larger sample sizes. Another limitation concerning confirmatory testing is the possibility for contrast-related kidney injury that could impact on the potential for future organ donation. Finally, review of the studies conducted via a retrospective chart review could prove limiting because there is perceived bias built into the review. Chart reviews often identify omissions in documentation of necessary laboratory results, vital sign numbers, and essential clinical examination information. Addressing these gaps in literature by conducting future research will continue to benefit clinical staff involved in performing BD examinations.


The integrative literature review for this project indicates an ongoing need to study and review current BD guidelines and policies, specifically related to the apnea examination and secondary confirmatory test, and include meta-analyses or systematic reviews. A better defined, evidence-based determination of BD policy was developed and implemented at UCMC. The goal of the policy change is to assist physicians at UCMC feel confident when performing a BD examination on a patient suspected of cessation of brain function. The new policy addressed the need to decrease variability among clinicians as well as define the secondary confirmatory test and outline the apnea test parameters. After implementation of the policy, a quality assurance process was developed to improve efficiency and clinical decision making during the examination. Additional research will need to focus on strengthening the clinical expertise of those conducting the examination at UCMC and building a team approach where all personnel involved in the examination understand their role and perform it with accuracy every time.

In the medical community, cessation of brain function is an acceptable medical diagnosis. There is no evidence published reporting recovery of neurologic function after BD has been diagnosed (Wijdicks et al., 2010). Although BD is an acceptable diagnosis, this does not make confirmation an easy examination to perform or help ease the difficulty of the conversation with families or loved ones. By updating the policy at UCMC, the medical and bedside staff will be better equipped with the latest evidence to perform the clinical examination to diagnose BD and then communicate this diagnosis with the family.


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Questions or comments about this article may be directed to Jennifer Jackson, DNP, at She is a Chief Nursing Officer at University of Cincinnati Medical Center, Cincinnati, OH.

Melissa Willmarth-Stec, DNPAPRN, is an Associate Professor of Clinical Nursing at the University of Cincinnati, College of Nursing, Cincinnati, OH.

Lori Shutter, MD, is a Professor at Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA.

The authors declare no conflicts of interest.

DOI: 10.1097/JNN.0000000000000110
TABLE 1. Changes to Brain Death Policy

Changes                        2007                 2013

Guidelines for              Listed        Defined in greater detail
determination of brain

Steps to perform the        Absent        Add and defined
clinical examination

Brain stem function         Listed        Defined in greater detail

Apnea examination           Absent        Steps outlined with

Secondary confirmatory      Absent        Options defined

Laboratories needed from    Listed        Result ranges defined
determination of brain

Core body temperature       Hypothermia   Core temperature defined

Hemodynamic                 Mentioned     Ranges defined for
                                          performance of

Checklist (Appendix C)      Available     Attached as addendum to
                            on units      policy
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Author:Jackson, Jennifer; Willmarth-Stec, Melissa; Shutter, Lori
Publication:Journal of Neuroscience Nursing
Article Type:Report
Geographic Code:1USA
Date:Feb 1, 2015
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