By Lauren Koffman, DO, MS
The Neurocritical Care Society (NCS) recently released the Brain Death Determination course to assist physicians on diagnosing brain death, created by David Greer, MD; Ariane Lewis, MD; Matthew Kirschen, MD, PhD; and Michael Rubin, MD. This group had previously worked together on the topic of brain death within the American Academy of Neurology, and had the opportunity to design the most practical and up to date brain death course. All members of the group have personal interests in the realm of brain death determination. Many of us can resonate with Dr. Rubin’s personal interest on this topic, saying it is “one of the most profound things we do in neurocritical care — something we have to get right.”
When asked about why this course was needed, there was a consensus amongst the group that there is a need for a uniform approach to the declaration of brain death. Dr. Greer recalls a time when he was practicing within a hospital system, but each hospital had its own protocol for determining brain death. This experience led him to examine what, if any, variability may exist in the United States. His 2015 study included 492 hospitals’ brain death determination policies and found there was significant variability in multiple domains, including absence of hypotension and hypothermia, specifications of all aspects of testing (clinical examination and apnea testing) as well as appropriate ancillary testing.1 This led him to recognize the need for proper testing and more meticulous diagnoses, with zero false positives.
The course follows the 2010 American Academy of Neurology guidelines and includes a one-hour video and a 20-question exam, with 80% completion required to pass. The course is designed to be as close to a simulation as possible, most valuable for those without access to in-person instruction, simulation or limited real-life exposure. Content includes the prerequisites for testing, documentation, determination of brain death (clinical examination, apnea testing, ancillary testing) and communication of the diagnosis. Beyond these basics, additional challenging situations are addressed, including determination on extracorporeal membrane oxygenation and after targeted temperature management. Even though the course has just launched, there are already plans for the next version to include more video footage, specifically apnea testing, as well as integration of decision making into the assessment portion.
This comprehensive course includes Dr. Kirschen’s insights as a pediatric neurointensivist because as he says, “death should be death, no matter how old you are.” Many of us do not routinely care for pediatric patients, but as pediatric neurointensivists are such a small subspecialty, this course provides one educational platform for all ages. The Brain Death Determination course includes minor differences that should be accounted for in the pediatric patient population: drug metabolism, blood pressure parameters, infantile reflexes and ancillary testing.
While participants can only claim CE credits (2.0 hours) at this point, it does establish a level of competency. Dr. Lewis says that “the distinction between life and death must be made with certainty, and ensuring that is the case requires all clinicians involved in brain death determination to be aware of the intricacies of the process.” As there is no current credentialing tool for the determination of brain death, there is a possibility for future iterations of the course to be recognized as a formal assessment of competency, if collaboration can occur with an accreditation body, such as The Joint Commission. Just as BLS/ACLS have become the standard for cardiac arrest, this may be the future method for standardizing the approach to brain death determination education and assessment of competency.
For more information on the course or to enroll, please visit: https://www.neurocriticalcare.org/education/braindeath.
- Greer DM, Wang HA, Robinson JD, Varelas PN, Henderson GV, Wijdicks EFM. Variability of brain death policies in the United States. JAMA Neurol. 2016;73: 213-218.