Requiring a second exam on a person considered brain dead is not only unnecessary, it can cause significant harm, according to research published in the December 15, 2010, online issue of Neurology. Hospitals need to change their policies on assessing brain death, and they need to do it quickly, says Dana Lustbader, MD, FCCM, FCCP, with The North Shore LIJ Health System in Manhasset, N.Y., one of the authors.
A single brain-death examination for patients (older than one year) is adequate, and the requirement for a second examination results in significant delay in brain-death diagnosis, adds anguish for grieving families, increases ICU costs, and reduces organ donation rate, they conclude.
Investigators reviewed the cases of 1,229 adults and 82 children ages one and older who were pronounced brain dead. The study found that none of those declared brain dead in the first exam was found to have restored brain stem function in the second exam. The information was taken from the New York Organ Donor Network database during a 19-month period.
In fact, not a single patient has recovered between the first brain-dead exam and the second, Lustbader reports; one neurologic examination performed by a skilled examiner is reliable. What about reports of “recoveries” one occasionally reads about? Patients who regain consciousness after “brain death” were never truly brain dead, she explains. They were in a coma or a persistent vegetative state. No one recovers from brain death, she says.
That second brain-death exam can cause significant harm, she says: Not only is the opportunity for organ donation reduced, but families may endure unnecessary suffering while waiting an average of 19 hours for that second, unnecessary, exam to be completed.
Lengthy waiting times appeared to make families more reluctant to give consent for organ donation, researchers found. As the time between exams increased, consent for organ donation decreased from 57% to 45%. Likewise, refusal of organ donation increased from 23% to 36% as the time between exams increased.
Moreover, organ viability decreases the longer a person is brain dead; 12% sustained a cardiac arrest while awaiting a second exam or after the second exam, making them ineligible for organ donation.
It also costs money, she adds: A repeat exam adds an extra day of intensive care resulting in additional costs of about a million dollars per year in the New York region alone. It is, she tells HealthLeaders Media, “postmortem care in the ICU.”
In 2010, the American Academy of Neurology updated its brain-death guidelines, which now call for only one brain-death examination. That should be the new standard, but it isn’t widely adopted. This study supports that approach and details the harm of waiting for a second exam. There is simply no benefit to a second exam, says Lustbader. Hospitals must now revise their policies to prevent such avoidable harm, she says. “This should be a wakeup call.”
An editorial in the same issue, by Gene Sung, MD, MPH, of the University of Southern California in Los Angeles, endorses her call to action: "This study helps build the case for a single competent brain death examination or ancillary study when the examination cannot be performed.”