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Hospitals vary widely in determining brain death and few adhere to parameters set by the American Academy of Neurology (AAN), according to a survey of respected neurology and neurosurgery facilities in the United States. Researchers requested guidelines for determination of brain death from the top 50 neurology and neurosurgery facilities named by U.S. News and World Report in 2006. Of the 41 facilities responding, 3 had no specific guidelines. Using information provided by the remaining 38 facilities with guidelines, researchers evaluated five categories of data: guideline performance, preclinical testing, clinical examination, apnea testing, and ancillary tests. Then they compared each facility's guidelines to those of the AAN for consistencies and differences.
Just 42% of facilities required that a neurologist or neurosurgeon be involved in brain death determination. In 37% of guidelines, the cause of brain death wasn't established as required by AAN guidelines, researchers were surprised to discover.
Overall, facilities adhered well to most of the AAN guidelines for the clinical examination. But fewer than half of the facilities required testing for pain above the foramen magnum, jaw jerk, and documentation of the absence of spontaneous respirations, as specified in AAN guidelines.
Researchers also found poor compliance with some other AAN recommendations, such as ruling out sedative and paralytic drug effects, severe acid-base disorders, and endocrine disorders. Of the 71% of facilities that required multiple examinations before a determination of brain death, the time required between exams varied from 1 hour to 24 hours.
Researchers say that if their findings reflect actual practice at each facility, these substantial differences have serious medical, ethical, and legal implications for the determination of death.
Greer DM, et al., Variability of brain death determination guidelines in leading U.S. neurologic institutions, Neurology, January 22, 2008.
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