The American Academy of Neurology (AAN), with endorsements from the Child Neurology Society and the American Neurological Association, has released a new position statement1 in support of the development of uniform legislation on brain death.

While evidence-based guidelines2,3 exist for the determination of brain death in infants, children, and adults, Nevada is currently the only state to adopt laws that require adherence to these guidelines.

“The AAN believes that a specific, uniform standard for the determination of brain death is critically important to provide the highest quality patient-centered neurologic and end-of-life care,” said position statement author James Russell, DO, MS, of Lahey Hospital and Medical Center in Burlington, Massachusetts, an AAN fellow and chair of the AAN Ethics, Law and Humanities Committee, in a statement.4 “The AAN supports the development of legislation in every state modeled after the Nevada statute, which specifically defers to these current adult and pediatric brain death guidelines and any future updates.”4

The position statement, published in Neurology, also calls for uniform adoption of these protocols across medical institutions, as inconsistency in adherence can contribute to different interpretations of brain death and create complicated, painful scenarios for physicians and families alike. Incidents in which this has been the case have been broadcast across national news over the last few years, highlighting the need for consistency in practice.

In line with the current Nevada statute, the AAN recommends the following actions be put in place:

The development of uniform institutional policies on brain death, in accordance with current guidelines, within all US medical facilities;

  • Training programs for physicians who determine brain death;
  • The creation of credentialing mechanisms for physicians, regardless of specialty, who may be involved in brain death determination;
  • Institution-based policies that enforce compliance with medical standards for determining brain death;
  • Increased research to further understand brain death and improve the accuracy of its determination; and
  • Enhanced public and professional education about these standards

The position statement also addresses requests for accommodation, from both physicians and caretakers, in the case that brain death determination or removal of life-sustaining measures is not in accordance with emotional or religious influences, or other legal or social considerations. The statement advises that should a physician be opposed to determination of brain death or continued care of the patient, he or she should seek transfer of their responsibility to another qualified physician.

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In an effort to enhance trust with caretakers, the statement recommends that physicians explicitly communicate that the patient is alive before undertaking a brain death examination; the exam should also follow a candid conversation with those responsible for the patient’s care regarding the medical status and prognosis of the patient.

In the case where there is opposition or a request for accommodation, the AAN recommends that physicians undertake a sensitive and empathetic position in an effort to reconcile differences in a way that is satisfactory to all parties involved, included but not limited to loved ones and lawful healthcare proxies, the medical care team, and institutional leadership. Still, the AAN points out that there is “no ethical obligation to provide medical treatment to a deceased person,” recognizing the potential for “harm to the patient, the family, or other patients and the health care team from indefinite accommodation.”

“Despite its respect for cultural and religious perspectives, and its empathy for grieving loved ones, the AAN endorses the implicit position of the UDDA that death is a biological reality that may result from irreversible injury to the heart or brain,” the statement authors wrote. “Physicians are uniquely qualified and authorized by their training, experience, and licensure to determine that death has occurred by either a circulatory or neurologic mechanism, and are professionally obligated to make this determination in a timely and accurate manner.”

References

  1. Russell JA, Epstein LG, Greer DM, et al. Brain death, the determination of brain death, and member guidance for brain death accommodation requests: AAN position statement [published online January 2, 2019]. Neurology. doi: 10.1212/WNL.0000000000006750
  2. Wijdicks EFM, Varelas PN, Gronseth GS, Greer DM. Evidence-based guideline update: determining brain death in adults. Neurology. 2010;74:1911–1918.
  3. Nakagawa TA, Ashwal S, Mathur M, Mysore M; The Society of Critical Care Medicine, Section on Critical Care and Section on Neurology of the American Academy of Pediatrics, and the Child Neurology Society. Clinical report: guidelines for the determination of brain death in infants and children: an update of the 1987 task force recommendations. Pediatrics. 2011;128:e720–e740.
  4. AAN calls for uniformity of brain death determination [news release]. Minneapolis, MN: American Academy of Neurology newsroom. Published January 2, 2019. https://www.aan.com/PressRoom/Home/PressRelease/2687