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Diaz Milian R, Moreno Franco P. The Indisputable Finality of Brain Death: Debunking Ambiguities and Reasserting a Fundamental Diagnosis. AJOB Neurosci 2023; 14:274-276. [PMID: 37682660 DOI: 10.1080/21507740.2023.2243879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
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Joffe AR, deCaen A, Garros D. Misinterpretations of Guidelines Leading to Incorrect Diagnosis of Brain Death: A Case Report and Discussion. J Child Neurol 2020; 35:49-54. [PMID: 31566107 DOI: 10.1177/0883073819876474] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Guidelines describe the process necessary for the diagnosis of brain death. We present a case of a 3-month-old former 36-week-gestation infant after a prolonged out-of-hospital cardiac arrest of 37 minutes who was clinically diagnosed as brain dead at 120 hours after the event. Unusual findings included a normal slightly sunken anterior fontanelle, normal cerebral blood flow perfusion scan at 73 hours after the event, only localized parieto-temporal edema on the latest computed tomographic (CT) scan of the brain at 48 hours after the event, and discussion of whether nonconvulsive seizures could have confounded the examination for brain death. In light of these unusual findings, we discuss and highlight what may be common misinterpretations of brain death guidelines that led to the mistaken diagnosis of death (as opposed to severe neurologic injury) in this child.
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Affiliation(s)
- Ari R Joffe
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, Edmonton, AB, Canada
| | - Allan deCaen
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, Edmonton, AB, Canada
| | - Daniel Garros
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, Edmonton, AB, Canada
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Doran M, Black P. Seeing for themselves - healthcare professionals' views about the presence of family members during brainstem death testing. J Clin Nurs 2017; 26:1597-1607. [PMID: 27486846 DOI: 10.1111/jocn.13488] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2016] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To provide an insight into the views of healthcare professionals on the presence of family members during brainstem death testing. BACKGROUND Brainstem death presents families with a paradoxical death that can be difficult to define. International research suggests families should be given the choice to be present at brainstem death testing, yet it appears few units offer families the choice to be present and little attention has been paid to developing practice to enable effective facilitation of choice. DESIGN A qualitative, exploratory design was adopted to understand the perceptions of healthcare professionals. Individual semi-structured interviews were audio-taped and carried out over two months. METHODS A purposive sample of 10 nurses and 10 doctors from two tertiary intensive care units in the United Kingdom was interviewed, and transcripts were analysed using content analysis to identify emergent categories and themes. RESULTS Healthcare professionals indicated different perceptions of death in the context of catastrophic brainstem injury. The majority of participants favoured offering families the choice to be present while acknowledging the influence of organisational culture. Identified benefits included acceptance, closure and better understanding. Suggested challenges involved the assumption of trauma or disruption and sense of obligation for families to accept if choice was offered. Key issues involved improving knowledge and communication skills to individually tailor support for families involved. CONCLUSIONS If families are to be offered the choice of witnessing brainstem death testing, considering that needs and conventions will differ according to global cultural backgrounds, then key needs must be met to ensure that effective care and support is provided to families and clinicians. RELEVANCE TO CLINICAL PRACTICE A proactive approach to facilitating family choice to be present at testing requires the development of guidelines that accommodate cultural and professional variations to provide excellence in end-of-life care.
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Affiliation(s)
- Majella Doran
- Clinical Education Centre, Altnagelvin Hospital, Londonderry, Northern Ireland
| | - Pauline Black
- School of Nursing, Ulster University, Londonderry, Northern Ireland
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Escudero D, Valentín MO, Escalante JL, Sanmartín A, Perez-Basterrechea M, de Gea J, Martín M, Velasco J, Pont T, Masnou N, de la Calle B, Marcelo B, Lebrón M, Pérez JM, Burgos M, Gimeno R, Kot P, Yus S, Sancho I, Zabalegui A, Arroyo M, Miñambres E, Elizalde J, Montejo JC, Domínguez-Gil B, Matesanz R. Intensive care practices in brain death diagnosis and organ donation. Anaesthesia 2015; 70:1130-9. [PMID: 26040194 DOI: 10.1111/anae.13065] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2015] [Indexed: 12/30/2022]
Abstract
We conducted a multicentre study of 1844 patients from 42 Spanish intensive care units, and analysed the clinical characteristics of brain death, the use of ancillary testing, and the clinical decisions taken after the diagnosis of brain death. The main cause of brain death was intracerebral haemorrhage (769/1844, 42%), followed by traumatic brain injury (343/1844, 19%) and subarachnoid haemorrhage (257/1844, 14%). The diagnosis of brain death was made rapidly (50% in the first 24 h). Of those patients who went on to die, the Glasgow Coma Scale on admission was ≤ 8/15 in 1146/1261 (91%) of patients with intracerebral haemorrhage, traumatic brain injury or anoxic encephalopathy; the Hunt and Hess Scale was 4-5 in 207/251 (83%) of patients following subarachnoid haemorrhage; and the National Institutes of Health Stroke Scale was ≥ 15 in 114/129 (89%) of patients with strokes. Brain death was diagnosed exclusively by clinical examination in 92/1844 (5%) of cases. Electroencephalography was the most frequently used ancillary test (1303/1752, 70.7%), followed by transcranial Doppler (652/1752, 37%). Organ donation took place in 70% of patients (1291/1844), with medical unsuitability (267/553, 48%) and family refusal (244/553, 13%) the main reasons for loss of potential donors. All life-sustaining measures were withdrawn in 413/553 of non-donors (75%).
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Affiliation(s)
- D Escudero
- Intensive Care Unit, Central University Hospital of Asturias, Oviedo, Spain
| | - M O Valentín
- Spanish National Transplant Organization (ONT), Madrid, Spain
| | - J L Escalante
- Intensive Care Unit, Gregorio Marañón University Hospital, Madrid, Spain
| | - A Sanmartín
- Intensive Care Unit, Virgen de la Arrixaca Hospital, Murcia, Spain
| | - M Perez-Basterrechea
- Unit of Transplants, Cell Therapy and Regenerative Medicine, Central University Hospital of Asturias, Oviedo, Spain
| | - J de Gea
- Intensive Care Unit, Virgen de la Arrixaca Hospital, Murcia, Spain
| | - M Martín
- Intensive Care Unit, Central University Hospital of Asturias, Oviedo, Spain
| | - J Velasco
- Intensive Care Unit, Son Espases University Hospital, Palma de Mallorca, Spain
| | - T Pont
- Intensive Care Unit, Vall D'Hebron Hospital, Barcelona, Spain
| | - N Masnou
- Intensive Care Unit, Vall D'Hebron Hospital, Barcelona, Spain
| | - B de la Calle
- Intensive Care Unit, Gregorio Marañón University Hospital, Madrid, Spain
| | - B Marcelo
- Intensive Care Unit, Infanta Cristina University Hospital, Badajoz, Spain
| | - M Lebrón
- Intensive Care Unit, Carlos Haya Hospital, Málaga, Spain
| | - J M Pérez
- Intensive Care Unit, Virgen de las Nieves University Hospital, Granada, Spain
| | - M Burgos
- Intensive Care Unit, Virgen de las Nieves University Hospital, Granada, Spain
| | - R Gimeno
- Intensive Care Unit, La Fe University Hospital, Valencia, Spain
| | - P Kot
- Intensive Care Unit, La Paz University Hospital, Madrid, Spain
| | - S Yus
- Intensive Care Unit, La Paz University Hospital, Madrid, Spain
| | - I Sancho
- Intensive Care Unit, Miguel Servet University Hospital, Zaragoza, Spain
| | - A Zabalegui
- Intensive Care Unit, General Yagüe Hospital, Burgos, Spain
| | - M Arroyo
- Intensive Care Unit, General Yagüe Hospital, Burgos, Spain
| | - E Miñambres
- Intensive Care Unit, Marqués de Valdecilla University Hospital, Santander, Spain
| | - J Elizalde
- Intensive Care Unit, Asistential Complex of Navarra, Pamplona, Spain
| | - J C Montejo
- Intensive Care Unit, 12 de Octubre University Hospital, Madrid, Spain
| | - B Domínguez-Gil
- Spanish National Transplant Organization (ONT), Madrid, Spain
| | - R Matesanz
- Spanish National Transplant Organization (ONT), Madrid, Spain
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Reid M. The Presence of Relatives during Brainstem Death Testing in an Intensive Care Unit. J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The issue of allowing relatives to witness brainstem death testing has sparked debate between all members of the multidisciplinary team working in intensive care. A literature search was carried out, highlighting the advantages and disadvantages of relatives observing brainstem death testing. Databases searched were the NHS Knowledge Network, OVID, CINAHL, the Cochrane Library, and Medline. Search items included: brainstem death, brainstem death testing, brain death, intensive care, relatives, families and witnessed cardiopulmonary resuscitation. Articles which were under ten years old were included; however articles which were pertinent to the topic were not excluded if outside this timeframe.
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Affiliation(s)
- Megan Reid
- Staff Nurse in Intensive Care, Royal Alexandra Hospital, Paisley
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Gardinery D, Danbury C, Manara A. Confirming Death Using Neurological Criteria: Are Two Sets of Tests Better than One? J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Dale Gardinery
- Consultant in Adult Intensive Care, Nottingham University Hospitals, Regional Clinical Lead for Organ Donation, Midlands
| | - Chris Danbury
- Consultant Intensivist and Clinical Lead for Organ Donation, Royal Berkshire Hospital, Reading
| | - Alex Manara
- Consultant in Anaesthesia and Intensive Care, Frenchay Hospital, Bristol, Regional Clinical Lead for Organ Donation, South West Region
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Egea-Guerrero J, Revuelto-Rey J, Gordillo-Escobar E. Cerebral death is not a synonym of whole brain death. NEUROLOGÍA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.nrleng.2012.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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ICS Medal and Research Abstract Presentations. J Intensive Care Soc 2012. [DOI: 10.1177/175114371201300120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Iriarte J, Palma J, Kufoy E, de Miguel M. Brain death: Is it an appropriate term? NEUROLOGÍA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.nrleng.2010.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Egea-Guerrero JJ, Revuelto-Rey J, Gordillo-Escobar E. [Cerebral death is not a synonym of whole brain death]. Neurologia 2011; 27:377-8. [PMID: 22018824 DOI: 10.1016/j.nrl.2011.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Accepted: 07/20/2011] [Indexed: 10/16/2022] Open
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Kompanje EJO, de Groot YJ, Bakker J, IJzermans JNM. A National Multicenter Trial on Family Presence During Brain Death Determination: The FABRA Study. Neurocrit Care 2011; 17:301-8. [DOI: 10.1007/s12028-011-9636-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Iriarte J, Palma JA, Kufoy E, Miguel MJD. [Brain death: is it an appropriate term?]. Neurologia 2010; 27:16-21. [PMID: 21163214 DOI: 10.1016/j.nrl.2010.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Revised: 06/07/2010] [Accepted: 06/20/2010] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION Brain death is generally accepted as a concept to indicate death. It was introduced about 40 years ago, and it was considered the ideal situation for donation of organs. METHODS During this time, however, there have been problems in the understanding of this concept both in the medical profession and in the general population. University students from medical and non-medical schools were tested for their understanding of this concept. RESULTS Our results show that less than one third of the non-medical students identified brain death as death. The data from the medical students changed as they progressed through their studies, but only 2/3 of the graduating medical class believed that brain death is death. CONCLUSION Similar results have been seen in other universities around the world, and a renewed effort on the re-education of the concept of brain death may be worthwhile. Although we cannot extrapolate these results to the general population, the confusion is probably similar; hence an effort should be made to solve this problem.
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Affiliation(s)
- J Iriarte
- Servicio de Neurofisiología,Facultad de Medicina, Universidad de Navarra, Pamplona, España.
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Bell D. Emergency medicine and organ donation--a core responsibility at a time of need or threat to professional integrity. Resuscitation 2010; 81:1061-2. [PMID: 20650558 DOI: 10.1016/j.resuscitation.2010.06.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Bohatyrewicz R, Bohatyrewicz A, Zukowski M, Marzec-Lewenstein E, Biernawska J, Solek-Pastuszka J, Sienko J, Sulikowski T. Reversal to whole-brain death criteria after 15-year experience with brain stem death criteria in Poland. Transplant Proc 2010; 41:2959-60. [PMID: 19857649 DOI: 10.1016/j.transproceed.2009.07.079] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Polish brain-death criteria, similar to the original Harvard criteria, were published in 1984. In 1990, they were converted to brainstem death criteria, and were revised twice, in 1994 and in 1996. However, they could not be used in many complicated clinical situations such as intoxication, metabolic alterations, major facial injury, infratentorial lesions, and cervical spinal cord injury. The new Polish Transplant Act, passed by the Polish Parliament in 2005, recommends implementation of criteria for whole-brain death for brain-death diagnosis. In 2007, the Polish Ministry of Health Commission outlined new Polish brain-death criteria. Optional use of instrumental confirmatory tests was implemented in the new Polish national code of practice for the diagnosis of brain death in adults. In children up to age 2 years, instrumental tests are obligatory. Initially, there were problems in understanding the new, slightly more complicated classifications of primary and secondary brain injuries, infratentorial and supratentorial processes, modified apnea test. A broad commentary that addressed the most frequently asked questions was published in Anesthesiology and Intensive Therapy, the official journal of the Polish Society of Anaesthesiology and Intensive Therapy. This article dealt with most of the problems associated with implementation of the new criteria for diagnosis of brain death.
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Affiliation(s)
- R Bohatyrewicz
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland.
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Death and Donation in Critical Care: The Diagnosis of Brainstem Death. Neurocrit Care 2010. [DOI: 10.1007/978-1-84882-070-8_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Escudero D, Matesanz R, Soratti C, Flores JI. Muerte encefálica en Iberoamérica. Med Intensiva 2009; 33:415-23. [DOI: 10.1016/j.medin.2009.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Revised: 07/14/2009] [Accepted: 07/27/2009] [Indexed: 12/24/2022]
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Figaji AA, Kent SJ. Brain Tissue Oxygenation in Children Diagnosed With Brain Death. Neurocrit Care 2009; 12:56-61. [DOI: 10.1007/s12028-009-9298-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Brain death has been recognized by the scientific community as the person's death, and accepted in the legislation of different countries. Brain death is defined as the irreversible ending of the functions of all the intracranial neurological structure in both the brain and brain stem. This clinical situation appears when intracranial pressure exceeds the patient's systolic blood pressure, leading to brain circulatory arrest. The most frequent are cerebral hemorrhage and cranioencephalic trauma. Clinical diagnostic must be done by doctors with expertise in neurocritical patient treatment. This diagnosis is based on a systematic, complete and extremely rigorous clinical examination that confirms a non-reactive coma, absence of brain stem reflex, and absence of spontaneous breathing. Instrumental tests may be obligatory in some cases, this depending on each country. Electroencephalogram and evoked potentials are the electrophysiological tests used. In patients treated with sedative drugs, cerebral blood flow evaluation tests, such as cerebral angiography, transcranial Doppler or 99Tc-HMPAO scintigraphy, will be used. More than 92% of the transplants performed in Spain are performed with brain death donor organs. Brain death confirmation is a high responsibility act, with medical, ethical and legal significance since it requires removal of all artificial support, or organs extraction for transplant. Extensive knowledge on its diagnostic and correct decision making avoid unnecessary use of resources and improves management of organs for transplant.
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Affiliation(s)
- Dolores Escudero
- Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain.
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Pratt OW, Bowles B, Protheroe RT. Brain stem death testing after thiopental use:A survey of UK neuro critical care practice. Anaesthesia 2006; 61:1075-8. [PMID: 17042846 DOI: 10.1111/j.1365-2044.2006.04829.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A postal survey was conducted to determine how thiopental is used in UK neurosurgery critical care units. Thirty units were contacted and 26 replied. Thiopental is used in 23 units. The majority (60%) of these units govern the use of thiopental with protocols or guidelines and 74% use cerebral monitoring to guide dosage. When patients have had thiopental, 20 units delay brain stem testing, two will not perform tests and one unit incorporates cerebral angiography into their protocol. Twelve units use serum thiopental assays in their brain stem testing procedures, but there is wide variation in the interpretation of the results. We found inconsistency and confusion surrounding brain stem testing in this patient group, raising the possibility of misdiagnosis of brain stem death.
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Doig CJ, Young K, Teitelbaum J, Shemie SD. Brief survey: determining brain death in Canadian intensive care units. Can J Anaesth 2006; 53:609-12. [PMID: 16738297 DOI: 10.1007/bf03021853] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Criteria for brain death were first described in 1968, and Canadian guidelines were published in 1988. However, international inconsistency persists in the process of determining brain death. We sought to determine self-reported practices and processes in the determination of brain death amongst Canadian intensive care unit (ICU) physicians. METHODS An email survey of members of the Canadian Critical Care Society was undertaken. A survey instrument was developed, then face and content validated prior to distribution. RESULTS Eighty eight responded (response rate = 49%), including adult and pediatric ICU physicians working in both tertiary referral (academic) and community hospitals. Most respondents admit patients with brain death to their ICUs. However, 9% reported refusing to admit this type of patient for reasons including inappropriate utilization of ICU resources (36%), and lack of either space or staff (32% and 29% of respondents, respectively). Community hospital-based ICU physicians were less likely to report a hospital policy on the determination of brain death (46% vs 78% of physicians in tertiary care hospitals). Nearly all physicians (96%) reported that a revised national standard and checklist for the determination of death would be useful. CONCLUSIONS Nearly one quarter, and over one half of tertiary care and community hospitals (respectively) in Canada lack an institutional policy on neurological determination of brain death. Canadian ICU physicians are interested in a national standard for the determination of death, and establishment of processes that may improve the clinical determination of death by neurological criteria.
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Affiliation(s)
- Christopher James Doig
- Department of Critical Care Medicine, The University of Calgary, Calgary, Alberta, Canada.
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