Are You Brain Dead? Depends on the Hospital

Top hospitals across the country follow different protocols for determining brain death, and often deviate from standards established by the American Academy of Neurology, a new survey finds.

The results, which will be published in the Jan. 22 issue of the journal Neurology, are based on surveys of top neurology and neurosurgery centers identified by U.S. News and World Report.

"We were surprised to find such significant differences among these hospitals in terms of their specified guidelines for brain death determination," said study leader David Greer of the Massachusetts General Hospital Neurology Service. "In reviewing the protocols, we would have anticipated more consistency with the American Academy of Neurology practice parameters."

First established in the 1960s, the concept of brain death refers to the irreversible loss of function in the entire brain. In 1981, a Presidential Commission confirmed that brain death was the legal equivalent of more traditional standards, such as when a person's heart and lungs stop functioning.

The AAN published brain-death determination guidelines in 1995 based on a review of actual medical research and accepted best practices.

Greer and his collaborators evaluated institutional guidelines for determining brain death from 38 of the top 50 neurology and neurosurgery programs, listed in the U.S. News 2006 Best Hospitals issue. They had contacted all 50 institutions. Out of the 41 respondents, three had no written guidelines at all.

The neurologists found significant differences among the hospitals, with several discrepancies from the AAN guidelines. For instance, some hospitals' guidelines deviated on AAN specifications regarding the specialty and level of training required for physicians tasked with determining brain death. In addition, the institutions differed on medical conditions that needed to be met before specific testing took place and the type and timing of examinations used to determine brain death.

"While our study was not designed to evaluate the actual practices at these institutions, which are among the leading hospitals in the country, our guess is that most of them try to adhere to their hospital's policies," Greer said.

The researchers urge a revamping of AAN guidelines so hospitals have clear principles for brain-death determination.

"We feel it is time for the previous AAN guidelines to be revised and made more explicit and possibly to create a web-based checklist that can help physicians perform brain death determination," Greer said. "We would hope that major institutions would then endorse these guidelines without further major modifications."