Are hospitals doing everything they should to make sure they don't make mistakes when declaring patients brain-dead? A provocative study finds that hospital policies for determining brain death are surprisingly inconsistent and that many have failed to fully implement guidelines designed to minimize errors.
"This is truly one of those matters of life and death, and we want to make sure this is done right every single time," says David Greer, a neurologist at the Yale University School of Medicine who led the study.
Greer helped write a detailed set of guidelines in 2010 that the American Academy of Neurology recommended every hospital follow when declaring patients brain-dead.
"The worst-case scenario would be if we were to pronounce somebody brain-dead and then they recovered some neurological function," Greer says. "That would be horrific if that were the case."
To see how well the guidelines have been adopted, Greer and his colleagues analyzed policies at 492 hospitals and health care systems across the country. While most have adopted the guidelines, the researchers report Monday in the journal JAMA Neurology that there are significant differences in how the key parts of the guidelines have been accepted.
More than 20 percent of the policies don't require doctors to check that patients' temperatures are high enough to make the assessment, as the guidelines call for. "If somebody has a low temperature then their brain function can actually be suppressed based on that," Greer says.
Almost half of policies don't require doctors to ensure patients' blood pressure is adequate for assessment of brain function. And some say doctors can skip tests that the guidelines recommend.
In addition, most of the policies don't require that a neurologist, neurosurgeon or even a fully trained doctor make the call. "In some hospitals they actually allowed for a nurse practitioner or a physician assistant to do it," Greer says.
Based on the findings, Greer says compliance needs to improve. "There are very few things in medicine that should be black and white, but this is certainly one of them," he says. "There really are no excuses at this point for hospitals not to be able to do this 100 percent of the time."
In a statement sent by email, Dr. John Combes, chief medical officer at the American Hospital Association, said that hospitals "work hard to reflect various national-based guidelines, as well as state and local regulations, as well as consulting multi-disciplinary advisory committees, in this very complicated arena." He added that the study "shows improvement associated with certain national guidelines" and also "serves as a reminder for hospitals and health systems to review these important policies."
Yale's Greer isn't alone in criticizing hospitals' lapses in implementing the guidelines.
Boston University bioethicist Michael Grodin calls the findings "unconscionable."
Dartmouth College neurologist James Bernat, a leading authority on brain death, says, "It's disturbing that despite all of the educational intervention to try to bring doctors up to the national standards that there remains such great variability."
The lack of uniformity could erode public trust, which could make people reluctant to become organ donors or donate their loved ones' organs. "If one hospital is using a testing method that's different from another hospital, people might wonder: 'Are they really dead?'" says Leslie Whetstine, a bioethicist at Walsh University in Ohio.
AUDIE CORNISH, HOST:
Are hospitals doing everything they should to make sure they're correct when they declare patients brain-dead? That's the provocative question being raised by new research that came out today in the journal JAMA Neurology. NPR health correspondent Rob Stein explains what the researchers found.
ROB STEIN, BYLINE: Five years ago, the American Academy of Neurology issued guidelines for every hospital to follow when declaring someone brain-dead. David Greer of the Yale University School of Medicine helped write the rules.
DAVID GREER: This is truly one of those matters of life and death, and we want to make sure that this is done right every single time.
STEIN: The experts hoped uniform guidelines would eliminate any doubt about when someone could be considered truly brain-dead.
GREER: The worst-case scenario would be if we were to pronounce somebody brain-dead and then they recovered some neurological function. That would be horrific if that were the case. So we have to be 100 percent accurate about this every single time.
STEIN: Greer and his colleagues decided to take a look at what hospitals are actually doing five years later, so they surveyed nearly all of them. Most hospitals did adopt some version, but hospitals still have lots of different rules about what is absolutely necessary to declare someone brain-dead.
GREER: One of them was making sure that patients were not too cold. If somebody has a low temperature, then their brain function can actually be suppressed based on that.
STEIN: And they may not actually be brain-dead. But more than 1 out of every 5 hospitals failed to require doctors to check body temperature. Almost half don't check their blood pressure. Some skip other tests the guidelines say are crucial. And most don't demand that a brain expert or even a fully trained doctor make the call.
GREER: In some hospitals, they actually allowed for a nurse practitioner or physician's assistant to do it.
STEIN: Now, no one thinks people are routinely being declared brain-dead when they're still alive, but Greer says hospitals still clearly have a long way to go to make their policies more consistent.
GREER: There are very few things in medicine that should be black and white, but this is certainly one of them. So there really are no excuses at this point for hospitals not to be able to do this 100 percent of the time.
STEIN: Other experts agree. James Bernat of Dartmouth is a leading authority on brain death.
JAMES BERNAT: It's disturbing that despite all of the educational intervention to try to bring doctors up to the national standards, that there remains such great variability.
STEIN: The patchwork of rules could make people start to wonder what's really going on when their loved ones end up in the ICU. That could make them reluctant to donate their family members' organs or become organ donors themselves. Leslie Whetstine is a bioethicist at Walsh University in Ohio.
LESLIE WHETSTINE: If one hospital is using a testing method that's different from another hospital, people might wonder, are they really dead?
STEIN: The American Hospital Association says hospitals work hard to make sure their policies reflect national guidelines and local regulations about brain-death, but the new study serves as a reminder that they need to review those policies. Rob Stein, NPR News. Transcript provided by NPR, Copyright NPR.