On Dec. 12, 2013, Jahi McMath was declared dead by her doctors at Children’s Hospital Oakland. She had lost blood circulation, causing brain death. But her family rejected the doctor’s criteria for death and solicited for continued life support, and the case engendered heated debate on the definition of death and the complications involved in brain death.
However, Vice Chair of Yale’s Department of Neurology David Greer said that diagnosing brain death is not confusing at all.
In a recent article in “Current Opinion in Critical Care,” which Greer co-authored with Shivani Ghoshal, a resident at the Yale School of Medicine, the authors reviewed four studies investigating differences in brain death declaration. Their article shows that despite the straightforward guidelines for brain death diagnosis published by the American Academy of Neurology in 2010, there are still variations across hospitals. This study, titled “Why is diagnosing brain death so confusing?,” was published on Feb. 13, 2015.
“Our motivation is to ensure that doctors making declarations on brain death are doing it consistently and conservatively, meaning testing things as meticulously as possible,” Greer said.
By pointing out the common variables concerning brain death, this paper aims to serve as a call for action for accrediting bodies to demand that the guidelines at hospitals be consistent with the AAN criteria, Greer added. He said this will motivate hospitals to change their current protocols so as to avoid losing accreditation.
Greer noted that national standardization for diagnosis of brain death is important for maintaining the public’s trust in physicians.
“This is not one of those you can do it right 99 times out of 100 and that’s okay. It has to be 100 percent,” he said. “You cannot have a patient who you say is brain dead, and it turns out at organ donation that he isn’t dead.”
Yale neurology professor Jennifer Dearborn agreed that there is a need for standardization. When talking about something as clear-cut as brain death, there needs to be a single standard, she said.
A national standard is important not just for neurologists to make calls about organ donation, but also for other medical and legal reasons, said Norman Werdiger, clinical professor of neurology at the School of Medicine and assistant chief of neurology at the Yale-New Haven Hospital.
From the medical standpoint, a standard helps physicians and health care providers know when to stop providing continuing medical care. When physicians continue caring for brain dead patients because they are not certain of the standard, it can deprive other critically ill patients of life-saving treatment. Ending treatment when it should be ended can also minimize family members’ false hopes, he added.
According to Shelly Kagan, a Yale professor of philosophy who teaches the course “Death,” ethical dilemmas also make it important to work out the standards, which raise the question of when it is morally permissible to turn off respirators, or harvest another’s organs for donation. Turning off respirators concerns not only the life of the patient but also the possibility of saving the lives of others who await organ transplantation — any delaying will result in the deterioration of those organs.
Though the ethical questions may be complex, Greer said diagnosis is not.
“The title of the study asks, ‘Why is diagnosing brain death so confusing?’ But the answer is it is not. It’s straightforward. It’s cookbook. It’s like Neurology 101 in college,” he said.
Greer noted that it is simple for hospitals to change their protocols to comply with the AAN guidelines. He and his co-authors created a toolkit on the neurocritical care website that includes a checklist for diagnosing brain death. It mandates a minimum number of criteria that must be met before declaration of brain death. All hospitals have to do is to insert their names on the website, he said. He added that the change does not require hospitals to retrain their physicians because the examinations on the checklist are standard.
But Werdiger said some hospitals will find it harder than others to adapt to the new standards. Whether or not they are able to do so will hinge on the commitment of their administration and staff.
“The only reason that they are not doing it right now is that nobody is holding their feet to the fire,” Greer said of hospitals not adopting the AAN brain death standards. “Doctors haven’t changed yet because they are lazy.”
Though the main aim of the article is to push hospitals to comply with the guidelines, educating the public about brain death is also extremely important, Werdiger said.
“Society as a whole needs to be educated with regards to a change in attitude about the traditional concept of death as being cessation of heart beat,” he said, noting that hearts can be kept beating even if the patients are not alive.
In a 2004 survey, only one-third of respondents felt that a brain dead patient was legally dead.