Many hospitals haven't fully implemented guidelines put forth in 2010 to minimize errors in the determination of brain death.
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Researchers Find Lapses In Hospitals’ Policies For Determining Brain Death

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.”  {It has happened and not just once, as I have reported on this blog}

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.  {That is not only incredible, it is sinful, it is criminal and provides the basis for wrongful death law suits.}

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.
{Given the evidence that the guidelines are not being followed in 20% of the cases, no one should be totally trusting of the announcement of brain death.  If you fail to ask for a second opinion you could be complicit in the murdering of your loved one !!!}


  • This is precisely why I made the very tough decision not to donate my 12 year-old daughter’s organs after she suffered a mortal brain injury from a drunken driver. I couldn’t get a straight answer from the physicians about what constitutes death and when they decide to harvest. I was required to say goodbye to my little girl in her ICU room while she was still on a ventilator and then trust that the harvesting surgeons in the operating room waited long enough for her to actually die before cutting into her. We ended up donating only those organs that were allowed after death–corneas, heart values, etc. I’m not opposed to organ donation by any means–and I am a listed organ donor myself. But I just couldn’t do that to my daughter without complete satisfaction that she wouldn’t suffer in any way–and the hospital couldn’t come through with any consistent policy for what constitutes death. In light of this story and many others over the years, I don’t regret my decision one bit.

    • My condolences on your daughter’s death, and of course this decision is and should be up to each family to make.

      Just to be clear: heartbeating organ donation isn’t intended to take place after the body has died; the intent is for the body to still be alive and the organs still oxygenated and viable. This is precisely why the legal definition of death includes brainstem death: to allow for the killing of a donor’s body by removing organs while the heart is beating, after the person has legally died, but while the body is still biologically alive.

      Re: suffering, my impression is that anesthesia is still used for organ donors (e.g., to prevent hypertension and tachycardia which can occur even though the brain is no longer functioning), and it prevents suffering in the same way as in other major surgery.

      • That could be. But I was never assured of this procedure or the details. I was merely told that everything would be handled according to strict protocols. Given the number of stories about wide variance among harvesting surgeons concerning how long to wait, how much anesthesia, etc., it was simply not something I wanted to subject my daughter to. Even the slightest potential for suffering was too much to ask a parent.

        • I totally understand your decision, and I hope that my comment didn’t come across as criticism, as my intent was only to clarify a couple of the issues (e.g., legal vs. biological death). I’m really sorry that no one was willing to take the time to answer all of your questions; that’s always important in medical care, and especially for such serious decisions. My condolences again.

    • I am so sorry for your loss. Thank you for sharing your story.

  • According to other reports, this isn’t just a theoretical risk. Hospitals are sometimes declaring people dead before they actually are. Now I can see how it happens.

  • Appalling.

  • Do we need federal policy to get all hospitals on the same page?
    I would hope not.

    • Single payer…

      • Yeah, we really need something like the NHS in the UK.

        A surgeon has been suspended over allegations that he “branded” his initials onto a patient’s liver.

        The letters were reportedly found by a colleague who was performing a routine operation on the unnamed patient.

        University Hospitals Birmingham NHS Foundation Trust confirmed that they were investigating the claims made against a surgeon at the Queen Elizabeth Hospital in Birmingham.

        The surgeon has been suspended while an internal investigation is carried out.

        The news comes after concerns were raised by a report published by NHS England in mid-December which exposed mistakes made by its staff.

        Errors which should never happen, or “never-events”, included patients being given the wrong blood type, and the wrong patient undergoing surgery.

        148 “never-events” occurred between April and September 2013, with 69 of those involving objects, such surgical swabs, being left inside patients after surgery. 37 patients had surgery performed on the wrong part of
        their body, while the wrong implant or prosthesis was administered to 21 patients

        • The NHS is not quite a single payer which is more commonly understood to be the Canadian model. And cherry picking “horror stories” among thousands and thousands of events doesn’t produce a strong argument. Read some peer reviewed literature as I have and you will see their system works pretty well. You might also note that according to studies conducted by the National Academy of Sciences in 2008 concluded that in 2008 20,000 Americans died from lack of access to the health care they needed. That doesn’t take place in any other wealthy democratic society.

        • In 2012, there were 4000 REPORTED never events in the US.
          I’ll take my chances with the NHS, which from my experience is great.

        • You people are duty-bound to bad-mouth anything going on in Europe. Too bad you will never visit there, or own a passport. Too much paranoia.

    • With the way the system is set up currently, we certainly aren’t doing enough to keep ourselves in check. The implementation of uniform guidelines within a single health care system is a challenge in and of itself – making sure people adhere to the guidelines is another, messier issue altogether. Many health care providers have mixed feelings about guidelines, often because it can be difficult to design a reasonably easy-to-follow set of recommendations that account for most situations one would be coming up against. Qualitative measures tend to be more plastic but less certain, while qualitative values are always assigned with the understanding that you’ll have to accept a certain percentage of false positives and false negatives. This is by no means a protest of guidelines – rather, I think we need to be exploring WHY certain guidelines aren’t being adopted or followed uniformly.

      With that being said, I find the public’s relationship to health care guidelines even more provocative. People tend to be much more supportive of uniform protocols to guide practice after reports such as these come out, although most people don’t like it when their health care provider (the actual practitioner or the system from which they receive their care) places restrictions on medical diagnostics or interventions. Even though there’s substantial data showing that many tests and essentially all interventions have the potential to cause harm, virtually everyone has a story about how they or someone they know was harmed either by under-testing/under-treatment or by over-testing/over-treatment.

      It’s understandable that we struggle with whether we’d actually be okay with more oversight (especially if that means more government intervention and regulation), although I often wonder whether people really know what they want out of their health care (apart from someone to blame when things don’t go right).

  • Not surprising. Healthcare is a for profit business. Don’t be surprised if shortcuts are taken.

  • Not a single statistic in sight. Sure you can play the “no possibility of error” card, but trying to achieve that will drive you crazy and bog everything down. What level of effort reduces the odds of error to, say, one in a thousand? How about one in ten thousand?

    • While I condone policies that reduce errors in hospitals, medical bureaucracy is the worst. Bureaucrats are there to keep their jobs and the way to do that is to come up with more rules and regulations. and then to study the benefit of those.

  • Unquestionably, being buried alive (while cognizant of your circumstances) is one of mankind’s greatest fears. This article is certainly playing on those fears. Yet another holiday morsel from NPR…

  • How many diagnostic errors are necessary for a person like you to feel that such a problem is noteworthy? For people of conscience, one is far too many. Your comment implies that you concede a certain amount of diagnostic imprecision is acceptable when it comes to assessing a person’s viability. If such imperfection must be endured, then we can only hope that someone exactly like you is lying on the gurney when such misjudgments occur.

    This is a serous matter indeed. Looking at the comments, I’m pretty shaken by the number from people who think they’re being funny. Not to say there isn’t always a place for humor, but common sense and taste should enter in.

  • I work for a large healthcare company that manages hospital systems all over the country. Every new acquisition includes reviews of various standards and procedures. Getting surgeons to follow the same standards for, say, hip replacements has been difficult to say the least. From where I sit, it seems to require an ego transplant.

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  • Medical errors are the third leading cause of death in the USA…if you add in all the other deaths linked to medical treatment, then medical care is the number one cause of death in the USA. Here’s the statistical death tally over a recent 10-year period:

    Adverse Drug Reactions – 1.06 million; Medical Error – 0.98 million; Bedsores – 1.15 million; Hospital Infections – 0.88 million; Malnutrition in Health Care – 1.09 million; Outpatients – 1.99 million; Unnecessary Procedures – 371,360; Surgery-related – 320,000.

    The “Death by Medicine” doctors also took a look at unnecessary medical care over the course of a decade. They found that 89 million people are hospitalized unnecessarily each year and that 17 million iatrogenic events will occur among this number. 75 million Americans receive unnecessary medical procedures over a decade, 15 million of which result in an iatrogenic event. 164 million people will receive unneeded medical treatment within a decade.

    • That paper was published over a decade ago in Life Extension magazine (a company that sells nutritional supplements). The first author, Gary Null, is an HIV/AIDS-denialist, promoter of untested (and some disproven) alternative treatments for otherwise treatable cancers, and marketer of his own line of nutritional supplements (including a vitamin D supplement that led to overdose in several individuals, including himself). Similarly, Carolyn Dean has leant her name to a line of unregulated supplements.

      I’m not trying to say that medical error isn’t a serious concern (it’s a huge issue in this country) – it’s just that I’m not certain this is a trustworthy source (I don’t think we’d accept a similar study published by Roche or Pfizer, either).

  • Makes you wonder how many people have been buried alive….Back in the early 1960s they dug up a bunch of coffins from earlier years to move the deceased, there were big reservoirs being built in the South. Some of the coffins had considerable claw marks on the inside.

    • Is that a story that relates to modern times? It’s been customary for a very long time in the US (although not required by law except in a few cases) to embalm corpses before burial, and in that case, you can be assured the corpse is dead before it gets to the coffin.

  • maybe something to be concerned about if you sign an organ donor card and the senator or CEO in the VIP wing is waiting for a transplant.

  • When my father was in hospice the nurses were trained and certified to declare time of death. They went with heart function and responsiveness to being touched on the eye. But it seemed to work OK.

    Unless someone is carted off with some sentient capacity for the purposes of having their organs “harvested” it isn’t clear how they would be harmed. They certainly could be but I would have preferred to see some discussion of how.

    • If brainstem death is misdiagnosed when it hasn’t actually occurred, it’s possible that someone with the capacity for sentience might be killed, whether by having their organs removed or by being taken off a ventilator. That’s why it’s so important that the recommended policies by followed and that the assessment be carried out by a qualified person.

      • Certainly true, although the idea of sentience is interesting in this context. I’m genuinely interested to know what the people writing on this message board think those mis-diagnosed brain death cases are like. From my own experience, I would estimate that the overwhelming majority of misdiagnosed cases would have never survived to hospital discharge, and that only a very very very small fraction of those remaining would have recovered to a level of independence resembling how they were before they got sick.

        This is not to say that guidelines for brain death diagnosis are unnecessary (I think they are essential). Rather, I think we need to broaden our understanding of what to expect at the end of life, and of what’s reasonable or unreasonable to expect of a dying person (because we can always keep oxygenated blood flowing to the brain stem, regardless of whether rest of the body might ever recover).

  • There is a reason malpractice lawyers water at the mouth.

    You have no idea how often a hospital uses untrained staff to diagnose. They depend greatly on your ignorance much like a mechanic.

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About abyssum

I am a retired Roman Catholic Bishop, Bishop Emeritus of Corpus Christi, Texas
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