Brain Death: An Update on New Important InitiativesCommunity of Practice Action Leader Meeting

Organ Donation & Transplantation AllianceNashville, TN

March 19, 2013You must be one of

Dr. Frank’s patients!

Jeffrey I. Frank, MD, FAAN, FAHAProfessor of Neurology and NeurosurgeryDirector, Neurocritical CareUniversity of Chicago Medicine

Disclaimer I am NOT a passionate about organ donation advocate

My presence at this meeting IS NOT about enhancing organ donation

My passion and presence IS about my role in: Improving contemporary understanding of brain death Assuring integrity in brain death diagnosis and

patient/family management through better education of physicians and nurses, and better uniformity of policies

Implications for organ donation but it NOT ABOUT organ donation (ODMT: DDWG)

Pre-Ventilator Era

Any process that arrested breathing led to asystole and a cold, blue corpse

Apnea Asystole

Ventilator Era (1960’s)

1928 1952 1972

Now patients with severe brain dysfunction were on ventilators!

?

Spectrum of Brain InjuryWith Mechanical Ventilation

Moderate: Awake or drowsy with disability

Major: Coma with some brain function

Extreme: No discernible brain function

Required Definition

Brain Death History

President’s Commission Report(1980)

NIH Collaborative Study(1977)

Uniform Declaration of Death Act

Harvard Report (1968)

“Irreversible Coma”No brainstem reflexes“Flat” EEGProposed brain death

Defined the futility of brain death

Affirmed the validity of brain death

Proposed guidelines on how to approach brain death diagnosis

Uniform Declaration of Death Act (1980)

Basis for Brain Death LawDead if irreversible cessation of either:

– Circulatory and respiratory functions, or– All functions of the entire brain, including brain-

stem (brain death)

BRAIN DEATH IS THE IRREVERSIBLE CESSATION OF WHOLE BRAIN FUNCTION

(HEMISPHERES AND BRAINSTEM)

1995 AAN Creates Practice Parameter:

Guideline

Brain Death in the U.S.

1920 20121965

Iron Lung Invented

Modern mechanical ventilation (critical care)

CT Scanner Invented

Harvard Report

NIH Study

UDDAPresident’s Commission

Report

Societal Evolution and Acceptance (death with a heart beat)

Irreversible cessation of whole brain function = Death

Real mechanism of death

Can be reliably diagnosedParadigm Shift

Transplant Reality

Brain Death Today

Mechanism of death: Widely accepted

Diagnosis: Important; Independent of OD

Contemporary Imperative Mandatory, accurate, and expeditious diagnosis Respect for process

Proactive management of physiology Thoughtful interaction with family/surrogates Thoughtful sequencing of involvement of health care teams

and OPOs

Profound variability in policy and practice

Guideline performancePre-clinical testingClinical examinationApnea testingAncillary testing

Physicians Responsible for Brain Death Diagnosis

11%

36%

11%

43%

Intensivist Primary Attending No mention N/NS

Preclinical Testing: Compliance with AAN Guidelines

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10%

20%

30%

40%

50%

60%

70%

80%

90%

100% 89%81%

72% 71%63%

55%45% 42%

Clinical Exam:Compliance with AAN Guidelines

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10%

20%

30%

40%

50%

60%

70%

80%

90%

100%100%100% 97% 95%

87% 87% 87% 82%

42%

27%18%

Apnea Testing:Compliance with AAN Guidelines

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30%

40%

50%

60%

70%

80%

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100% 87% 87%76% 71% 66%

55% 48%39%

16%

Ancillary Testing

Indic

ation

sEEG

EEG det

ails

TCD

TCD det

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tails

SPECT

SPECT det

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SSEP

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ails

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er0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

66%

84%

33%42%

21%

74%

29%

66%

21% 24% 18% 24%

Variability in BD Determination

Practice:

Claire Shappell MS2, Jeffrey Frank MD

a review of 226 brain dead organ donors (2011)

AAN Approach to Determining Brain Death

Known Cause

Irreversible

PupillaryDoll’s Eyes

Cold Water Calorics

Gag Cough

Corneal

Motor

“Pre-Requisites”

Loss of respiratory drive

Neuroimaging compatible

Specific method of testing for apnea

Rise in CO2 with no breaths observed

Sometimes, Part 4Ancillary Tests

Nuclear Medicine Blood Flow Study

Electroencephalography (EEG)

CT Angiography

Conventional Angiography

Required ONLY if clinical examination or apnea testing cannot be fully performed

Results: Overview and Part 1

Total Patients 226 Age, mean (SD), y 46 (16) Male Sex, No. (%) 115 (51)

Cause of Death, No. (%) Intracranial Hemorrhage 95 (42) Trauma 59 (26) Anoxia 44 (19) Unknown 9 (4) Ischemic Stroke 8 (4) Other 8 (4)

Results: Brain Stem Reflexes

Pupillary Corneal Motor Gag Doll's Eyes Cough Calorics0%

20%

40%

60%

80%

100% 99% 96% 95% 94%

80%

69% 66%

Mean # of reflexes documented: 6 ±1.2

All reflexes documented (7 of 7): 101 (44.7%)

Apnea and Ancillary StudiesApnea Test # Donors

(%)

Completed 162 (71.7)

Aborted 12 (5.3)

Not Performed 46 (20.4)

NM EEG CTA TCD Angio Other0%

20%

40%

60%

80%

100%

35%28%

13%2% 2% 8%

Putting it all togetherAll Brain Dead Organ Donors

n=226

Coma Cause Known

n=217

Normothermic (≥36°C)n=184

Reflexes Absent ± Redundant

n=157

Apnea Test OR Ancillary Study

n= 151

67%

100%

81%96%

69%

Conclusions 36.7% documented adherence to all AAN practice

recommendations for brain death diagnosis

66.8% documented adherence to AAN recommendations with weaker brain stem reflex

standard (± redundant reflexes)

At least 1/3 of brain death determinations do NOT have documentation of necessary features of brain death

What are we doing to improve the field?

Educational/training endeavors Web-based training: Acute Review (CCF, Prpvencio) Webinars: Frank, Greer, Goldenberg, Provencio Simulation training:

Basic training (Yale, Greer) “Champions”: Training Leaders (UofC, Frank, Goldenberg)

Brain Death Simulation Training

November 12, 2012Second International Brain Death Simulation Workshop: Training Future Leaders

What are we doing to improve the field?

Educational/training endeavors Web-based training: Acute Review Simulation training: Basic training “Champions”: Training Leaders

Creation of a national/international standard Re-evaluate protocols since the 2010 AAN

Practice Parameters (WE NEED YOUR HELP) Lobby at a national level for uniformity

Brain Death Ethics Subcommittee of NCS Taking leadership/ownership regarding Brain Death Education, Advocacy, Policy

Adaptation to Technology

Continuous Flow Ventricular Assist

Device

End-Stage Cardiomyopathy

VAD Insertion

Perioperative MI and

Cardiac Arrest

Death of Heart Muscle: Permanent

Asystole

Post-Event Scenario

• Permanent asystole

• Maintained perfusion through VAD

• Brain with continued blood flow

• Systemic perfusion

• No heart beating

Heart Stops = Dead Brain Death = Dead

Heart stops but device maintained systemic perfusion = Alive

Summary

Brain Death is an Important Diagnosis

Shift in accountability and responsibility for the

integrity of brain death diagnosis, patient/family

management, and policies/advocacy

Educational efforts

Academic efforts

Policy change

Better uniformity

“Growth means change and change involves risk, stepping from the known to the unknown”