1. Brain Death: An Update on New Important Initiatives
Community of Practice Action Leader Meeting
Organ Donation & Transplantation Alliance
Nashville, TN
March 19, 2013
You must be one of
Dr. Frank’s patients!
Jeffrey I. Frank, MD, FAAN, FAHA
Professor of Neurology and Neurosurgery
Director, Neurocritical Care
University of Chicago Medicine

2. 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)

3. Pre-Ventilator Era
Any process that arrested breathing led to asystole and a cold, blue corpse
Apnea
Asystole

4. Now patients with severe brain dysfunction were on ventilators!
Ventilator Era (1960’s) ?
1928
1952
1972
Now patients with severe brain dysfunction were on ventilators!

5. Spectrum of Brain Injury With Mechanical Ventilation
Moderate: Awake or drowsy with disability
Major: Coma with some brain function
Extreme:
No discernible brain function
Required Definition

6. Brain Death History Harvard Report (1968) NIH Collaborative Study
(1977)
“Irreversible Coma”
No brainstem reflexes
“Flat” EEG
Proposed brain death
Defined the futility of brain death
President’s Commission Report (1980)
Affirmed the validity of brain death
Proposed guidelines on how to approach brain death diagnosis
Uniform Declaration of Death Act

7. Uniform Declaration of Death Act (1980)
Basis for Brain Death Law
Dead 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)

8. AAN Creates Practice Parameter: Guideline
1995
AAN Creates Practice Parameter: Guideline

9. Brain Death in the U.S. Paradigm Shift Real mechanism of death
President’s Commission Report
UDDA
Harvard Report
NIH Study
1920
1965
2012
Transplant Reality
Iron Lung Invented
Modern mechanical ventilation (critical care)
CT Scanner Invented
Societal Evolution and Acceptance (death with a heart beat)
Irreversible cessation of whole brain function = Death
Real mechanism of death
Can be reliably diagnosed
Paradigm Shift

10. 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

11. Guideline performance
Pre-clinical testing
Clinical examination
Apnea testing
Ancillary testing

12. Physicians Responsible for Brain Death Diagnosis

13. Preclinical Testing: Compliance with AAN Guidelines

14. Clinical Exam: Compliance with AAN Guidelines

15. Apnea Testing: Compliance with AAN Guidelines

16. Ancillary Testing

18. Variability in BD Determination Practice:
a review of 226 brain dead organ donors (2011)
Jenkins et all, Critical Care 1997
Claire Shappell MS2, Jeffrey Frank MD

19. AAN Approach to Determining Brain Death
Part 1
Coma
Part 2
Absent Reflexes
Part 3
Apnea
Loss of respiratory drive
Brain Dead Patients must meet demonstrate all 3:
Coma: lack of any response to external environment, must have known etiology and be irreversible, must rule out potential mimics
Reflexes: absence of pupillary response, ocular movements (doll’s and calorics), corneal reflex, motor response to painful stimuli, pharyngeal and tracheal reflex (cough and gag)
Apnea: absence of the respiratory drive to breathe, very specific way to test this, but basically involves disconnecting the patient from the ventilator and observing for efforts to breathe after a defined rise in CO2 level in the blood.
Pupillary
Known Cause
Doll’s Eyes
Cold Water Calorics
Specific method of testing for apnea
Irreversible
Corneal
Gag
Cough
“Pre-Requisites”
Rise in CO2 with no breaths observed
Neuroimaging compatible
Motor

20. Sometimes, Part 4 Ancillary Tests Nuclear Medicine Blood Flow Study
Electroencephalography (EEG)
CT Angiography
Conventional Angiography
Required ONLY if clinical examination or apnea testing cannot be fully performed

21. 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

22. Results: Brain Stem Reflexes
Mean # of reflexes documented: 6 ±1.2
All reflexes documented (7 of 7): (44.7%)

23. Apnea and Ancillary Studies
Apnea Test
# Donors (%)
Completed
162 (71.7)
Aborted
12 (5.3)
Not Performed
46 (20.4)

24. Putting it all together
All Brain Dead Organ Donors
n=226
Coma
Cause Known
n=217
Normothermic
(≥36°C)
n=184
0.26
1.15
Reflexes Absent
± Redundant
n=157
Apnea Test OR Ancillary Study
n= 151

25. 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
Discuss Implications:
Need better uniformity at least in DOCUMENTATION, but also probably in practice
Need contemporization and universalization of local/institutional guidelines- federal Health Resources and Services Administration task force
Better training in examination and documentation – U of C-led simulation workshops, future standard for education and credentialing of local leaders in BD diagnosis

26. 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)

27. Brain Death Simulation Training
November 12, 2012
Second International Brain Death Simulation Workshop: Training Future Leaders BD
Clinical Cases
Intoxication
Isolated BS Injury
Post CA w/o CE
Grade V SAH
Catastrophic Brain Injury
Dummy Simulation Station
DDNC
Apnea Test
Physiological Management Station
Ancillary Tests Station
Involuntary Movements Station
MD/Family Interaction Station

28. 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

29. Adaptation to Technology
Perioperative MI and Cardiac Arrest
End-Stage Cardiomyopathy
VAD Insertion
Death of Heart Muscle: Permanent Asystole
Post-Event Scenario
Permanent asystole
Maintained perfusion through VAD
Brain with continued blood flow
Continuous Flow Ventricular Assist Device
Systemic perfusion
No heart beating
Heart stops but device maintained systemic perfusion = Alive
Heart Stops = Dead
Brain Death = Dead

30. 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”