1. Understanding Brain Death: for laypersons, experts & everyone in between

2. This webcast is a collaborative effort between the Society of Critical Care Medicine’s Emergency Medicine Section and Project Dispatch. Funding for this project is provided by a grant from the Agency for Healthcare Research & Quality. Any views presented by the speakers in this webcast are those of the presenters.

3. Thanks for Joining Us Submit questions throughout the presentation using the Question box located on your control panel. Today’s presentation will also include an interactive audience poll. Answer by clicking the bubble next to your choice.

4. Presenters for Today’s Webcast Isaac Tawil MD, FCCM Associate Professor: Critical Care/ Emergency Medicine Neurosciences ICU Medical Director University of New Mexico School of Medicine New Mexico Donor Services: Associate Medical Director Albuquerque, New Mexico David B. Seder, MD, FCCM Director, Neurocritical Care Maine Medical Center Portland, Maine

5. Understanding Brain Death: for laypersons, experts & everyone in between Isaac Tawil MD, FCCM Associate Professor: Critical Care/ Emergency Medicine Neurosciences ICU Medical Director University of New Mexico School of Medicine New Mexico Donor Services: Associate Medical Director Disclosures?

6. Learning Objectives Review current level of understanding among Laypersons & Brain Death Experts Discuss educational interventions Medical student education Family Presence during brain death evaluation Review Fundamentals of Brain Death Evaluation Identify further areas of study Brain Death… Death By Neurologic Criteria

7. A Short Story 18 y.o. s/p MVC – Devastating TBI – GCS 1T1, no evidence of brainstem reflexes – Appears to be dead by neurologic criteria

8. Questions that encounter prompted 1.Do families in this situation understand the concept of death by neurologic criteria? 2.Has a family presence strategy during brain death evaluation ever been studied or shown to improve understanding?

9. Layperson/ Family Understanding of Death by Neurologic Criteria is POOR As many as 1/3 of relatives of patients diagnosed with brain death DO NOT UNDERSTAND that DEATH has OCCURRED! – Do people accept brain death as death? Tessmer et al. Prog Transplant 2007 – What does a prognosis of brain death mean to family members approached about organ donation. Long T et al. Prog Transplant 2008 – A survey of families of brain dead patients. Pearson IY et al. Anaesth. Int. Care 1995 – Explaining brain death; A critical feature of the donation process. Franz H. et al. J Transplant Coord. 1997

10. Patient’s Families often consent to organ donation on patient’s behalf without a clear understanding of Death By Neurologic Criteria…

11. Next of kin who decided against organ donation had far less understanding of brain death than did those who were in favor of donation…

12. Expert Understanding: Physicians Brain death & Organ retrieval; A cross sectional survey of knowledge and concepts among health professionals. Youngner et al. JAMA 1989 63% of MDs correctly defined brain death as irreversible loss of brain function. 35%provided correct definition and correctly interpreted a brain death scenario

13. Expert Understanding: Med Students * Essman C et al. Assessing medical student knowledge, attitudes, and behaviors regarding organ donation. Transplant Proc. 2006 - Ohio students; faired worse than random layperson sample Connie FO et al. Knowledge, acceptance and perception towards brainstem death among medical students in Hong Kong. A questionnaire survey on brainstem death. Med Teach 2008 – < Half made distinction between BD & PVS Alfonso RC et al. Future Doctors and Brain death: What is the Prognosis? Transplant Proc 2004 - Canadian students Garcia CD et al. Educational program of organ donation and transplantation at medical school. Transplant Proc 2008. - Brazilian students *A validated assessment tool was not used

14. To address these gaps in medical education: To start we had to develop a tool to truly measure level of understanding… Validated: – “internal consistency” – “test-retest validity” – “discriminatory capacity” (experts versus laypersons)

16. Then we used the tool to measure understanding among the UNM SOM student body

18. What about that second question? Has a family presence strategy during brain death evaluation ever been studied or shown to improve understanding?

19. Share your practice with this poll: Is family presence offered during brain death evaluation in your ICU? Always Sometimes (~ 50%) Rarely (<25%) Never

20. Family Presence During Resuscitations & Procedures

21. Family Presence During Brain Death Evaluation Editorial Observational Failed trial Survey study

22. PRCT 2009- 2011 Enrolled immediate family members of patients suspected to be dead by neurologic criteria Group randomized to Presence vs. Absence Outcomes 1.Understanding Brain death survey scores 2.Measures of psychological distress at 1 mo. f/u

23. Family Presence Study Protocol Consent Family Member for Randomization Family Member Not Present For Brain Death Exam Family Member Present For Brain Death Exam Complete Second Survey Discussion Regarding Organ Donation Complete Third Survey One to Three Months Later Contact With Family Care Coordinator – Complete First Survey

24. Results Randomized 58 family members during 17 BDEs Present; N = 38 Absent; N = 20 Families unwilling to be randomized = 12 – ( 8 insisted on presence, 4 insisted on absence ) Follow up; N= 41 (71%)

25. Understanding Brain Death Scores

26. Follow –up Psychological Evaluation: No difference between groups

27. Other Results: # Achieving Expert Scores (5) – 66% of Present group – 20% of Absent group 95% of those “Present” reported that being present helped them understand Brain Death. 84% reported that they would recommend “Presence” to other family members.

28. Keys to Successful Family Presence Educational Intervention Should be family preference Clinician/ Chaperone dedicated to family education Clinician performing the exam experienced & prepared for family presence Limited # of family members (educational efficacy & space) Sensitivity to educational barriers & cultural differences

29. Conclusions

30. Beyond the evidence….

31. So we need to continue to improve Brain death Education at all levels! And in that spirit…

32. Brain Death Determination: Prerequisites Clinical or neuroimaging evidence of an acute CNS catastrophe that is compatible with the clinical diagnosis of brain death Exclusion of complicating medical conditions that may confound clinical assessment: No severe electrolyte, acid base, endocrine, or hemodynamic disturbances. No drug intoxication or poisoning (including hospital administered sedatives or paralytics) Core temperature > 36 o C

33. Brain Death Determination: once prerequisites are met, move on to assessing the 3 Cardinal findings in Brain Death… Coma or Unresponsiveness Absence of brainstem reflexes Apnea testing without a respiratory response

34. Cardinal Finding #1: Coma / unresponsiveness Prove absence of response to noxious stimuli. This includes the absence of a motor response to painful stimuli such as nail-bed or supra-orbital pressure. Spinal reflexes may remain intact and do not rule out the diagnosis of brain death.

35. Cardinal finding #2: Absence of Brainstem reflexes 1.Pupilary light reflex: tests cranial nerves II & III 2.Corneal reflex: tests cranial nerves V &VII 3.Gag & cough reflex: tests cranial nerves IX & X 4.Oculocephalic (doll’s eyes) reflex: cranial nerves III, VI, VIII 5.Vestibulo-ocular (cold calorics) reflex: cranial nerves III, VI, VIII

36. Cardinal finding #3: Apnea Once all previous criteria have been met, the physician must perform the apnea test. The patient must be relatively stable to tolerate this challenge. Pre-requisites include: Core body temp >36 o C (>34 o in pediatrics) Systolic blood press >100 (vasopressors acceptable) Euvolemia/ positive fluid balance PaO 2 and PCO 2 within normal range for patient Normal pH, not requiring high FiO2 or mean airway pressure

37. Apnea Test Set ventilator to obtain a PCO 2 within normal limits for the patient and pre-oxygenate for 10 minutes. The patient is disconnected from the ventilator while oxygenation of the lungs is continued passively. The patient’s PCO 2 is allowed to rise to 60 mm Hg or 20 mm Hg above their baseline and a diagnosis of brain stem death is supported if there is no respiratory effort.

38. Ancillary Studies Additional studies are not required unless the clinical exam is equivocal, apnea test cannot be completed or a full exam cannot be performed. Ancillary tests include cerebral angiography (the gold standard), Nuclear imaging studies, TCDs, CTA, MRA, and EEG monitoring.

39. Is there one way everyone performs the brain death evaluation? Greer DM et al. Neurology 2008

40. Guideline performancePre- Requisites for testing

41. The clinical examApnea testing

42. 2010 Guidelines Update – In adults, no published cases of return of neurologic function where 1995 AAN guidelines followed – Complex motor movements and false ventilator triggering occur in those who are brain dead – No strong evidence to guide a minimal observation period, or serial exams – Insufficient evidence to guide apnea testing technique – Insufficient evidence to guide new ancillary testing

43. What we do know? All families should be offered the opportunity to be present during the brain death evaluation and we must see our job as being educators and not just clinicians. “It is no longer acceptable for doctors and nurses to have the benefit of witnessing confirmation of death whilst expecting the relatives to accept brainstem death in the face of so much apparent life” M. Doran, The Presence of family during brainstem death testing. Crit care Nursing 2004

44. Questions / Comments? Isaac Tawil MD, FCCM Associate Professor: Critical Care/ Emergency Medicine Neurosciences ICU Medical Director University of New Mexico School of Medicine New Mexico Donor Services: Associate Medical Director Albuquerque, New Mexico David B. Seder, MD, FCCM Director, Neurocritical Care Maine Medical Center Portland, Maine