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Brief survey: Determining brain death in Canadian intensive care units

[Enquête ponctuelle : la détermination de la mort encéphalique dans les unités de soins intensifs au Canada]

Christopher James Doig, MD MSc, Kimberly Young, RN BSN, Jeannie Teitelbaum, MD and Sam D. Shemie, MD

From the Departments of Critical Care Medicine, Medicine, and Community Health Sciences,* Faculty of Medicine, The University of Calgary, Calgary, Alberta; the
Canadian Council for Donation and Transplantation;
the Department of Neurology, Montreal Neurological Institute, McGill University, Montreal, Quebec; and the
Division of Critical Care Medicine, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Quebec, Canada.

Address correspondence to: Dr. Christopher James Doig, Associate Professor, Rm EG23G Foothills Medical Centre, 1403-29^th Street NW, Calgary, Alberta T2N 2T9, Canada. Phone: 403-944-1691; Fax: 403-283-9994; E-mail: cdoig{at}ucalgary.ca

	Abstract

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Purpose: Criteria for brain death were first described in 1968, and Canadian guidelines were published in 1988. However, international inconsistency persists in the process of determining brain death. We sought to determine self-reported practices and processes in the determination of brain death amongst Canadian intensive care unit (ICU) physicians.

Methods: An email survey of members of the Canadian Critical Care Society was undertaken. A survey instrument was developed, then face and content validated prior to distribution.

Results: Eighty eight responded (response rate = 49%), including adult and pediatric ICU physicians working in both tertiary referral (academic) and community hospitals. Most respondents admit patients with brain death to their ICUs. However, 9% reported refusing to admit this type of patient for reasons including inappropriate utilization of ICU resources (36%), and lack of either space or staff (32% and 29% of respondents, respectively). Community hospital-based ICU physicians were less likely to report a hospital policy on the determination of brain death (46% vs 78% of physicians in tertiary care hospitals). Nearly all physicians (96%) reported that a revised national standard and checklist for the determination of death would be useful.

Conclusions: Nearly one quarter, and over one half of tertiary care and community hospitals (respectively) in Canada lack an institutional policy on neurological determination of brain death. Canadian ICU physicians are interested in a national standard for the determination of death, and establishment of processes that may improve the clinical determination of death by neurological criteria.

	Introduction

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IN 1968, the Ad Hoc Committee of the Harvard Medical School published a seminal report on the neurological criteria to determine death (brain death). ¹ The concept of death by neurological rather than cardiopulmonary criteria has been adopted widely since that time. However, there remains considerable international variation in the clinical criteria or processes for determining death based upon neurological criteria.² In Canada, guidelines were published in 1986. ³ In 1999, a small committee of neurocritical care specialists updated these guidelines.⁴ We undertook a national survey of Canadian intensive care unit (ICU) physicians to determine the variability in use of clinical criteria to diagnose brain death. A secondary objective was to explore if available ICU resources might affect brain dead individuals becoming organ donors.

	Methods

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In 2003 we conducted an email survey of critical care physicians practicing in Canadian ICUs. The study sample was identified from members of the Canadian Critical Care Society (n = 277) who had a valid email address (n = 178). Prior to the survey, an information letter was sent to all participants, followed by the survey form 48 hr later, two reminder emails seven and ten days later, and a follow-up phone call at two weeks. Surveys were only accepted if received within four weeks of the initial mailing. In accordance with Research Ethics board requirements at the institution of the primary author, informed consent was not obtained, as return of the survey was considered as assent, and the survey did not include personal identifying information.

The survey was developed by the authors for the sole purpose of this study, and conducted by Decima Research Inc. (Toronto, ON, Canada). Face and content validity were assessed by circulating the questionnaire to a select group of experts in the fields of neurosciences (n = 5), and survey design (n = 5) at the institution of the primary author. Comments on the syntax and structure of the questions were obtained from individuals at Decima Research Inc. who have considerable experience in conducting surveys of this type. Finally, the survey was field tested on a small sample (n = 10) of ICU physicians in the intended target population. Feedback on content and construction of questions was incorporated prior to distribution of the survey. Testing of the criterion and construct validity assessment of the survey were not undertaken. The survey development and study design did not include examining testing or variable-response reliability such as test-retest, inter-rater or internal consistency computations.

An administrative assistant independent of the research team was designated to receive all completed surveys, and stripped ‘sender’ email addresses from the responses prior to forwarding the surveys for collation and analysis. Data are presented in the form of simple descriptive statistics.

	Results

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The Canadian Critical Care Society included 277 members, of whom 178 had valid electronic mail addresses available at the time of the survey. The response rate was 88/178 (49%). Of the respondents, 77% identified themselves as working in adult ICUs, and 79% worked in university affiliated urban referral ICUs, 12% in urban community hospitals, 7% in non-university urban referral hospitals, and 2% in non-urban community hospitals. Ninety-five percent of represented ICUs had more than 11 beds, of which 42% had 11 to 20 beds, and 53% had more than 20 beds. Three-quarters (76%) of pediatric and 84% of adult ICUs had 11 or more beds. All non-university ICUs were less than 20 beds in size. The respondents reported that they cared for surgical patients (96%), medical patients (94%), neurosurgical patients (77%), cardiac surgical patients (46%), and organ transplant recipients (46%).

The survey responses are summarized in the Table. Eighty-nine percent of respondents reported that patients presenting to their emergency department with severe brain injury and a poor anticipated neurological outcome are always, or usually admitted to the ICU for a trial of therapy and prognostication. Intensive care physicians caring for pediatric patients (86%) always admit patients with these presentations, compared to ICU physicians caring for adult patients who reported always, (20%) or usually (64%) admitting this type of patient. Nine percent of respondents reported that they had at least once refused admission or transfer of patients with severe brain injury and poor neurological outcome. The most common responses for refusing admission were: 1) inappropriate utilization of ICU resources - not otherwise defined (48%); 2) lack of physical bed space (20%); 3) lack of ICU staff (20%); 4) family declined admission (15%); and 5) patient not deemed a suitable candidate for organ donation (9%). Patients assessed in the emergency department and determined to be brain dead were reported as always admitted to ICU for the purpose of organ donation by 51% of respondents, and usually admitted, by 34% of respondents. The main reasons for not admitting a case of brain death to ICU were: 1) perceived inappropriate use of resources - not otherwise defined (36%); 2) lack of physical ICU bed space (32%); 3) lack of ICU staff (29%); 4) not a suitable candidate for organ donation (6%); and 5) admission declined by family (4%).

	Discussion

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This survey describes self-reported patterns of practice of ICU physicians in Canada relating to the process of care of patients with severe brain injury who progress to brain death. Why is this important? The Harvard Ad Hoc Committee’s seminal report on brain death criteria described the need to establish a process, in part, to prevent controversy in obtaining organs for transplantation.¹ Public surveys have identified the important link between the public’s confidence in the determination of death, and the willingness to donate organs for transplantation purposes. Although families do not always conceptually understand brain death, the willingness to donate organs in part reflects the great trust and confidence in the medical profession, reasonably inferred that practices about the determination of death, end-of-life care, and organ donation are similar between physicians and hospitals.⁵

This survey found that most physicians agree with the concept of a national non-legislated standard for the determination of brain death, and tools such as ‘checklists of elements’ may help. Our survey did not ask why such checklists would be helpful: for example, to ensure the correct criteria were used, or to standardize documentation of the process used. However, previously published Canadian criteria for brain death may be applied inconsistently.⁶ This problem is not unique to Canada. In 1995, Mejia and Pollack reported the variability of practice in pediatric ICUs.⁷ Identified variations include a lack of apnea testing in 23% of cases, "controversial" apnea testing in 22% of cases, and other "contradictory" practices. Bell et al. recently conducted a survey in the United Kingdom of neurocritical care experts, and found similarly variable practices. ⁸ Finally, Keogh and Akhtar reported omissions in the documentation of the clinical criteria for brain death in medical notations in the chart. ⁹ In those centres which used checklists, clinical criteria omissions were significantly lower. These authors suggested that documentation on a checklist would be beneficial. Standardizing the processes (criteria and documentation) for determining brain death may be crucial to maintaining public confidence in these important medical decisions.

This survey was only intended to be descriptive, and there are several limitations which must be considered. The sampling frame identified only intensive care physicians who are members of the Canadian Critical Care Society. Use of a professional society is common surveying physician practices, although all physicians who work in Canadian ICUs may not be members of this society. Furthermore, this survey was limited by a response rate of only 49%. However, responses were received from all regions of the country, from physicians who practice in different clinical settings (i.e., community to tertiary-academic hospitals), from physicians who see different types of ICU patients (for example medical, surgical, neurocritical, and trauma), and from different sized ICUs. Although non-response is a potential bias of any survey, the diversity of clinical practice represented by these respondents decreases the likelihood of this type of systematic error affecting these study results. Finally, only the face and content validity of the survey was examined. However, as the purpose was only to describe certain attitudes in ICU physicians, and given the lack of data or prior hypotheses in this area, we felt that our approach to not proceed with construct or criterion testing was reasonable.

This survey does demonstrate variability in some processes of care in the determination of brain death, and the likelihood of admission to an ICU. Although our survey is limited by a response rate of 49% - albeit a response rate similar to other studies - there is reasonable support amongst ICU physicians for the development of a national standard for the neurological determination of death, and a standard process, such as by checklist, for documenting these clinical findings. A consensus conference to facilitate such a standard may help maintain and foster the public’s confidence in the determination of death by neurologic criteria, and requests to families to consider organ donation.

	Footnotes

 
Competing interests: None declared.

Accepted for publication August 12, 2005. Revision accepted January 16, 2006. Final revision accepted January 17, 2006.

	References

TOP Abstract Introduction Methods Results Discussion References

 
1 Anonymous. A definition of irreversible coma. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. JAMA 1968; 205: 337–40.[Medline]

2 Wijdicks EF. Brain death worldwide: accepted fact but no global consensus in diagnostic criteria. Neurology 2002; 58: 20–5.[Abstract/Free Full Text]

3 Anonymous. Death and brain death: a new formulation for Canadian medicine. Canadian Congress Committee on Brain Death. CMAJ 1988; 138: 405–6.[Medline]

4 Anonymous. Guidelines for the diagnosis of brain death. Canadian Neurocritical Care Group. Can J Neurol Sci 1999; 26: 64–6.[Medline]

5 Hazony O. Increasing the supply of cadaver organs for transplantation: recognizing that the real problem is psychological not legal. Health Matrix Clevel 1993; 3: 219–57.[Medline]

6 Shemie S, Teitelbaum J, Doig C. Variability in hospital-based brain death guidelines in Canada. Can J Anesth 2006; 53: 613–19.[Abstract/Free Full Text]

7 Mejia RE, Pollack MM. Variability in brain death determination practices in children. JAMA 1995; 274: 550–3.[Abstract]

8 Bell MD, Moss E, Murphy PG. Brainstem death testing in the UK—time for reappraisal? Br J Anaesth 2004; 92: 633–40.[Abstract/Free Full Text]

9 Keogh AT, Akhtar TM. Diagnosing brain death: the importance of documenting clinical test results. Anaesthesia 1999; 54: 81–5.[Medline]

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