It may be unnecessary to require a second exam on a patient who is brain dead; it also prolongs the anguish for the patient’s loved ones, and negatively impacts on the viability of organ donations, researchers from The North Shore LIJ Health System in Manhasset, New York, wrote in the medical journal Neurology. The authors had gathered data on 1,229 adults and 82 children from the New York Organ Donor Network over a 19-month period.

A person who is brain-dead has no clinical evidence of brain function when examined physically by a doctor. There is no response to pain and no cranial nerve reflexes. The pupils are fixed (no response to stimuli, such as light), neither is there any response to the caloric reflex test. There are no spontaneous respirations. A brain-death (cerebral death) diagnosis needs to be vigorous in order to be sure that the condition will never change (irreversible). The criteria for brain death may vary from country to country. In America two independent physicians must carry out neurological examinations.

Study author Dana Lustbader, MD, FCCM, FCCP, said:

    “One of the most disturbing findings of our study is the prolonged anguish imposed on grieving families in the intensive care unit waiting for the second brain death exam. Not only is the opportunity for organ donation reduced, but families may endure unnecessary suffering while waiting an average of 19 hours for the second exam to be completed.

    Since organ viability decreases the longer a person is brain dead, our results show that conducting more than one brain death examination results in the loss of potentially life-saving organs. A repeat exam adds an extra day of intensive care resulting in additional costs of about a million dollars per year in the New York region alone.”

None of the second exams on the patients who had been declared brain dead after the first exam found any traces of restored brain stem function, the authors reported.

While waiting for the second exam, or soon after, 12% (166) of the patients had a cardiac arrest, making their chances of becoming organ donors impossible.

On average, there is an interval of 19 hours between each exam – three times what the new York State Health Department recommends. Organ donation consent dropped from 57% to 45% as the gap between exams increased, while refusals jumped from 23% to 36%.

2005 Guidelines, according to the NY State Department of Health, recommend a breathing test and two clinical brain death exams, one six hours after the other. The AAN (American Academy of Neurology) is now calling for just one brain death examination.

The authors concluded:

    “A single brain death examination to determine brain death for patients older than 1 year should suffice. In practice, observation time to a second neurologic examination was 3 times longer than the proposed guideline and associated with substantial intensive care unit costs and loss of viable organs.”

Gene Sung, MD, MPH, of the University of Southern California, also an AAN member, wrote:

    “These findings illustrate why there’s a crucial need to standardize approaches for determining brain death.”

“Evidence-based guideline update: Determining brain death in adults : Report of the Quality Standards Subcommittee of the American Academy of Neurology”

“Second brain death examination may negatively affect organ donation”
D. Lustbader, MD, D. O’Hara, MS, E.F.M. Wijdicks, MD, PhD, L. MacLean, PhD, W. Tajik, A. Ying, MS, E. Berg and M. Goldstein, MD
Neurology doi: 10.1212/WNL.0b013e3182061b0c

Written by Christian Nordqvist