Faculty Bibliography

OBJECTIVES/OBJECTIVE:We sought to (1) identify the countries in the Latin America/Caribbean Group of the United Nations (GRULAC) that have protocols for brain death/death by neurologic criteria (BD/DNC) and (2) review the similarities and differences between these protocols. MATERIALS AND METHODS/METHODS:Between January 2018 and April 2019, we obtained and reviewed BD/DNC protocols from countries in GRULAC. RESULTS:We communicated with contacts in 30/33 countries in GRULAC (91 % of countries) and found that 16 (53 % of countries with contacts, 48 % of Latin American/Caribbean countries) had BD/DNC protocols. Of the 13 protocols that provided a definition of death, 10 (77 %) referred to whole brain death. The number of exams/examiners, prerequisites for BD/DNC, and descriptions of the clinical assessment and apnea test were inconsistent among protocols. Although Brazil and Panama required an ancillary test, the indications for ancillary testing, and the types of accepted ancillary tests, varied by country. CONCLUSION/CONCLUSIONS:BD/DNC determination protocols in the countries in GRULAC are inconsistent. Acknowledging the fact that there are diverse cultural, legal and religious perspectives on death, and human and technological resources differ by region, we recommend that attempts be made to harmonize protocols on BD/DNC both regionally and worldwide.

BACKGROUND:We sought to evaluate how Muslim allied healthcare professionals view death by neurologic criteria (DNC). METHODS:We recruited participants from two listservs of Muslim American health professionals to complete an online survey questionnaire. Survey items probed views on DNC and captured professional and religious characteristics. Comparative statistical analyses were performed after dichotomizing the sample based on religiosity, and Chi-squared, Fisher's exact tests, likelihood ratios and the Kruskal-Wallis test were used to assess differences between the two cohorts. RESULTS:There were 49 respondents (54%) in the less religious cohort and 42 (46%) in the more religious cohort. The majority of respondents (84%) believed that if the American Academy of Neurology guidelines are followed and a person is declared brain dead, they are truly dead; there was no difference on this view based on religiosity. Less than a quarter of respondents believed that outside of organ donation, mechanical ventilation, hydration, nutrition or medications should be continued after DNC; again, there was no difference based on religiosity of the sample. Importantly, half of all respondents believed families should be able to choose whether an evaluation for DNC is performed (40% of the less religious cohort and 60% of the more religious cohort, p = 0.09) and whether organ support is discontinued after DNC (49% of both cohorts, p = 1). CONCLUSIONS:Although the majority of allied Muslim healthcare professionals we surveyed believe DNC is death, half believe that families should be able to choose whether an evaluation for DNC is performed and whether organ support should be discontinued after DNC. This provides insight that can be helpful when making medical practice policy and addressing legal controversies surrounding DNC.

OBJECTIVE:To identify similarities and differences in protocols on determination of brain death/death by neurologic criteria (BD/DNC) around the world. METHODS:We collected and reviewed official national BD/DNC protocols from contacts around the world between January 2018 and April 2019. RESULTS:We communicated with contacts in 136 countries and found that 83 (61% of countries with contacts identified, 42% of the world) had BD/DNC protocols, 78 of which were unique. Protocols addressed the following prerequisites and provided differing instructions: drug clearance (64, 82%), temperature (61, 78%), laboratory values (56, 72%), observation period (37, 47%), and blood pressure (34, 44%). Protocols did not consistently identify the same components for the clinical examination of brain death; 70 (90%) included coma, 70 (90%) included the pupillary reflex, 68 (87%) included the corneal reflex, 67 (86%) included the oculovestibular reflex, 64 (82%) included the gag reflex, 62 (79%) included the cough reflex, 58 (74%) included the oculocephalic reflex, 37 (47%) included noxious stimulation to the face, and 22 (28%) included noxious stimulation to the limbs. Apnea testing was mentioned in 71 (91%) protocols; there was variability in the technique and target across protocols. Ancillary testing was included as a requirement for all determinations of BD/DNC in 22 (28%) protocols. CONCLUSIONS:There is considerable variability in BD/DNC determination protocols around the world. Medical standards for death should be the same everywhere. We recommend that a worldwide consensus be reached on the minimum standards for BD/DNC.

Background/UNASSIGNED:We explored factors associated with admission and discharge code status after nontraumatic intracranial hemorrhage. Methods/UNASSIGNED:We extracted data from patients admitted to our institution between January 1, 2013, and March 1, 2016 with nontraumatic intracerebral hemorrhage or subarachnoid hemorrhage who had a discharge modified Rankin Scale (mRS) of 4 to 6. We reviewed data based on admission and discharge code status. Results/UNASSIGNED:.06). There was no significant difference between discharge code status and sex, age, marital status, premorbid mRS, discharge GCS, or bleed severity. Conclusions/UNASSIGNED:Limitation of code status after nontraumatic intracranial hemorrhage appears to be associated with older age, white race, worse APACHE II score, and active cancer. The role of palliative care after intracranial hemorrhage and the racial disparity in limitation and de-escalation of treatment deserves further exploration.