Faculty Bibliography

The neurocritical care treatment team frequently interacts with patient surrogates and Organ Procurement Organizations (OPOs) at the end-of-life. A 2025 survey of Neurocritical Care Society (NCS) members assessing experiences and attitudes related to organ donation identified the need to enhance education for the treatment team about organ donation and opportunities for improvement in palliative interventions after withdrawal of life-sustaining therapies for potential donation after cardiac death/death by circulatory-respiratory criteria. Additionally, members noted concerns regarding blurred boundaries between patient care and care directed towards organ donation; a potential lack of transparency, empathy and cultural sensitivity in communication between OPOs and patient surrogates; and the ethics of first-person authorization for organ donation. In response to these concerns, the NCS Ethics Committee developed this statement to provide education and ethical guidance for organ donation at the end-of-life. Members had an opportunity to share feedback on the statement from April 6-19, 2026. This statement provides an informal narrative review of the literature related to organ donation that is pertinent to the care of potential organ donors at the end-of-life and includes practical guidance related to the legal definitions of death and first-person authorization, collaborative communication, and management of potential conflicts.

BACKGROUND:Public understanding about brain death/death by neurologic criteria (BD/DNC) is generally poor. With the rising popularity of utilization of large language model (LLM) chatbots to answer medical questions, we sought to determine the quality of information about BD/DNC provided by ChatGPT 4o-mini and Gemini 3 Flash (Fast). METHODS:With the assistance of a family advocate, we developed 45 open-ended questions about BD/DNC and submitted them to ChatGPT 4o-mini and Gemini 3 Flash (Fast) in January 2026. We recorded response word count, Flesch-Kincaid Readability Score and source reputability (non-reputable sources were defined as nonmedical, nongovernmental, nonlegal and not affiliated with an organ donation organization). Two authors of the 2023 BD/DNC guidelines independently assessed response accuracy relative to accepted medical standards and a third adjudicated discrepancies. RESULTS:Most responses were ≥ 10th grade level [ChatGPT 4o-mini: 44/45 (98%), Gemini 3 Flash (Fast): 39/45 (86%)]. After adjudication, 22/45 (49%) responses from Gemini 3 Flash (Fast) and 20/45 (44%) from ChatGPT 4o-mini were considered completely correct (p = 0.673). There was no relationship between accuracy and: word count; readability; or citation of at least one non-reputable source. CONCLUSION/CONCLUSIONS:ChatGPT 4o-mini and Gemini 3 Flash (Fast) responses to questions about BD/DNC may include inaccuracies. This could promote confusion and distrust. There is remarkable potential for integration of artificial intelligence in public education about healthcare, but there is a need for improvement to ensure responses are accurate and readable. The healthcare team should be prepared to address misconceptions about BD/DNC based on use of LLMs.

INTRODUCTION AND PROBLEM STATEMENT/UNASSIGNED:Competency in brain death/death by neurologic criteria (BD/DNC) determination is an Accreditation Council for Graduate Medical Education (ACGME) milestone in neurology residency and neurocritical care fellowship; however, trainees have limited clinical exposure and receive inconsistent training across institutions. Simulation offers a standardized, safe environment to teach and assess BD/DNC, but multi-institutional implementation remains unstudied. The aim of this study was to evaluate the feasibility of implementing a consensus-based BD/DNC curriculum and to assess its impact on trainee confidence. LEARNING OBJECTIVES/UNASSIGNED:By the end of the curriculum, trainees will be confident in assessing BD/DNC prerequisites, performing a complete neurologic examination, safely conducting and interpreting apnea testing, and accurately declaring BD/DNC. METHODS AND CURRICULUM DESCRIPTION/UNASSIGNED:test. RESULTS/UNASSIGNED:Nineteen participants (9 female [47%]; predominantly PGY-4 trainees) were enrolled. Median [IQR] pre-post composite confidence scores improved significantly across all domains: "Setup and Family Counseling," 4 [3.5-4] to 4.5 [4-5]; "Prerequisites," 4 [4-5] to 4.5 [4-5]; "Neurologic Examination," 4 [4-4] to 4.5 [4-5]; and "Apnea Test and Declaration of BD/DNC," 3 [3-4] to 5 [4-5]. The effect sizes (Wilcoxon r) ranged from 0.79 to 0.88 across domains. There were no significant differences in the magnitude of improvement between high-fidelity and low-fidelity groups. After curriculum implementation, 13 of 19 participants (68%) self-assessed their ACGME BD/DNC milestone competency to be level 4 or 5. DISCUSSION AND LESSONS LEARNED/UNASSIGNED:This multi-institutional pilot demonstrated that a consensus-based BD/DNC simulation curriculum is feasible and improves trainee confidence despite limited previous clinical exposure. Key lessons include the feasibility of multicenter collaboration, standardizing core practices while accommodating local variability, and designing adaptable curricula that achieve similar outcomes across resource-diverse settings.

BACKGROUND:The risk of intracerebral hemorrhage (ICH) hematoma expansion (HE) is highest in the first hours after onset, and coagulopathy is believed to further increase this risk. However, there is a paucity of data comparing the risk of HE over time for various antithrombotic agents. METHODS:We conducted a retrospective study of spontaneous ICH patients enrolled at a comprehensive stroke center between December 2016 and May 2022, excluding those who underwent surgical evacuation. ICH volumes were calculated using ABC/2 methodology and HE was coded for a ≥ 33% and/or ≥ 6-mL increase in ICH volume. Multivariable logistic regression and Cox proportional hazards models were constructed to evaluate risk of HE among patients exposed to the following antithrombotics: aspirin, P2Y12 inhibitors, aspirin + P2Y12 inhibitors, warfarin, oral factor Xa inhibitors, direct thrombin inhibitors, full dose heparinoids, and combined antiplatelet + anticoagulant. RESULTS:Of 319 patients with ICH, 141 (44%) were on an antithrombotic at the time of ICH and 65 (20%) had HE in a median of 10 h (interquartile range (IQR) 7-21) from last known normal (LKN). In multivariable logistic regression analyses, the odds of HE decreased by 2% for every hour from LKN (adjusted odds ratio (aOR) 0.98, 95% CI 0.97-0.99, P = 0.038), and HE occurred significantly more often in patients taking combined antiplatelet + anticoagulant (9/24, 38%) compared with those who were not (56/295, 19%, aOR 2.71, 95% CI 1.09-6.73, P = 0.032). No other antithrombotic was significantly associated with HE. In multivariable Cox analysis adjusting for admission National Institutes of Health Stroke Scale (NIHSS), only antiplatelet + anticoagulant use was associated with significantly increased rates of HE (adjusted HR (aHR) 2.33, 95% CI 1.14-4.75, P = 0.020), with the highest probability of HE occurring immediately after ICH onset. CONCLUSIONS:Use of combined antiplatelet + anticoagulant was associated with a twofold increased hazard of HE, with the highest probability of expansion occurring early after ICH onset. No increased rate of HE was observed for other antithrombotics.

INTRODUCTION/BACKGROUND:There has been a surge in attention to ethical controversies associated with organ donation in the USA. The Neurocritical Care Society (NCS) Ethics Committee sought to understand member experiences and attitudes related to organ donation in the USA. METHODS:We designed a survey of members who practice in the USA and have interacted with an organ procurement organization (OPO)/potential donor. The survey was disseminated by NCS from 1 June 2025 to 1 September 2025. Free-text responses were reviewed to identify themes. RESULTS:Of 2204 NCS members in the USA, there were 71 respondents who completed the survey and 37 respondents who provided free-text comments. Experiences and attitudes varied, but 59% of respondents indicated that they generally think that communication between the OPO and patient surrogates about donation after brain death/death by neurologic criteria seems appropriate, and 34% indicated that they generally think that communication between the OPO and patient surrogates regarding donation after cardiac death/death by circulatory-respiratory criteria (DCD) seems appropriate. Themes included (1) the need to improve education for the treatment team about organ donation; (2) blurred boundaries between patient care and care directed toward organ donation; (3) misalignment between OPOs and treatment team priorities; (4) loss of trust between patient surrogates and the treatment team based on interactions with OPOs; (5) suboptimal timing of communication between OPOs and patient surrogates; (6) concerns regarding a potential lack of transparency, empathy, and cultural sensitivity in communication between OPOs and patient surrogates; (7) opportunities for improvement in preoperative care before donation and palliation after extubation for DCD; and (8) changes in willingness to donate organs based on interactions with OPOs. CONCLUSIONS:Although the results from this survey reflect the experience and attitudes of a small percentage of NCS members in the USA, they indicate that there are opportunities for improvement in organ donation processes. Survey results will guide the NCS Ethics Committee in supporting members navigating ethical controversies related to organ donation.

Persons with disorders of consciousness (DoC) occupy an ethically charged space in modern medicine and biomedical research. Their decisional capacity is characteristically absent or limited or unpredictably fluctuates, requiring clinicians and investigators to rely on surrogates. Although there is general guidance for informed consent (IC) for research studies, there is no specific guidance for research involving persons with DoC. There are inconsistencies in IC forms for these studies related to explanation of a DoC, evaluation of capacity, description of risks/benefits, and sharing investigational results. This is problematic for persons with DoC, their surrogates, researchers, and institutional review boards (IRBs)/research ethics boards (REBs). To address these issues, the Curing Coma Campaign (CCC) Ethics Workgroup developed the Common Consent Elements for Research Involving Persons with Disorders of Consciousness (CCE-DoC). This practical framework aims to clarify and standardize consent processes in this complex and ethically sensitive research area. Through this structured, adaptable approach, CCE-DoC may have the potential to enhance participant protections, strengthen trust, help families and decision-makers understand studies, reduce duplicative efforts across research groups, and guide investigators and IRBs/REBs in navigating the complex ethical terrain of consent in DoC research. In so doing, CCE-DoC seeks to extend respect for autonomy and trust and promote responsible research urgently needed to advance paradigms of diagnosis, prognosis, and treatment for individuals with disorders of consciousness. The framework offers example language to encourage standardization, while allowing teams flexibility to customize to local needs.

The frequency and nature of neurological exams (neuro-checks) in patients with severe acquired brain injury resulting in coma or disorders of consciousness (DoC) remain variable, with limited evidence guiding practice and poor understanding of their role in predicting and preventing neurological deterioration, functional recovery and adverse effects such as delirium. This scoping review aims to explore the frequency of bedside neurological exams within the first 7 days of injury impact on clinical outcomes in adult patients with severe acquired brain injury including mortality, neurological deterioration, long-term function, and delirium. METHODS: A comprehensive literature search was conducted using the PubMed, CINAHL, Medline and EMBASE databases from 2003 to 2023. Search terms captured a range of acute brain injuries and neuro-assessment tools. Eligible studies included adult patients with severe traumatic or non-traumatic brain injury or stroke that addressed frequency of bedside neurological exams within the first 7 days of admission. RESULTS: Of 1327 studies screened, 20 met inclusion criteria, representing over 16,000 patients across 14 countries. Assessment tools varied, but use of the Glasgow Coma Scale was prevalent. Frequency of neuro-checks ranged from hourly to daily. Multiple outcome measures were utilized. Some studies found that continuing hourly neuro-checks beyond the first 48 hours did not provide additional clinical benefit. Others associated excessive assessment with increased stress or delirium. CONCLUSION: There is very low evidence supporting an association between the frequency of neuro-checks and functional outcomes, mortality, length of stay, or delirium. Although early assessments may aid prognostication, excessive exams may not improve outcomes and may contribute to harm. The heterogeneity, lack of evidence, and limited standardization of neuro-check frequency highlight the need for clinical research to guide future practice.