Second Brain Death Exam Unnecessary, Study Finds
Families sometimes have to endure an extra day or more of waiting for final diagnosis
WEDNESDAY, Dec. 15, 2010 (HealthDay News) -- Making families wait for a second exam to confirm a brain death diagnosis is not only unnecessary but may make it less likely that the family will agree to donate their loved one's organs, a new study finds.
Researchers reviewed records from the New York Organ Donor Network database of 1,229 adults and 82 children who had been declared brain dead. All of the people had died in New York hospitals over a 19-month period between June 2007 and December 2009.
Patients had to wait an average of nearly 20 hours between the first and second exam, even though the New York State Health Department recommends a six-hour wait, according to the study.
Not only did the second exam add nothing to the diagnosis -- not one patient was found to have regained brain function between the first and the second exam -- lengthy waiting times appeared to make families more reluctant to give consent for organ donation.
About 23 percent of families refused to donate their loved ones organs, a number that rose to 36 percent when wait times stretched to more than 40 hours, the investigators found.
The converse was also true: Consent for organ donation decreased from 57 percent to 45 percent as wait times were dragged out.
Though the research did not look at the causes of the refusal, for families, waiting around for a second exam means another emotionally exhausting, stressful and uncertain day waiting in an intensive care unit to find out if it's time to remove their loved one from life support, said study author Dr. Dana Lustbader, chief of palliative care at The North Shore LIJ Health System in Manhasset, N.Y.
At the same time, the patient's already precarious condition can further decrease the odds of organ donation occurring as waiting times go up. Organ viability decreases the longer a person is brain dead, Lustbader said.
About 12 percent of patients declared brain dead had a cardiac arrest while waiting for the second exam or after the second exam, making them ineligible for organ donation, Lustbader added.
"We wanted to determine the accuracy of the first exam and determine if the second exam adds anything. The answer to that is an emphatic 'No,'" Lustbader said. "The second exam does not add anything and in fact, has several negatives or harmful effects, including prolonged anguish for families who are waiting to find out if their loved one is dead or alive."
The study is published in the Dec. 15 online issue of Neurology.
Though New York's health department requires two exams, elsewhere, neurologists are already moving away from two exams. The American Academy of Neurology's 2010 guidelines call for one, comprehensive exam done by an experienced and qualified physician. The exam includes a step-by-step checklist of some 25 tests and criteria that must be met before a person can be considered brain dead.
Dr. Gary Gronseth, a professor of neurology at the University of Kansas, said this is the right strategy.
More important than doing two exams is the waiting period between the time the person suffered the catastrophic injury that caused the brain death, determining the person is unlikely to ever regain consciousness and doing the first exam to make the official diagnosis.
"This insistence on the second exam has been a distraction from the main issue, which is selecting an appropriate observation period from the time of the catastrophic brain injury to the first exam," Gronseth said.
For example, the waiting period might be relatively shorter for someone who has devastating structural injury to the brain itself such as from a hemorrhage than the waiting time for someone who is brain dead due to other causes that aren't as obvious.
According to the study, lengthy waiting periods for the exam are also costly, with the extra day of intensive care for brain dead patients costing about $1 million a year in New York alone, according to the study.
For more on end-of-life issues, visit the U.S. National Library of Medicine.