To the Editor:—
Dr. Van Norman’s review article concerning medical, legal, and ethical aspects of declaring brain death is at times perfunctory and unconvincing. 1A general theme is that anesthesiologists should watch over other physicians’s declarations of brain death, and one of the concrete demands is summarized as follows:“Anesthesiologists have an important responsibility in the process of assuring that some living patients are not sacrificed to benefit others.”
Three cases that involve blatant misinterpretation and errors by “physicians” set the stage for a nimbly crafted report that discusses a variety of views surrounding the diagnosis of brain death. In addition to these three cases, which in their journalistic description unfortunately contain little detail about the neurologic assessment of these patients, Dr. Van Norman claims that in one study, two thirds of physicians were unable to correctly identify or apply the whole-brain criteria for the determination of brain death. 2This study, which surveyed health professionals, indeed found major differences in the assessment of brain death and vegetative state among respondents when two fictitious cases were presented. The study included intensive care nurses, medical residents, attending anesthesiologists, operating room nurses, and intensive care unit physicians; however, no neurologists and only 16 attending neurosurgeons or neurosurgeons in training were included in the survey.
It is encouraging to read that Dr. Van Norman believes that, in the determination of brain death, at least one of the attending physicians should be a neurologist or a neurosurgeon. The declaration of brain death necessitatess academic precision, but who is qualified to determine brain death is a matter of discussion. One may argue that the determination should involve critical care neurologists and neurosurgeons, and perhaps one or two dedicated neurologists or neurosurgeons on call.
Although the article does not contain gross factual errors, there are some confusing recommendations when the confirmatory tests are discussed. The article lacks a comprehensive discussion of the validity of confirmatory tests. In addition, the report fails to address the interpretation of clinical observations that may be compatible with brain death (but suggest otherwise) and critical evaluation of the apnea test procedure. These topics can be found in a practice parameter developed by the American Academy of Neurology and approved by its executive board. 3,4Many hospitals in and outside of the United States have adopted this parameter in its present form, or in a slightly modified form. These parameters are used by neurologists as the guidelines for declaration of brain death.