Date of Award

January 2016

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

David M. Greer

Abstract

In accordance with the Uniform Determination of Death Act, from 1981 until today, guidelines for brain death determination have been developed at an institutional level and have been shown to have wide variability of practice. The 2010 update to the American Association of Neurology Practice Parameters (AANPP) stands as a landmark effort to improve guideline uniformity, but it is not known whether it has achieved its intended effect.

In this study, we seek to show that progress has been made in unifying brain death determination guidelines in the last decade by directly comparing the policies of the US News and World Report’s Top 50 ranked neurologic institutions from 2006 and 2015. We solicited official hospital guidelines in 2015 from these top 50 institutions, generated summary statistics of their criteria as benchmarked against the AANPP and the comparison 2006 cohort1 in five key categories, and statistically compared the two cohorts’ compliance to published guidelines.

Overall, hospital policies exhibited significant improvements (p<0.01) in compliance to certain portions of official guidelines, particularly with respect to criteria related to apnea testing (p<0.026), and positive trends in improved compliance with validated ancillary testing (p<0.082). Hospitals in 2015 also showed more internal consistency in complying with a greater percentage of the AANPP than in 2006 (average of 71% of criteria complied with vs 58%, p<0.001). Significant variability, however, remain in other portions of the policies, both ones with specific recommendation from the AANPP (e.g. specifics for ancillary tests) and those without firm guidance (e.g. the level of involvement of neurologists, neurosurgeons, or physicians with education/training specific to brain death in the determination process).

Thus, while the 2010 AANPP update seems to be concordant with progress in achieving greater uniformity in guidelines at the top 50 neurologic institutions, more needs to be done. Whether further interventions come as grassroots initiatives that leverage technological advances in promoting adoption of new guidelines or as top-down regulatory rulings to mandate speedier approval processes, this study shows that solely relying on voluntary updates to professional society guidelines is not enough.

Comments

This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.

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