An institutional study of awareness of brain-death declaration among resident doctors for cadaver organ donation.

BACKGROUND AND AIMS: Brain death is defined as irreversible and complete cessation of all brain function including that of the brainstem. The aim of this study was to assess the level of knowledge and awareness about brain-death declaration among resident doctors.
METHODS: This was an observational questionnaire-based study conducted in single institute in which 112 junior residents and 46 senior resident doctors in various medical specialities were included by universal sampling method. A prevalidated questionnaire consisting of questions related to knowledge, attitude and performance of brain-death declaration were distributed among residents as per the inclusion criteria to fill in the time limit of 30 min. Statistical tools used were mean and standard deviation, proportion and Chi-square test.
RESULTS: A total 87 resident doctors consisting of 71.26% males and 28.73% females responded to the questionnaire. About 91.95% correctly defined it as complete cessation of brain activity including brainstem reflexes. Most of the resident doctors (80.45%) knew about the documentation of absence of brainstem reflexes at 6 h intervals and 64.36% were aware about positive apnoea test. When asked about whether there is legal sanction for disconnecting life support in India, 56.32% said no, and 43.67% said yes. Only 12.64% of resident doctors were aware about a panel of 4 physicians are mandatory to declare brain death in India.
CONCLUSION: Awareness and attitude towards the identification of brain death and possible deceased donor organ transplantation were lacking amongst resident doctors.

INTRODUCTION

Brain death is defined as irreversible and complete cessation of all brain function including brainstem. The term ‘Brain death’ was introduced by Ad Hoc Committee of the Harvard Medical School to facilitate organ donation.[1] Common causes of brain death are traumatic brain injury, subarachnoid haemorrhage, post-resuscitation hypoxic insult, brain tumours, drowning, etc. In most cases, brain death is diagnosed at the bedside. Determination of brain death has significant legal and ethical implications; hence, it should be diagnosed and documented carefully. The concept of brain death and brain stem death is still in evolving stages in India. Many brain dead patients are kept on life support needlessly because of lack of awareness in public and medical professionals.[2]

In June 1994, the Indian parliament passed the Transplantation of Human Organs Act.[3] This law required brain death to be declared only in the institutions recognised by the state appropriate authority, leading to unnecessary transfer of brain-dead patient from one hospital to other for organ retrieval. As per the amendment of law in 2014, some of the institutions have been recognised as organ retrieval centres.[4]

The aim of this study was to assess the awareness and level of knowledge about brain death and its subsequent declaration among the resident doctors.

METHODS

This study was an observational questionnaire-based study conducted in government medical college and tertiary care hospital in metropolitan city over a period of seven days. In this study, 112 junior residents and 46 senior residents in various medical specialities were included by universal sampling method. They were from the Departments of Anaesthesiology, General Surgery, Medicine, Paediatrics and superspeciality departments, namely, paediatric surgery, urology, nephrology, cardiovascular and thoracic surgery, neurology and neurosurgery [Figure 1]. These specialities were included considering their direct involvement during the procedure of brain-death declaration and maintenance of organs after brain death, as also during harvesting and transplantation. They were made aware about the purpose of this study. Those doctors who were willing to participate in the study and had given their consent were included in this study.

Figure 1

Departments participating in the study

Resident doctors who were involved in the pilot study were excluded. First-year junior residents of all the departments were excluded assuming their lesser exposure about the subject.

First, a semi-structured questionnaire consisting of open-ended and close-ended questions were prepared and distributed among faculties of the department and checked for common errors. Then, a pilot study was conducted among 10 junior residents and 5 senior resident doctors. The questionnaire was then restructured after the analysis of the pilot study.

After ethics committee approval, permission of all the heads of the departments was taken. A prevalidated questionnaire consisting of questions related to knowledge, attitude and performance of brain-death declaration was distributed among resident doctors. [Appendix 1, Questions 1 to 25] They were assured regarding the confidentiality of answers. After formal introduction, questionnaires were given to be filled in the time limit of 30 min. Data collected was entered in Microsoft Excel Software 2010 version and analysed using SPSS Software Version 17.0.by IBM Corp. (IBM SPSS 17) Statistical tools used were mean and standard deviation, proportion percentage and Chi-square test.

RESULTS

A total of 158 resident doctors were called for participation out of which 87 resident doctors consisting of 62 males (71%) and 25 females (29%) responded to the questionnaire [Table 1].

Table 1

Demographic data

When the criteria for brain-death declaration were assessed, majority of resident doctors were aware about the exact definition of brain death. Eighty resident doctors (91.95%) correctly defined it as complete cessation of brain activity including brainstem reflexes [Figure 2]. They could differentiate between brain death and cardiac death as two different entities. Seventy-three resident doctors (83.90%) stated that coma and vegetative state are two different conditions.

Figure 2

Responses for definition of brain death. X-Axis: Correct def of BD: Correct definition of Brain Death - Complete cessation of brain activity including brainstem reflexes; b – Brain death is defined as Partial cessation of brain activity with brainstem reflexes; c – Brain death is defined as Decerebrate state; d – Brain death is defined as Brain injury. Y-axis: Number of responses(%)

Seventy resident doctors (80.45%) said ‘yes’ that it is mandatory to document the absence of brainstem reflexes at two examinations 6 h apart for documentation of brain death. However, only 25 resident doctors (54.73%) could correctly identify that absence of pupillary and corneal reflex, absence of oculovestibular reflex and absent grimace to noxious painful stimulus are required.

Fifty-six resident doctors (64.36%) responded positively that it is mandatory to do apnoea test and 75 resident doctors (86.20%) knew about positive apnoea test [Figure 3]. Regarding confirmatory test for brain death, 29 resident doctors (33.33%) responded that electroencephalogram should be done. Six resident doctors (6.89%) responded Somatosensory evoked potential, five responded as cerebral angiography (5.74%) and 47 resident doctors (54.02%) said that all above investigations should be done to confirm inconclusive apnoea testing.

Figure 3

Responses to questions regarding the Apnoea test for brain death declaration. X-axis: A.T. Apnoea test; a – Positive Apnoea test if PaCO2 >60 mmHg; b - Positive Apnoea test if there is an increase in PCO2 >20 mmHg over baseline; c - Positive Apnoea test if there is no respiratory movement during test; d - Positive Apnoea test if all criteria a-c are met. Y-axis: number of responses (%)

When asked about whether it is legal to disconnect life support in India, 49 resident doctors (56.32%) said no and 38 resident doctors said yes (43.67%). Only 11 resident doctors (12.64%) were aware about a panel of 4 physicians, i.e., one neurosurgeon/neurologist, one treating physician and surgeon are mandatory to declare brain death in India.

Seventy-three resident doctors (83.90%) replied positively when asked about organ donation of family member if the situation arises. However, when they were asked about the presumed consent, very few knew about it. In addition, resident doctors were not aware about the little percentage of deceased donor organ transplant performed in India.

DISCUSSION

The term ‘brain death’ is widely accepted by health-care professionals in most parts of the world.[5] There are no published reports of recovery of neurologic function after a diagnosis of brain-death.[6] The concept of brain-death declaration and cadaveric organ harvesting for organ transplantation is still in primitive stages in India. Rather live donor transplant is preferred. There are various reasons behind it, such as lack of awareness, religious beliefs, social issues, ethical concerns, lack of motivation and huge disparity between the government and private hospitals in terms of infrastructure and trained humanpower, etc.[789] A major limiting factor in organ donation from a brain dead donor is the attitude of health-care professionals. It is very stressful for a physician to explain brain death to bereaved relatives. In-house counsellors with good interpersonal communication skills are required in such situations to coordinate between relatives and hospital staff. In addition, good cooperation of the Intensive Care Unit and hospital staff for maintenance of organ function after brain death is necessary.[101112]

Determination of brain death requires a process of certification which includes identification of findings that provide a clear aetiology of brain dysfunction. It also requires exclusion of conditions that may confound the clinical diagnosis of brain death. This is followed by two complete neurological examinations and apnoea tests 6 h apart. The time of the death is the time at which PaCO2 reaches target value during the second apnoea test.[13] There is no sufficient evidence to determine the minimally acceptable observation period between two clinical examinations and safety of apnoea test techniques. Ancillary tests can be used when uncertainty exists about neurologic evaluation. However, the clinician has to judge on the use of ancillary tests to support brain death.[14] The lack of evidence to determine the minimally acceptable observation period and reliability of newer ancillary tests affects early diagnosis of brain death.[15]

The knowledge about determination of brain death involves, number of physicians required to certify it, controversies of presumed consent against informed consent and medicolegal aspects such as methods of registering for organ donation were lacking in the majority of resident doctors. Only 12.64% resident doctors knew about the panel of four physicians are required to certify brain death in India. These physicians should not be part of transplant team.

A major article on international brain-death criteria by Wijdicks revealed that the majority of nations have guidelines for determination of brain-death. There is a scarcity of evidence-based literature on practices of brain-death determination.[16] Although guidelines are available in many countries for the diagnosis of brain death, the variations and inconsistencies necessitate an international consensus and uniform guidelines.[17] Despite global acceptance of brain death, from ‘total brain death’ to ‘whole brain death’ and with clear drafted policies in the Western world, still, differences in concept, assessment of clinical criteria and ancillary tests persist.[18]

Seventy-three resident doctors admitted that they would encourage friends and family to donate organs and agreed that there was a need for creating awareness through media. Relatives are reluctant to donate because prior wishes of the deceased are not communicated to family members. The Spanish model of organ donation and transplantation by providing education to health-care professionals has directly resulted in continuous rise of families willing to donate organs.[19]

Providing appropriate education regarding identification and notification of brain death can influence successful maintenance of potential donor for organ procurement.[20] A formal training to initiate discussion about brain-death declaration and organ donation can significantly improve knowledge and positive attitude of health-care professionals. They can prevent the loss of potential donors and affect the rates of family refusal to donate organs.[21] A multidisciplinary approach and good transplant coordinators can help in the successful management of brain-dead donors. Mandatory reporting of brain dead cases to appropriate authorities has to be enforced to gain momentum to this program.[22]

This study was conducted in one of the premier government institute where live donor kidney and corneal transplant are regularly done. However a limitation of this study is that it was a single-centre study. A multicentre study should be conducted to provide more precise information.

CONCLUSION

It was observed that awareness of brain death, procedure followed during declaration of brain death and deceased organ donation was lacking in resident doctors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.