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1.  A survey of American neurologists about brain death: understanding the conceptual basis and diagnostic tests for brain death 
Background
Neurologists often diagnose brain death (BD) and explain BD to families in the intensive care unit. This study was designed to determine whether neurologists agree with the standard concept of death (irreversible loss of integrative unity of the organism) and understand the state of the brain when BD is diagnosed.
Methods
A previously validated survey was mailed to a random sample of 500 board-certified neurologists in the United States. Main outcomes were: responses indicating the concept of death that BD fulfills and the empirical state of the brain that would rule out BD.
Results
After the second mailing, 218 (44%) surveys were returned. Few (n = 52, 27%; 95% confidence interval (CI), 21%, 34%) responded that BD is death because the organism has lost integrative unity. The most common justification was a higher brain concept (n = 93, 48%; 95% CI, 41%, 55%), suggesting that irreversible loss of consciousness is death. Contrary to the recent President's Council on Bioethics, few (n = 22, 12%; 95% CI, 8%, 17%) responded that the irreversible lack of vital work of an organism is a concept of death that the BD criterion may satisfy. Many responded that certain brain functions remaining are not compatible with a diagnosis of BD, including EEG activity, evoked potential activity, and hypothalamic neuroendocrine function. Many also responded that brain blood flow and lack of brainstem destruction are not compatible with a diagnosis of BD.
Conclusions
American neurologists do not have a consistent rationale for accepting BD as death, nor a clear understanding of diagnostic tests for BD.
doi:10.1186/2110-5820-2-4
PMCID: PMC3310851  PMID: 22339807
2.  Variability in the pediatric intensivists' threshold for withdrawal/limitation of life support as perceived by bedside nurses: a multicenter survey study 
Background
We hypothesized that bedside nurses perceive significant variability in the pediatric intensivist thresholds for approaching a family about withdrawal/limitation of life-sustaining therapy.
Methods
All nurses working in four university-affiliated medical-surgical pediatric intensive care units staffed by 11, 7, 6, and 5 intensivists with 36, 18, 10, and 8 beds were sent three mailings of a survey asking questions about intensivist decisions for withdrawal/limitation of life-sustaining therapy. Responses were tabulated; chi-square compared results among centers; a p < 0.05 after Bonferroni correction was significant.
Results
The response rate was 205 of 415 (49%); 152 of 205 (74%) disagreed with the statement that each of the intensivists had the same threshold for approaching a family to suggest withdrawal/limitation of life-sustaining therapy, with no significant difference between centers. Also, 110 of 205 (54%) and 119 of 205 (58%) disagreed with the statement that each intensivist has the same threshold of the patient's chance for survival or projected quality of life when making a decision to withdraw/limit life-sustaining therapy with no significant difference between centers. The threshold to suggest withdraw/limit life-sustaining therapy based on chance of survival or projected quality of life differs between intensivists by at least 10% according to 113 of 184 (61%) and 121 of 184 (66%) nurses; the two larger centers had significantly higher difference among intensivists for projected quality of life. Fifty-five of 200 (27%) disagreed with the statement that they would have equal confidence in each intensivist accepting a recommendation for withdrawal/limitation of life-sustaining therapy for their own child, with no difference between centers.
Conclusions
Bedside pediatric intensive care unit nurses in this multicenter Canadian study perceive wide variability in intensivist thresholds for approaching a family to suggest withdrawal/limitation of life-sustaining therapy.
doi:10.1186/2110-5820-1-31
PMCID: PMC3224498  PMID: 21906385

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