Anaesthesia 2016, 71, 232–244
Correspondence Diagnosing brain death In their overview of organ donation following brainstem death in Spain [1], Escudero et al. reported conversion rates of 70%, which are higher than many other countries, and which they attribute to the presence of specialists in the deceased donation process. Similar practitioners operate in the UK (specialist nurses in organ donation), yet a conversion rate of only 57% in cases of confirmed brain stem death is achieved [2]. This disparity is likely attributable to the Spanish ‘opt-out’ system of presumed consent, in contrast with the UK ‘opt-in’ system. We would like to ask the authors whether they noticed any common themes amongst the relatives of the 244 individuals for whom consent for donation was refused? Ancillary testing was used to diagnose brainstem death in over 95% of reported cases. Were the authors able to identify whether this was carried out as a legal requirement or whether specifically at the direction of the treating physician? The determination of brainstem death using clinical criteria is widely accepted as the gold standard, but the place of ancillary test-
ing is yet to be fully determined [3], which is why UK national guidance does not mandate it [4]. Do the authors have data on how often a clinical diagnosis of brain death was refuted on the basis of ancillary testing in their dataset? Lastly, a high proportion of hospitals contributing data were neurosurgical centres, which may care for a different population of brain-injured patients and consequently report significant differences in outcome, where in fact, none exist. Do the authors think that selection bias may have contributed to the results reported? M.J. Jackson L. Coleman A. Wilson J. Hanison D. Horner On behalf of the North West Research and Audit Group Journal Club, Salford Royal Foundation Trust, Salford, UK Email:
[email protected] No external funding and no conflicts of interest declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com
References
1. Escudero D, Valentın MO, Escalante JL, et al. Intensive care practices in brain death diagnosis and organ donation. Anaesthesia 2015; 70: 1130–9. 2. UK Potential Donor Audit 2013-2014. www.odt.nhs.uk/pdf/pda_report_1314. pdf (accessed 19/10/2015). 3. Wijdicks EFM, Varelas PN, Gronseth GS, Greer DM. Evidence-based guideline update: determining brain death in adults. Neurology 2010; 74: 1911–8. 4. British Transplantation Society. A code of practice for the diagnosis and confirmation of death. http://www.bts.org.uk/ Documents./A%20CODE%20OF%20PRAC TICE%20FOR%20THE%20DIAGNOSIS%20 AND%20CONFIRMATION%20OF%20DEATH. pdf (accessed 19/10/2015). doi:10.1111/anae.13337
Diagnosing brain death – a reply We thank Jackson et al. for their thoughtful questions about our study [1]. In reply to their questions, in Spain, although there is a law about presumed consent, it is not used in daily clinical practice. The opinion of the deceased person about organ donation when alive is always investigated. If there is no information about his/her wishes, family members or next-of-kin are asked for their written authorisation, as legal representatives.
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