Protocol-Based Management of Medication Confounders in Brain Death Determination: A Multi-Institutional Review.

Area of Science:

• Neurology
• Critical Care Medicine
• Forensic Medicine

Background:

• Determination of death by neurologic criteria (DNC) relies on clinical examination.
• Current guidelines lack specificity in assessing and managing confounding conditions, leading to practice variability.
• This study addresses the need for clarity in DNC protocols regarding medication confounders.

Purpose of the Study:

• To review U.S. institutional protocols for DNC determination.
• To evaluate how these protocols address medication confounders and ancillary testing.

Main Methods:

• Follow-up study requesting exact protocol language from U.S. institutions.
• AI-assisted qualitative theme extraction of de-identified protocol excerpts.
• Investigator review for accuracy of AI-extracted themes.

Main Results:

• Protocols consistently use pharmacokinetic clearance strategies (half-lives, drug levels, toxicology screens) for medication confounders.
• Ancillary testing is reserved for when clinical exams are unsafe and discouraged as a substitute for drug clearance.
• Significant variability exists in addressing reversal agents, patient-specific factors, and practitioner responsibilities.

Conclusions:

• Institutional DNC protocols exhibit substantial variability in assessing medication confounders.
• There is a clear need for evidence-based, standardized protocols to ensure reliable DNC determinations.
• Improved guidelines are essential for consistent and accurate application of DNC criteria.