Exploring the Impact of Medication Confounders on Determining Death by Neurologic Criteria: An International Survey Investigating Practice Variations

Background and Objective: The determination of death by neurologic criteria (DNC) is completed by a clinical examination alone if no confounding conditions render the clinical examination unreliable. Currently, consensus guidelines on DNC state the patient should be free of any confounders prior to neurologic testing; however, how these confounders are reviewed and evaluated is not specified. This project aimed to investigate the assessment of medication confounders during the determination of DNC. Methods: A 28-question survey was developed by the study team and reviewed by the Neurocritical Care Society (NCS) Research Operations Subcommittee. Neurocritical care practitioners who are NCS members received invitations to participate in an institutional review board (IRB) – exempt, electronic survey. Results: Of the 69 respondents who completed the survey, most were physicians (48%) or pharmacists (41%), work in an urban area (94%) and at an academic medical center (78%). Respondents have a neurology admitting service (81%), a neurocritical care unit (91%), and a guideline that governs DNC (94%). Out of those who have a DNC guideline, 83% require medications to be reviewed prior to determination and the majority (89%) do not require it to be completed by a pharmacist. When asked who reviews medications (select all that apply), respondents reported that physicians reviewed the medications 90% of the time in addition to pharmacists (40%) and advanced practice providers (28%). Additionally, when ancillary testing is appropriate, it is recommended by the institutional DNC guideline when medication confounders are present in most centers (74%). However, when drug confounders are suspected, only 15% of respondents said ancillary testing would be pursued ‘always’ and 35% said ‘frequently’. Conclusion: Most centers have a guideline that recommends/requires medication review prior to DNC. Variation exists in how ancillary testing is utilized in the setting of medication confounders and who is responsible to review patients’ medication prior to DNC. More research is essential to develop standardized protocols that ensure reliable and accurate DNC determinations in the presence of medication confounders.