title: Brain death declaration: Practices and perceptions worldwide.
abstract: OBJECTIVE
  To assess the practices and perceptions of brain death determination worldwide and analyze the extent and nature of variations among countries.
  
  
  METHODS
  An electronic survey was distributed globally to physicians with expertise in neurocritical care, neurology, or related disciplines who would encounter patients at risk of brain death.
  
  
  RESULTS
  Most countries (n = 91, response rate 76%) reported a legal provision (n = 63, 70%) and an institutional protocol (n = 70, 77%) for brain death. Institutional protocols were less common in lower-income countries (2/9 of low [22%], 9/18 lower-middle [50%], 22/26 upper-middle [85%], and 37/38 high-income countries [97%], p < 0.001). Countries with an organized transplant network were more likely to have a brain death provision compared with countries without one (53/64 [83%] vs 6/25 [24%], p < 0.001). Among institutions with a formalized brain death protocol, marked variability occurred in requisite examination findings (n = 37, 53% of respondents deviated from the American Academy of Neurology criteria), apnea testing, necessity and type of ancillary testing (most commonly required test: EEG [n = 37, 53%]), time to declaration, number and qualifications of physicians present, and criteria in children (distinct pediatric criteria: n = 38, 56%).
  
  
  CONCLUSIONS
  Substantial differences in perceptions and practices of brain death exist worldwide. The identification of discrepancies, improvement of gaps in medical education, and formalization of protocols in lower-income countries provide first pragmatic steps to reconciling these variations. Whether a harmonized, uniform standard for brain death worldwide can be achieved remains questionable.
authors: From the Department of Neurology (S.W., F.J.M.), Massachusetts General Hospital, Boston; Department of Neurology (S.W.), Brigham and Women's Hospital, Boston; Harvard Medical School (S.W., F.J.M.), Boston, MA; Division of Neurocritical Care (E.F.M.W.), Mayo Clinic, Rochester, MN; Department of Anesthesiology and Pain Medicine (P.V.P.), Harborview Medical Center, Seattle, WA; Department of Neurology (D.M.G.), Yale University School of Medicine, New Haven, CT; Department of Neurology (J.C.H.), San Francisco General Hospital, CA; and Department of Biostatistics (M.C.), University of Washington, Seattle.
authors: Sarah
authors: S
authors: Wahlster
authors: From the Department of Neurology (S.W., F.J.M.), Massachusetts General Hospital, Boston; Department of Neurology (S.W.), Brigham and Women's Hospital, Boston; Harvard Medical School (S.W., F.J.M.), Boston, MA; Division of Neurocritical Care (E.F.M.W.), Mayo Clinic, Rochester, MN; Department of Anesthesiology and Pain Medicine (P.V.P.), Harborview Medical Center, Seattle, WA; Department of Neurology (D.M.G.), Yale University School of Medicine, New Haven, CT; Department of Neurology (J.C.H.), San Francisco General Hospital, CA; and Department of Biostatistics (M.C.), University of Washington, Seattle.
authors: Eelco F M
authors: EF
authors: Wijdicks
authors: From the Department of Neurology (S.W., F.J.M.), Massachusetts General Hospital, Boston; Department of Neurology (S.W.), Brigham and Women's Hospital, Boston; Harvard Medical School (S.W., F.J.M.), Boston, MA; Division of Neurocritical Care (E.F.M.W.), Mayo Clinic, Rochester, MN; Department of Anesthesiology and Pain Medicine (P.V.P.), Harborview Medical Center, Seattle, WA; Department of Neurology (D.M.G.), Yale University School of Medicine, New Haven, CT; Department of Neurology (J.C.H.), San Francisco General Hospital, CA; and Department of Biostatistics (M.C.), University of Washington, Seattle.
authors: Pratik V
authors: PV
authors: Patel
authors: From the Department of Neurology (S.W., F.J.M.), Massachusetts General Hospital, Boston; Department of Neurology (S.W.), Brigham and Women's Hospital, Boston; Harvard Medical School (S.W., F.J.M.), Boston, MA; Division of Neurocritical Care (E.F.M.W.), Mayo Clinic, Rochester, MN; Department of Anesthesiology and Pain Medicine (P.V.P.), Harborview Medical Center, Seattle, WA; Department of Neurology (D.M.G.), Yale University School of Medicine, New Haven, CT; Department of Neurology (J.C.H.), San Francisco General Hospital, CA; and Department of Biostatistics (M.C.), University of Washington, Seattle.
authors: David M
authors: DM
authors: Greer
authors: From the Department of Neurology (S.W., F.J.M.), Massachusetts General Hospital, Boston; Department of Neurology (S.W.), Brigham and Women's Hospital, Boston; Harvard Medical School (S.W., F.J.M.), Boston, MA; Division of Neurocritical Care (E.F.M.W.), Mayo Clinic, Rochester, MN; Department of Anesthesiology and Pain Medicine (P.V.P.), Harborview Medical Center, Seattle, WA; Department of Neurology (D.M.G.), Yale University School of Medicine, New Haven, CT; Department of Neurology (J.C.H.), San Francisco General Hospital, CA; and Department of Biostatistics (M.C.), University of Washington, Seattle.
authors: J Claude
authors: JC
authors: Hemphill
authors: From the Department of Neurology (S.W., F.J.M.), Massachusetts General Hospital, Boston; Department of Neurology (S.W.), Brigham and Women's Hospital, Boston; Harvard Medical School (S.W., F.J.M.), Boston, MA; Division of Neurocritical Care (E.F.M.W.), Mayo Clinic, Rochester, MN; Department of Anesthesiology and Pain Medicine (P.V.P.), Harborview Medical Center, Seattle, WA; Department of Neurology (D.M.G.), Yale University School of Medicine, New Haven, CT; Department of Neurology (J.C.H.), San Francisco General Hospital, CA; and Department of Biostatistics (M.C.), University of Washington, Seattle.
authors: Marco
authors: M
authors: Carone
authors: From the Department of Neurology (S.W., F.J.M.), Massachusetts General Hospital, Boston; Department of Neurology (S.W.), Brigham and Women's Hospital, Boston; Harvard Medical School (S.W., F.J.M.), Boston, MA; Division of Neurocritical Care (E.F.M.W.), Mayo Clinic, Rochester, MN; Department of Anesthesiology and Pain Medicine (P.V.P.), Harborview Medical Center, Seattle, WA; Department of Neurology (D.M.G.), Yale University School of Medicine, New Haven, CT; Department of Neurology (J.C.H.), San Francisco General Hospital, CA; and Department of Biostatistics (M.C.), University of Washington, Seattle. fmateen@partners.org.
authors: Farrah J
authors: FJ
authors: Mateen
mesh_terms: D001291:Attitude of Health Personnel; D001926:Brain Death / Q000175:diagnosis* / Q000331:legislation & jurisprudence; D019049:Developed Countries; D003906:Developing Countries; D004569:Electroencephalography; D006761:Hospitals; D006801:Humans; D009460:Neurologic Examination; D009462:Neurology / Q000379:methods*; D016134:Organizational Policy; D010818:Practice Patterns, Physicians'; D013997:Time Factors