All right, so I get the pleasure of wrapping this up by spending some time talking about how does this actually impact on us as intensivists? This guideline has come out, what do we need to do? Disclosures fairly similar, no financial ones, but I have been part of the working group and was the liaison and representative of SCCM on the group. So, some general thoughts for intensivists. Determination of death based on neurologic criteria is done in the critical care setting. Thus, all intensivists must be familiar. That's the greatest impact, you all need to know this. This is your job, okay? Show of hands, how many in this audience have been part of a brain death exam in the last three months? Good, so we all know that this is important. Another major issue is we wanted to standardize language within institutions, across institutions. We wanted to have a consistent approach to how you determine brain death so that we can build public trust in this area. Just today, I heard somebody use the term essentially brain dead. We need to strike that language from our vocabulary. You're either brain dead or you are not. We cannot use inaccurate terms in this situation. We have to manage care appropriately, we have to prognosticate appropriately, and we have to declare death in patients with this level of injury appropriately. So death is death, and we need to be 100% accurate 100% of the time. So what do you need to do? Preparations, this guideline is out now. Review it, and review your local policy. When was the last time it was updated? Do you need to change this? What are your own state laws, because they vary? Does your institution have overarching policies and some of the institutions that have religious affiliations may have overarching policies that vary from state. Do you have separate policies for adult and pediatrics? We did, we're now gonna combine them all together. So UPMC is gonna have one policy for all age. What updates do you need to do, be prepared for that, and who will be overseeing these policy updates? Who's gonna have some comments about this? I am not gonna get into issues regarding the UDDA and efforts to update that. It is still in place, and we're gonna follow that practice. So, a few state laws. This gives you a breakdown of which states use the UDDA, which states have enacted it, but also have other variations, okay? The brain death concept only applies when artificial life support is used. I think most of the patients are on artificial life support, so light blue should be the same as the dark blue. The gray, brain death is a criteria for death is permissive, but it's not required. And then black areas, brain death must be accompanied by the loss of spontaneous respiratory function in order to constitute death. Well, that's the apnea test. So, but be aware of your own laws and be able to address them. There's other special considerations. There are certain states that require unique things that you accommodate religious or moral objections, that you have a specialist in neuroscience doing this rather than an intensivist. So, be familiar if you have special considerations by the laws in your particular states. Then know about pregnancy. In preparing for this, I actually wasn't aware of some of the state laws regarding pregnancy. And it turns out that if you happen to be in Texas, and even if you have advanced directives that say what you want done in the event of a catastrophic neurologic event, if you are pregnant, those don't count anymore. Your advanced directives as a woman in the state of Texas, if you are pregnant, are null and void. So, be aware of these laws. Revising your own policy, coordinate efforts, please. Identify your stakeholders, not only in your hospital, but in your community. Who is gonna have some input on this? Who may have some thoughts? Intensivist, neurosurgery, neurology, common stakeholders. But what about other services? Do you have a post-cardiac arrest team? Do you have an organ donation support team? Your local organ procurement agency. Are there providers that will contribute to this? Radiology, interventionalist. They need to be on board if they're gonna be part of the testing. And I already mentioned your community groups. Know your local resources. What do you have available? You notice that EEG is now not an ancillary test anymore. So, what is available at your location? Both providers, do you have adequate number of providers that are competent in doing this and have training and credentialing? Do you have backup options in place to get extra assistance? And what are your ancillary testing options locally that you have? Regarding remote locations, Dr. Joe Darby was the lead on this. He's one of my colleagues at UPMC and we actually did a small study, but looked at using tele-ICU to support providers in remote locations. So, if they hadn't done a brain death exam for an extended time period, we didn't wanna transport the patient all the way down to our helicopter ride to do this exam. Could we provide support and help do the exam and talk people through it remotely? Please look at this. It actually, it was only 29 patients, but we did 30 exams. And there was anywhere between 97 to 100% agreement. The 97 was usually when it came to pupils and it was dark eyes and you couldn't see the pupils well. So, we actually started using pupillometry and made that a requirement because the pupillometry was accurate in that situation. Standardization of doing your exam. If you don't have checklists, do it. We're in the process of creating a checklist for preparation for doing the exam. How do we script this? How do we discuss it? How do we make sure that everybody's on board to do this properly? And then what are the examination steps? Dr. Greer did a great job of walking you all through it, but if it's been a little while, make sure you have the steps available so you don't skip anything. There is no cutting corners on this exam. So, develop these, have them available. If you need help getting started, there are tools available to you. The American Academy of Neurology has this option that you can go in and there is a link and it will actually walk you through the process of doing this evaluation. There are a number of options available to assist you in making sure that you are doing this correctly. There is standardization training. The Neurocritical Care Society has the Brain Death Toolkit. There is also a Brain Death Determination Course that is being revised to reflect the current revised guidelines. But these are in place to help people so you can get adequate training and develop a local credentialing process in your own institution to make sure people doing this test know how to do it right and are competent to do it. I also want to make sure just to emphasize, and this is my last area of focusing on, communication and accuracy. Communicate to your staff, work as a team, okay? Respect each other and recognize there may be unspoken needs. This is often uncomfortable for people to go through. Families have a hard time understanding this. Use your team as a group to help make sure that we've identified if there are any people that need assistance with this or are uncomfortable with it. And then communication to family. I want to end with something Dr. Kirshen actually talked about that's so important. Empathy, respect, body language when you're talking to families. Be aware of potential cultural differences. Address them up front. Let families know what you're going to do and watch your word choices, okay? After the patient has been declared, don't send mixed messages. The patient is no longer on life support. They are dead. They are now on organ support. Don't examine the patient again once you've declared them dead. If you walk in the room to see them, I've put my hand on a family member's shoulder. I talk to the family members. If I do anything to the patient, it's usually just resting my hand on their hand in a calm type of way, but I don't examine the patient again. Don't send mixed messages. And make sure you use all support systems in your hospital. The family will need assistance. Chaplains, social workers, whatever the family needs, help them through this so that they feel comforted through the most horrific experience they're gonna ever encounter. So in summary, intensivists need to be familiar with this process. There is a revised guideline. There are state laws that vary. Cultures differ. Be aware of those differences. Update your local policies. If you have not done it, go back and start doing it right now. Standardize your test. Make sure people know how to do the test properly. Maintain your own competency. And then choose your words. Let's be accurate 100% of the time. And with that, we now have lots of time that we can answer questions, discuss different things, and I'm gonna open this up to discussion. Thank you.

brain death criteria

standardized procedures

local and state laws

communication and empathy

training programs