Few people among the general public understand the meaning of brain death, and in the past several years, legal and ethical controversies have arisen around the condition. Now, a new study published in Clinical Neurology and Neurosurgery shows that a short training at NYU School of Medicine significantly improved medical students’ knowledge of and ability to diagnose brain death, as well as their comfort communicating with patients’ families about the subject.
“Determining brain death is a complicated, nuanced process, and it is imperative that medical students be educated about what it is and how to evaluate for it,” says the study’s first author Ariane Lewis, MD, assistant professor in the Departments of Neurology and Neurosurgery at NYU Langone Health. “Other studies have demonstrated that medical student knowledge about brain death is limited, but our institution is one of the few to offer interventions to enhance education about this important topic.”
Brain death is the legal equivalent of cardiopulmonary death in the United States, so a patient who is found to be brain dead is legally deceased. Despite this fact, medical student and physician awareness about brain death is limited.
Although fewer than 5 percent of medical students go into neurological or neurosurgical residencies, Dr. Lewis says it is important for all physicians to understand brain death, given that 67 percent of hospitals in the United States do not require a neurologist or neurosurgeon to perform brain death evaluations.
It is also important that future physicians be able to communicate about brain death with families, since studies show that the general public does not understand the difference between brain death, a persistent vegetative state, and a coma.
Evaluating the Effectiveness of the Training
The NYU School of Medicine training began in July 2016 and was mandatory for all medical students during their neurology rotation. It consisted of a 90-minute brain death lecture and simulation session.
In the first 45 minutes of the session, Dr. Lewis, a board-certified neurologist, led a classroom-based lecture that addressed the medical and legal history of brain death, as well as prerequisites and instructions for performing a brain death evaluation, tests associated with confirming brain death, and recommendations for communicating with families about brain death. Following the lecture, students practiced diagnosing brain death using an intubated mannequin during a 45-minute simulation session. A simulation facilitator adjusted the vitals and manipulated the mannequin from a control room. Actors were added in sessions beginning in October 2016 to play the role of the patient’s wife. The medical student was instructed to speak with her before and after evaluating the patient.
Simulations have been used to teach trainees and faculty in critical care, emergency medicine, and neurology in the United States and medical students in Germany about brain death, but NYU School of Medicine is the first medical school described in the literature to teach students about communication about brain death using actors playing the role of a family member.
Between July 2016 and June 2017, 145 students participated in the mandatory training, and 86 percent, or 124, consented to have their data used for research purposes. Comfort with both performing a brain death evaluation and talking to a family member about brain death improved significantly after the session. Before the training, 18 percent of students were comfortable performing a brain death evaluation and 18 percent were comfortable talking to a family member about brain death. After, 86 percent were comfortable performing a brain death evaluation and 76 percent were comfortable talking to a family member about brain death. Students also answered 53 percent of questions about brain death correctly on a pretest and 86 percent of questions correctly on a test following the training.
Adding actors to the education initiative significantly improved understanding and comfort with performing the brain death evaluation. Only one student (4 percent) in a session without actors reported being very comfortable doing the brain death evaluation, whereas 24 students (25 percent) in sessions with actors reported being very comfortable determining brain death. Comfort discussing brain death with a family improved after actors were added, but not significantly.
“Combining teaching with simulation and adding actors to portray family members can significantly improve a medical student’s knowledge and comfort with determining brain death,” Dr. Lewis says. “For medical schools that have the access to simulation centers and have clinical staff to provide the education for students, this is a great opportunity to learn about brain death and walk through the process of a brain death determination.”