Teleneurology Consultations for Prognostication and Brain Death Diagnosis

Introduction

Historically, there have been many cases in which declaration of brain death has been controversial, circumstantial, and inefficient. One of the first cases to bring this to light was that of Theresa Marie “Terri” Schiavo, a woman in an irreversible persistent vegetative state from 1990 to 2005. Challenges to Schiavo's lack of a firm medical diagnosis resulted in a highly publicized and prolonged series of legal challenges, which ultimately involved state and federal politicians and caused a 7-year delay before Schiavo's feeding tube was ultimately removed. ¹

A more recent case involved Israel Stinson in 2016, who suffered an asthma attack and was declared brain dead. Nearly 5 months of legal battling ensued, as the California toddler's parents—who did not agree with the prognosis—fought to keep him on life support. The fight ended abruptly after a “surprise ruling” by a Los Angeles Superior Court judge that life support be removed. ² Cases such as these highlight the need for clinically relevant, broadly recognized, and comprehensive legislation to support the legal and ethical framework in which the diagnosis of brain death and neurology prognosis determination can occur.

Brain death, by adoption of the Uniform Determination of Death Act (UDDA), is defined as “the irreversible cessation of all functions of the entire brain, including the brain stem, as a valid criterion for death.” ³ A patient who has experienced brain death is also considered legally and clinically dead. In the prior cases reviewed above, neurologists were involved early on, however, in situations where a neurologist is not available on-site for evaluation, few options currently exist and patients may languish while temporary privileges are arranged, or complex and costly interfacility transfers are contemplated.

It should be possible and permissible to use telemedicine to support the diagnostic process, bringing expertise to the bedside as required. Its application in such situations could be beneficial in several ways, including reassuring family of an accurate diagnosis, decreasing the utilization of unnecessary intensive care resources, and enhancing the likelihood of successful organ donation and transplantation when appropriate. ^4,5

Acknowledging that advances in medical technology have changed the ways in which death could be determined, the UDDA has recommended that a standardized notion/definition of brain death be incorporated into the law of every state in the United States. In an era of rapid innovation and technological change, it is not uncommon for innovation to render prevailing therapeutic, social, and lawful commonplaces obsolete. Advances in medical technologies and hardware have made it important to re-examine conventional lawful benchmarks for pronouncing a person dead. As technologies and resources in the field of telemedicine advance, legal commonplaces have the potential to hinder further innovation.

The role of telemedicine in diagnosing and treating other serious neurological disorders and injuries has been proposed in the legal sphere, and some of the suggestions have been approved. Notably, on September 26, 2017, the Senate passed House Bill S.870 Chronic Care Act, which expands Medicare funding for telemedicine coverage of stroke patients. ⁶ It was later passed by the Congress and signed into law in the Bipartisan Budget Act of 2018 in February 2018. The importance of an efficient, rapid, and accurate diagnosis for treatment of stroke is widely accepted, and substantial evidence exists for the reliability of telemedicine-enabled stroke assessments. ^{7 –10}

Clinical Aspects and Guidelines

Death by neurological criteria is defined under the Massachusetts state law (Section 1–107: Evidence of death or status) based on the UDDA.

The diagnosis of brain death is primarily clinical. An evaluation for brain death should be considered in patients who have suffered a serious brain injury of identifiable cause, global ischemic brain insults, or fulminant hepatic failure. Diagnosis of brain death is determined through a comprehensive clinical examination that includes conducting an apnea test, confirming the absence of brainstem reflexes, and determining if the patient is in a coma. No other diagnostic or confirmatory tests are required if a single full clinical evaluation is conclusively performed. ¹¹ Ancillary testing is required in situations in which the clinical determination is unavoidably inadequate, such as in cases of severe facial trauma, drug intoxication, severe metabolic disturbances, or when the apnea test cannot be performed safely.

In the process of developing these guidelines, the American Academy of Neurology (AAN) specially considers the possibility of patients “who fulfill the clinical criteria of brain death who recover neurologic function” and ensures an “adequate observation period to ensure that cessation of neurologic function is permanent.” Furthermore, the clinical criteria designed by the AAN sought to address the safety of certain apnea tests and the presence of motor movements that incorrectly suggest brain function. ¹² Simulation models that train doctors in the procedure required to determine brain death have been evaluated and have shown that brain death diagnosis is difficult and specialized training is crucial to teach and re-enforce skills. ¹³ As an example of the steps required, Table 1 shows the checklist for determination of brain death approved at the Massachusetts General Hospital. ¹⁴

Telemedicine

The number of available neurologists in many communities, especially in rural areas, is very limited relative to the demand for diagnosis and treatment of neurological conditions. The use of telemedicine for remote consultations helps neurologists provide access to specialized care for a wider group of patients more rapidly, most notably in treating acute stroke, due to the widely recognized urgency of patient assessment before decisions regarding thrombolytic treatment. ^{15 –17}

Teleneurology, particularly in stroke care, has been shown to provide quality neurologic care, yield overwhelming patient satisfaction, and save considerable time and resources. ¹⁸ A study involving veterans living remotely with chronic neurologic conditions showed that 90% of patients were satisfied with their care. Researchers also calculated an average time savings of 5 h and 325 miles driven, aggregating to at least $48,000 in total cost savings. Ninety-five percent reported they wanted to continue their neurologic care by teleneurology. ¹⁹ A 2018 study analyzing the role of teleneurology in urban settings also showed the effective application of telehealth to evaluate and manage a diverse group of neurological disorders among veterans in California. In contrast to the case with face-to-face patients, patients in teleneurology clinics were less likely to miss their appointments. The majority of patients were satisfied with the care they received through teleneurology, and preferred clinical video telehealth rather than a face-to-face encounter. ²⁰ Telemedicine has also been used to assess the level of consciousness in critically ill patients, and in those with suspected coma. ²¹

These and other studies show that teleneurology is an accepted, feasible, time-saving, alternative to traditional specialist consultations for neurologic conditions and provide the motivation to extend its use for evaluating brain death situations. ²²

Discussion

In 2010, AAN provided updated practice parameters for determination of brain death that included step-by-step instructions and a detailed checklist. ¹² These comprehensive and unified guidelines were reaffirmed by AAN on April 30, 2014, and April 25, 2017, and are further endorsed by other societies in medicine. However, the conception and the determination of brain death continue to raise scientific, legal, philosophical, and religious controversies. ²³ Furthermore, instead of having a common and consistent set of guidelines across the United States, policies related to determination of brain death differ significantly across states in the United States. ²⁴ Therefore, one option is to explore if regulations related to brain death can be enacted at the federal level in the United States. To do so, the underlying issues that deserve consideration are licensing requirements; medical malpractice; coverage; legal liability; privacy of information; and payment of services. ²⁵

If there was an effort to create a central coordination center staffed by neurological experts that would be available 24/7 to support local providers in high-quality and consistent assessment of brain death, a doctor practicing at this central brain death evaluation center under current law would need to be licensed in all the concerned states. ²⁶ The only exemption to this licensure requirement is for doctors employed in the Department of Veterans Administration, Department of Defense, and Indian Health Service who can use the license granted by one state of the United States to assist patients across all over the United States.

Overall, the evolutions in the areas of medicine, technology, and systems engineering motivate serious consideration of delineation of nationwide policies in the area of brain death and address the situation at the national level. ²⁷