Clinicians Face Ethical Dilemmas with Brain Death Testing
February 1, 2025
By Stacey Kusterbeck
If a brain death assessment becomes necessary, clinicians can be taken aback if the family strongly objects. A one-hour simulation training improves medical trainees’ confidence in managing these ethically challenging cases, a recent study found.1 “In bioethics, we are well-aware of the long history of debate over the legitimacy of brain death. Recently, however, these debates have generated greater national interest. It’s important for physicians to be aware of this issue so they are not caught flat-footed, should it arise in their practice,” says Nick Ludka, the study’s lead author and a medical student at Oakland University William Beaumont School of Medicine.
Some ethicists have called for revision to the Uniform Determination of Death Act — the model statute created by the Uniform Law Commission that has strongly influenced how various states and the medical community determine death.2 Many residents and fellows know little about this ethical controversy, however. This leaves physicians struggling to understand why the families are objecting to brain death testing. “Some feel unprepared regarding how to handle the ethical and communication challenges that arise in these cases,” says Ludka. Ludka and colleagues saw the need for a simulation exercise that placed physicians in this unexpected, challenging situation. A clinical ethicist, a neurologist, and a co-director for the surgery simulation fellowship at William Beaumont University Hospital developed a training session. “We wanted a simulation that could deliver the basics on this issue in one hour. This was an important practical consideration, given the demanding time commitments of residency,” says Ludka.
First, faculty cover key communication issues, such as the importance of avoiding mixed messaging to families by first pronouncing the patient dead and then asking if they want to withdraw life support. During the simulation, a member of the research team acts the part of the patient’s spouse. The trainee discusses the need for a brain death examination, performs the exam, and explains the findings. If the trainee uses medical jargon, the “spouse” challenges the trainee. For example, if the trainee says that the patient is dead, and, therefore, they will be withdrawing life support, the spouse asks, “How can it be life support if you’re telling me that they are dead?” The spouse objects to the exam and expresses concerns about the removal of medical support devices.
After the simulation, trainees participate in a debriefing with a clinical ethicist and neurologist. “Many trainees found it especially difficult to respond to the spouse when they refused to consent to the brain death examination,” says Ludka. Faculty are able to clarify that consent is not required for a brain death examination.
Researchers surveyed 35 trainees who completed the simulation in 2022-2023. Participants reported increased confidence in responding to ethical issues that surround brain death, communicating with families, and performing brain death testing. “One of the advantages of using simulation is you can help the physicians immediately identify their own knowledge gaps, then reflect on ways to be better prepared for an actual case,” says Ludka.
Many residents and fellows lack basic knowledge, or even awareness of, the ethical controversy around brain death. “This is not limited to brain death, but applies to many issues in bioethics. While many teaching hospitals like ours have ethics services with members who are well-versed on bioethics issues, it is important for physicians to also have some essential knowledge of the medical ethics domain,” says Ludka.
At Oakland University William Beaumont School of Medicine, the curriculum focuses heavily on many topics in bioethics, including the issue of brain death, to prepare graduates for complex moral issues that will arise in their practice. “We have tried to carry over some of this teaching for the residents and fellows at our hospital, by developing educational interventions like this simulation,” says Ludka.
Some physicians assume the family is objecting because of a simple misunderstanding of the medical facts. “Rather, these families can well understand the medical facts but base their objections upon religious or philosophical beliefs that conflict with those of the medical community,” says Ludka.
In the case used for the simulation, the conflict is over whether a patient who has been declared dead by neurological criteria, but still has a beating heart and is respirating on a ventilator, is dead. Such disputes cannot always be resolved by further attempts at education with the family, because the issue is conflicting views of death. “That is a philosophical question, not a scientific one. Even understanding this initial point is immensely helpful for the physicians, because it can change how they think about the objecting families,” says Ludka.
References
1. Ludka N, Nguyen N, Menkes D, Brummett A. A simulation to improve understanding and communication of ethical dilemmas that surround brain death. MedEdPORTAL. 2024;20:11444.
2. Lewis A. Perspectives of medical organizations, organ procurement organizations, and advocacy organizations about revising the Uniform Determination of Death Act (UDDA). Neurocrit Care. 2024;40(3):1045-1058.
If a brain death assessment becomes necessary, clinicians can be taken aback if the family strongly objects. A one-hour simulation training improves medical trainees’ confidence in managing these ethically challenging cases, a recent study found.
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