Practice Variations in Timing of Declaring Death by Neurologic Criteria Across Intensive Care Units

Introduction: Given evidence that longer evaluation times of death by neurologic criteria (DNC) can result in reduced organ donation rates, it is important to determine what factors result in prolonging the evaluation of DNC. We hypothesized that being declared deceased by DNC by neurointensivists occurs in a shorter period of time than other declaring intensivists. Secondary objectives were to determine whether longer DNC declaration times were associated lower likelihood of tissue/organ donation authorization, and to determine whether there was a difference in the use of ancillary testing between ICUs.


Methods: This was a retrospective, observational, single-center cohort study that included DNC patients from January 2021 to December 2023. The first cohort was patients admitted to the neurology or neurosurgery ICUs (NICU cohort), and the second consisted of those admitted to the medical, surgical, and cardiac ICUs (non-NICU cohort). Time of DNC evaluation was determined as the time from the first DNC examination or test to the time of death. Our institution requires two clinical exams. Statistical analysis for the primary outcome was done using linear regression, both unadjusted and adjusted by age, sex, race, and overall ICU length of stay. Secondary outcomes were analyzed using binomial logistic regression and chi-squared test.


Results: A total of 18 patients were included in the NICU cohort and 93 in the non-NICU cohort. The cohorts had similar baseline characteristics. The primary outcome of difference in time of DNC evaluation was significantly lower in the NICU cohort in both the unadjusted (9.3 hours vs 17.7 hours, p=0.039) and adjusted regression (13.7 hours vs 23.9 hours, p=0.016). There was no significant relationship between time of DNC evaluation and organ donation authorization. There was no significant difference in the use of ancillary testing between cohorts.


Conclusions: DNC declarations are completed in a shorter amount of time in ICUs staffed by neurointensivists than other ICUs. This may be due to more familiarity with the process of DNC by neurointensivists. We next plan to investigate if there are patterns of protocol deviation by ICU type. Further study is warranted to determine the exact practices and training gaps that are leading to this difference in declaration times.