Neurocritical Care

, Volume 21, Issue 3, pp 383–391 | Cite as

Simulation-Based Training in Brain Death Determination

  • Benjamin J. MacDougall
  • Jennifer D. Robinson
  • Liana Kappus
  • Stephanie N. Sudikoff
  • David M. GreerEmail author
Original Article



Despite straightforward guidelines on brain death determination by the American Academy of Neurology (AAN), substantial practice variability exists internationally, between states, and among institutions. We created a simulation-based training course on proper determination based on the AAN practice parameters to address and assess knowledge and practice gaps at our institution.


Our intervention consisted of a didactic course and a simulation exercise, and was bookended by before and after multiple-choice tests. The 40-min didactic course, including a video demonstration, covered all aspects of the brain death examination. Simulation sessions utilized a SimMan 3G manikin and involved a complete examination, including an apnea test. Possible confounders and signs incompatible with brain death were embedded throughout. Facilitators evaluated performance with a 26-point checklist based on the most recent AAN guidelines. A senior neurologist conducted all aspects of the course, including the didactic session, simulation, and debriefing session.


Ninety physicians from multiple specialties have participated in the didactic session, 38 of whom have completed the simulation. Pre-test scores were poor (41.4 %), with attendings scoring higher than residents (46.6 vs. 40.4 %, p = 0.07), and neurologists and neurosurgeons significantly outperforming other specialists (53.9 vs. 38.9 %, p = 0.003). Post-test scores (73.3 %) were notably higher than pre-test scores (45.4 %). Participant feedback has been uniformly positive.


Baseline knowledge of brain death determination among providers was low but improved greatly after the course. Our intervention represents an effective model that can be replicated at other institutions to train clinicians in the determination of brain death according to evidence-based guidelines.


Brain death Coma Training course Simulation 


Conflict of interest

Benjamin MacDougall, Jennifer Robinson, Liana Kappus, Stephanie Sudikoff, and David Greer declare that they have no conflicts of interest.

Supplementary material

Supplementary material 1 (MOV 7874 kb)


  1. 1.
    Wijdicks EFM, Varelas PN, Gronseth GS, Greer DM. Evidence-based guideline update: determining brain death in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2010;74:1911–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Greer DM, Varelas PN, Haque S, Wijdicks EF. Variability of brain death determination guidelines in leading U.S. neurologic institutions. Neurology. 2008;70:284–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Wijdicks EF. The diagnosis of brain death. N Engl J Med. 2001;344:1215–21.PubMedCrossRefGoogle Scholar
  4. 4.
    Wang M, Wallace P, Gruen JP. Brain death documentation: analysis and issues. Neurosurgery. 2002;51:731–6.PubMedGoogle Scholar
  5. 5.
    Shappell CN, Frank JI, Husari K, Sanchez M, Goldenberg F, Ardelt A. Practice variability in brain death determination: a call to action. Neurology. 2013;81:2009–14.PubMedCrossRefGoogle Scholar
  6. 6.
    McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med. 2011;86:706–11.PubMedCentralPubMedCrossRefGoogle Scholar
  7. 7.
    Zigmont JJ, Kappus L, Sudikoff S. The 3D model of debriefing: defusing, discovering, and deepening. Semin Perinatol. 2011;35:52–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Dismukes RK, Gaba DM, Howard SK. So many roads: facilitated debriefing in healthcare. Simul Healthc. 2006;1:23–5.PubMedCrossRefGoogle Scholar
  9. 9.
    Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc. 2007;2:115–25.PubMedCrossRefGoogle Scholar
  10. 10.
    The Cleveland Clinic Death by Neurologic Criteria course website:
  11. 11.
    University of Chicago International Brain Death Simulation Workshop website:;jsessionid=C50E5D92211CB65C99BED86509B148FB.bw06.

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Benjamin J. MacDougall
    • 1
  • Jennifer D. Robinson
    • 2
  • Liana Kappus
    • 3
  • Stephanie N. Sudikoff
    • 3
    • 4
  • David M. Greer
    • 5
    Email author
  1. 1.Yale University School of MedicineNew HavenUSA
  2. 2.Department of NeuroscienceYale-New Haven HospitalNew HavenUSA
  3. 3.SYN:APSE Center for Learning, Transformation, and InnovationYale-New Haven Health SystemNew HavenUSA
  4. 4.Department of PediatricsYale University School of MedicineNew HavenUSA
  5. 5.LLCI 912, Department of NeurologyYale University School of MedicineNew HavenUSA

Personalised recommendations