Neurocritical Care

, Volume 23, Issue 3, pp 401–408 | Cite as

Testing Confounders in Brain Death Determination: A New Simulation Model

  • Sara Hocker
  • Donna Schumacher
  • Jay Mandrekar
  • Eelco F.M. Wijdicks
Original Article



Given the rarity of brain death in clinical practice, trainees may complete their training without ever performing a brain death exam. Little is known about the performance of trainees in the evaluation of brain death. The accuracy of brain death determination can be audited and improved through simulation models.


A simulated brain death scenario was designed to incorporate numerous potential confounders. We utilized a SimMan 3G mannequin, registered nurse, simulation technician, and a facilitator. Critical care and neurology trainees were evaluated using a 24-point checklist based on the AAN guidelines. Trainees rated their confidence (5 point scale with 1 = novice, 3 = competent, and 5 = fully confident) in the evaluation of brain death and apnea testing before and after completing the scenario. Following the simulation, trainees participated in debriefing sessions involving a review of the checklist and playback of simulation videos.


Forty-one trainees completed the simulation. Trainees successfully completed 352/492 (71.5 %) tasks pertaining to the evaluation of prerequisites and 262/369 (71.0 %) tasks pertaining to the clinical examination. Trainee confidence in the evaluation of brain death (2.12 ± 0.74 vs 3.29 ± 0.62, p = 0.0001) and apnea testing (2.10 ± 0.74 vs 3.59 ± 0.77, p = 0.001) significantly improved.


We successfully tested a new simulation model which emphasized training in crucial pitfalls. More than one in four trainees performed poorly in the evaluation of prerequisites and the clinical examination. Few trainees considered the possibility of drug or alcohol ingestion. Simulation training improved clinical performance and trainee confidence in the evaluation of brain death.


Brain death Simulation Medical education Curricular milestones Error in medicine 


Conflict of interest

The authors declare that they have no conflict of interest.


Dr. Hocker, Donna Schumacher, Dr. Mandrekar, and Dr. Wijdicks report no disclosures.


  1. 1.
    MacDougall BJ, Robinson JD, Kappus L, Sudikoff SN, Greer DM. Simulation-based training in brain death determination. Neurocrit Care. 2014;21(3):383–91.CrossRefPubMedGoogle Scholar
  2. 2.
    University of Chicago International Brain Death Simulation Workshop website:
  3. 3.
    The Cleveland Clinic Death by Neurologic Criteria course website:
  4. 4.
    Lewis SL, Józefowicz RF, Kilgore S, Dhand A, Edgar L. Introducing the neurology milestones. J Grad Med Educ. 2014;6(1 Suppl 1):102–4.PubMedCentralCrossRefPubMedGoogle Scholar
  5. 5.
    Fessler HE, Addrizzo-Harris D, Beck JM, Buckley JD, Pastores SM, Piquette CA, Rowley JA, Spevetz A. Entrustable professional activities and curricular milestones for fellowship training in pulmonary and critical care medicine: report of a multisociety working group. Chest. 2014;146(3):813–34.CrossRefPubMedGoogle Scholar
  6. 6.
    Wijdicks EF, Varelas PN, Gronseth GS, Greer DM, American Academy of Neurology. Evidence-based guideline update: determining brain death in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2010;74(23):1911–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Wijdicks EF. Pitfalls and slip-ups in brain death determination. Neurol Res. 2013;35(2):169–73.CrossRefPubMedGoogle Scholar
  8. 8.
    Clinical Diagnosis of Brain Death (Video). In: Wijdicks EFM, editor. The Comatose Patient. 2nd ed. New York: Oxford University Press; 2014.Google Scholar
  9. 9.
    Dieckmann P, Lippert A, Glavin R, Rall M. When things do not go as expected: scenario life savers. Simul Healthc. 2010;5(4):219–25.CrossRefPubMedGoogle Scholar
  10. 10.
    Zigmont JJ, Kappus LJ, Sudikoff SN. The 3D model of debriefing: defusing, discovering, and deepening. Semin Perinatol. 2011;35(2):52–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Benjamini Y, Hochberg Y. Controlling the false discovery rate: a practical and powerful approach to multiple testing. J R Stat Soc. 1995;57:289–300.Google Scholar
  12. 12.
    Wijdicks EF, Rabinstein AA, Manno EM, Atkinson JD. Pronouncing brain death: contemporary practice and safety of the apnea test. Neurology. 2008;71(16):1240–4.CrossRefPubMedGoogle Scholar
  13. 13.
    Gaba DM. Improving anesthesiologists’ performance by simulating reality. Anesthesiology. 1992;76(4):491–4.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Sara Hocker
    • 1
  • Donna Schumacher
    • 2
  • Jay Mandrekar
    • 3
  • Eelco F.M. Wijdicks
    • 1
  1. 1.Division of Critical Care Neurology, Department of NeurologyMayo ClinicRochesterUSA
  2. 2.Department of Nursing EducationMayo ClinicRochesterUSA
  3. 3.Department of Biomedical Statistics and InformaticsMayo ClinicRochesterUSA

Personalised recommendations