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Verification of the Determination of Brain Death (2.02)

Verification of the Determination of Brain Death (2.02) - Policies, Clinical, UWHC Clinical, Department Specific, UW Organ and Tissue Donation

2.02



POLICY
Established Date: July 2008
Effective Date: January 2018
Title: Verification of the Determination of Brain
Death
Policy Number: 2.02

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 1 of 2

PURPOSE

The purpose of this policy is to define standard procedures for the University of Wisconsin Organ and
Tissue Donation (UW OTD) staff to verify a donor hospital’s diagnosis and documentation of brain death of
patients being evaluated for organ donation potential by UW OTD. It is the policy of UW OTD to ensure
brain death declaration and documentation completed by the donor hospital is compliant with all federal
and/or state requirements.

POLICY

A. The diagnosis of brain death will be determined by donor hospital staff per donor hospital
policy.
1. The donor hospital will identify staff that may diagnose brain death in donor hospital
policy.
2. If a donor hospital does not have a policy on brain death diagnosis, staff will defer to UW
OTD guidelines.
3. Brain death declaration will not be completed by any member of any organ recovery or
transplant team.
B. The diagnosis of brain death will be completed by clinical exam and/or confirmatory tests and
per donor hospital policy and applicable federal and/or state requirements.
C. The diagnosis will be documented in the donor hospital medical record of the patient.
D. Documentation of brain death will include the clinical exam (including the absence of brain stem
reflexes and apnea testing) and/or confirmatory tests performed, the date and time of brain
death, and the physician signature. The date and time of brain death will be the date and time
of death recorded on the death certificate.
E. A UW OTD organ procurement coordinator (OPC) will review the brain death documentation to
verify that the language is unequivocal and it is acceptable documentation.
1. If an OPC encounters a discrepancy or has a concern about brain death documentation,
the OPC will consult with the UW OTD medical director and/or his/her designee.
2. The donor hospital staff that completed the diagnosis and created the brain death
documentation will be contacted, notified of the concerns, and asked to reevaluate the
patient and/or rewrite the brain death documentation as needed by an OPC.



POLICY
Established Date: July 2008
Effective Date: January 2018
Title: Verification of the Determination of Brain
Death
Policy Number: 2.02

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 2 of 2
F. A copy of the brain death documentation and confirmatory test results, if applicable, will be
maintained in the UW OTD patient chart.

REFERENCES

UW OTD Apnea and Brain Death Guidelines
State of Illinois Uniform Anatomical Gift Act (755 ILCS 50/1)
State of Michigan Determination of Death Act 333/1031
State of Wisconsin Determination of Death Act 146.71