Teleneurology to Support Death by Neurologic Criteria Exams Feasible

Data from a recent study published in Neurology suggest that performing teleneurology (TN) consultations for patients with severe neurologic damage and for expert supervision of death by neurologic criteria (DNC) examination is feasible.¹

Researchers found that there was a 2.56-fold increase in the proportion of patients meeting DNC criteria medically suitable for donation in the 17-month post-TN period (21.1%) compared to the 94-month pre-TN period (8.9%; P = .02). There was also a 2.12-fold increase in the proportion of donors from 6.14% pre-TN to 13.1% post-TN (P = .14).

First author Marcelo Matiello, MD, director, Neurology Inpatient Services, Routine and Urgent Teleneurology Program, Massachusetts General Hospital, and assistant professor of neurology, Harvard Medical School, and colleagues wrote that, “our study suggests that TN evaluation to perform neuro-prognostication or determination of DNC is feasible, can be employed to improve early evaluation of critically ill patients, can be done in a timely manner that likely exceeds typical performance in community hospital settings lacking dedicated neurohospitalists, and provides access to experts who can help explain the meaning of death by neurologic criteria with greater confidence to families and loved ones facing difficult decisions about organ donation.”

Matiello and colleagues analyzed data from 99 consults of 60 intensive care unit patients. These consults were performed with a median time of 20.2 minutes (interquartile range [IQR], 5.4-65.3) from request to start of consult. The most common cause of neurologic injury (n = 48; 80%) in these patients was pulseless electrical activity cardiac arrest of undetermined etiology.

Most consults (n = 80; 81%) were requested for determination of prognosis and 19 (19%) were requested for supervision of DNC examinations. One (1.2%) prognostication consult proceeded to DNC examination and met DNC criteria. Of the 19 DNC examination consults, 11 (57.9%) met DNC criteria. 

Brain scintigraphy in 4 cases and electroencephalogram in 3 was requested due to the potentially confounding presence of myoclonic movements. Clinical determination of DNC by the teleneurologist was supported in all cases.

Matiello and colleagues obtained information related to organ screening and donation processes from the largest hospital involved in the study in which 45 (75%) of patients were seen. This hospital saw a 2.56-fold increase in the proportion of patients meeting DNC criteria medically suitable for donation in the 17-month post-TN period (21.1%) compared to the 94-month pre-TN period (8.9%; P = .02), as well as a 2.12-fold increase in the proportion of donors from 6.14% pre-TN to 13.1% post-TN (P = .14).

“This study represents an important first step in decreasing uncertainty and helping to establish the introduction of a standardized approach to teleneurology prognosis and remote death by neurologic criteria assessment as a valid clinical use case in a manner similar to telestroke evaluation. Prospective validation studies are warranted to determine the reproducibility of our findings and identify areas in need of improvement,” Matiello and colleagues wrote.

Matiello was previously the senior author on a paper exploring the ethical and legal framework for TN use in determination of DNC. Matiello and colleagues identified a few potential issues with TN for DNC, 1 of which was the fact that policies relating to determining DNC vary greatly across states in the US.²

“Overall, the evolutions in the areas of medicine, technology, and systems engineering motivate serious consideration of delineation of nationwide policies in the area of brain death and address the situation at the national level,” Matiello and colleagues concluded.