Harrison A M, Botkin J R
Department of Pediatrics, Division of Critical Care, SUNY Health Science Center at Syracuse, Syracuse, New York 13210, USA.
Pediatrics. 1999 Jun;103(6):e82. doi: 10.1542/peds.103.6.e82.
We sought to determine pediatric residents' and attending physicians' ability to define brain death, their ability to apply this standard of death to a clinical scenario, and their knowledge regarding the legal necessity of confirmatory testing when determining death by brain criteria. We compared resident and attending self-confidence at discussing brain death with their ability to define brain death and apply this concept to a clinical scenario.
A questionnaire was sent to 136 residents, postgraduate years 1 through 3, at four accredited pediatric training programs in the United States. Participation was tracked by return address. One follow-up request for participation was made. A similar procedure was followed for 140 faculty pediatricians at two of the institutions. Demographic information including level of training, subspecialty training, training program, and formal ethics training was collected. Respondents defined brain death, interpreted a clinical scenario, and stated whether confirmatory testing is legally required to determine death by brain criteria. Respondents rated their confidence at explaining brain death to a patient's family on a scale from 1 to 5.
Eighty-seven percent (118/136) of resident surveys were returned. Thirty-six percent (42/118) of the residents correctly defined brain death. Forty-three percent (51/118) of residents correctly interpreted the clinical scenario. Fifty-five percent (65/118) of the residents correctly recognized that brain death could be determined without a confirmatory test. Residents who correctly defined brain death were as confident as those who did not (2.8 +/- 1 vs 1.5 +/- 1). Residents who correctly interpreted the clinical scenario were as confident as those who did not (2.6 +/- 1 vs 1.9 +/- 0.9). Eighty percent (112/140) of attending physician surveys were returned. Thirty-nine percent (44/112) of attending physicians correctly defined brain death. Fifty-three percent (59/112) correctly interpreted the clinical scenario. Fifty-eight percent (65/112) recognized that brain death can be diagnosed without confirmatory testing. All pediatric intensivists (n = 12) correctly answered all three questions. Their performance was significantly better than other pediatricians. Attendings who correctly defined brain death were more confident than those who did not (4.2 +/- 1 vs 1.1 +/- 0. 9). Attendings who correctly interpreted the clinical scenario were more confident than those who did not (3.8 +/- 1.2 vs 2.2 +/- 1.2).
Pediatric residents and attendings have difficulty defining and applying the concept of brain death. This concept is difficult to grasp and internalize for many pediatricians. To ensure that critical decisions are made by knowledgeable physicians and well-informed families, more effective educational strategies need to be identified.
我们试图确定儿科住院医师和主治医师对脑死亡的定义能力、将这种死亡标准应用于临床情景的能力，以及他们关于在依据脑标准判定死亡时进行确认性检测的法律必要性的知识。我们比较了住院医师和主治医师在讨论脑死亡时的自信程度与其定义脑死亡并将这一概念应用于临床情景的能力。
向美国四个经认可的儿科培训项目中1至3年级的136名住院医师发送了一份问卷。通过回信地址追踪参与情况。进行了一次参与情况的跟进请求。对其中两个机构的140名儿科主治医师采用了类似程序。收集了包括培训水平、亚专业培训、培训项目和正式伦理培训在内的人口统计学信息。受访者定义脑死亡、解读一个临床情景，并说明依据脑标准判定死亡时是否在法律上需要进行确认性检测。受访者就向患者家属解释脑死亡的自信程度按1至5分进行评分。
87%（118/136）的住院医师调查问卷被收回。36%（42/118）的住院医师正确定义了脑死亡。43%（51/118）的住院医师正确解读了临床情景。55%（65/118）的住院医师正确认识到无需进行确认性检测即可判定脑死亡。正确定义脑死亡的住院医师与未正确定义的住院医师自信程度相同（2.8±1对1.5±1）。正确解读临床情景的住院医师与未正确解读的住院医师自信程度相同（2.6±1对1.9±0.9）。80%（112/140）的主治医师调查问卷被收回。39%（44/112）的主治医师正确定义了脑死亡。53%（59/112）的主治医师正确解读了临床情景。58%（65/112）的主治医师认识到无需进行确认性检测即可诊断脑死亡。所有儿科重症监护医师（n = 12）三个问题均回答正确。他们的表现明显优于其他儿科医师。正确定义脑死亡的主治医师比未正确定义的主治医师更自信（4.2±1对1.1±0.9）。正确解读临床情景的主治医师比未正确解读的主治医师更自信（3.8±1.2对2.2±1.2）。
儿科住院医师和主治医师在定义和应用脑死亡概念方面存在困难。对于许多儿科医师来说，这个概念难以理解和内化。为确保由知识渊博的医师和信息充分的家庭做出关键决策，需要确定更有效的教育策略。
