Temporal changes in clinical practices for patients considered clinically brain dead: a single-center cohort study

BACKGROUND: Patients considered clinically brain dead undergo neurological assessment and critical care management, along with discussions with their families regarding goals of care and, when appropriate, organ donation. However, how these clinical and organ donation-related practices have evolved over time remains poorly characterized in Japan. We aimed to evaluate temporal changes in neurological assessment, critical care management, and organ donation-related processes among patients considered clinically brain dead. METHODS: We conducted a retrospective single-center cohort study including consecutive patients considered clinically brain dead in the Emergency ICU of Okayama University Hospital between January 2017 and December 2025. Patients were identified through routine auditory brainstem response testing during evaluation for a brain-death-compatible state. Temporal changes in the determination of a brain-death-compatible state, organ donation discussion, and critical care management were evaluated by calendar year, with three study phases (2017-2019, 2020-2022, and 2023-2025) used for descriptive presentation. Annual trends were assessed using logistic regression and nonparametric trend analyses. RESULTS: Among 128 eligible patients, organ donation was discussed with the families of 110 (85.9%), and 41 (37.3%) subsequently underwent organ donation after brain death. Calendar-year analyses showed increasing corticosteroid use (odds ratio [OR] per year, 1.64; 95% confidence interval [CI] 1.34-2.01; p < 0.001) and earlier initiation of corticosteroids and vasopressin, whereas no significant trends were observed in vasopressin use or in the timing of determination of a brain-death-compatible state or the initial organ donation discussion. The likelihood of organ donation discussion increased significantly over time (OR per year, 1.44; 95% CI 1.17-1.79; p = 0.001) and remained significant in a sensitivity analysis restricted to patients in whom discussion was considered feasible (OR per year, 2.11; 95% CI 1.42-3.15; p < 0.001). CONCLUSIONS: The opportunity for organ donation discussion increased over time among patients considered clinically brain dead, while the proportion of families consenting to donation remained relatively stable. This increase occurred alongside the progressive development of structured multidisciplinary processes, although their contribution to the observed temporal trend cannot be determined from this descriptive study.