• Ariane Lewis, Panayiotis Varelas, and David Greer.
• Division of Neurocritical Care, Department of Neurology, NYU Langone Medical Center, 530 First Avenue, HCC-5A, New York, NY, 10016, USA. ariane.kansas.lewis@gmail.com.
• Neurocrit Care. 2016 Jun 1; 24 (3): 481-7.

BackgroundThe manner in which brain death protocols in the United States address family objection to death by neurologic criteria has not been explored.MethodsInstitutional brain death protocols from hospitals in the United States were reviewed to identify if and how the institution addressed situations in which families object to determination of brain death or discontinuation of organ support after brain death.ResultsProtocols from 331 institutions in 25 different states and the District of Columbia were reviewed. There was no mention of how to handle a family's objections in 77.9 % (258) of the protocols. Of those that allowed for accommodation, reasons to defer brain death declaration or prolong organ support after brain death declaration included: (1) religion; (2) moral objection; (3) nonspecific social reasons; or (4) awaiting arrival of family. Recommendations to handle these situations included: (1) seek counsel; (2) maintain organ support until cardiac cessation; (3) extubate against the family's wishes; (4) obtain a second opinion; or (5) transfer care of the patient to another practitioner or facility. Protocols differed on indications and length of time to continue organ support, code status while support was continued, and time of death.ConclusionsThe majority of protocols reviewed did not mention how to handle circumstances in which families object to determination of brain death or discontinuation of organ support after brain death. The creation of guidelines on management of these complex situations may be helpful to prevent distress to families and hospital staff.

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