• Determination of Brain Death and Family Communication Physician Training Program

    Demographic and Pre-Training Survey Questions

  • Consent for Use/Disclosure

    Your responses to the study questionnaire are confidential. Gift of Life Institute and Penn Medicine are committed to protecting your confidential data. You will be assigned a unique identifier to be used in reports and data analysis. Your name or any other identifying information will not be used in reports or publications resulting from this study. We will stop using your information at the conclusion of the study. You may contact us with questions and/or withdraw permission for us to use your information for this research study at any time by sending an email to Theresa A. Daly, Sr. Director at Gift of Life Institute at tdaly@giftoflifeinstitute.org. You may copy and paste this link to view the Consent Form - https://www.giftoflifeinstitute.org/wp-content/uploads/2023/01/Final-Participant-Full-Consent-Form-3.pdf. You may save or print a copy for your records.
  • I have read the above Consent for Use/Disclosure required to participate in the "Determination of Brain Death and Family Communication Physician Training Program" research study.*

  • Please "submit" to view information on accessing the "Determination of Brain Death and Family Communication Physician Training Program."

    If you have any questions, please email info@giftoflifeinstitute.org.  We will respond within 24 hours. Thank you, Gift of Life Institute
  • Which category below includes your age? (Please choose only one.)*
  • How do you identify? (Please choose only one.)*
  • Which race or ethnicity best describes you? (Please choose only one.)*
  • What is your degree? (Select all that apply.)*
  • What was your primary medical residency training? (Select all that apply.)*
  • Did you do a fellowship in Critical Care?*
  • In what area of Critical Care (CC) did you complete your fellowship training?*
  • What is your primary site of clinical practice?*
  • DO WE NEED THIS??What is your current medical environment:
  • What is your current specialty? (Select all that apply.)*
  • If you selected Critical Care above, is that:*
  • How frequently do you perform brain death determination exams? (Please choose only one.)*
  • When was the last time you performed a brain death examination? (Please choose only one.)*
  • How frequently do you interact with an organ procurement organization (OPO) professional? (Please choose only one.)*
  • How many years have you been in practice since the end of your training? (Please choose only one.)*
  • What type of affiliation/s does the hospital you practice in have? (Please choose only one.)*
  • Have you had any prior training in performing brain death determination?*
  • If yes, when did this occur? (Select all that apply.)*
  • Have you had any prior training in how to prepare a family for, and how to deliver bad news?*
  • If yes, when did this occur? (Select all that apply.)*
  • Have you had any prior training in how to prepare a family for, and how to deliver news of brain death?*
  • If yes, when did this occur? (Select all that apply.)
  • A family's ability to comprehend brain death is based on: (Select all that apply.)*
  • If a patient clinically appears brain dead and a cause has not yet been identified, one should proceed with brain death testing.*
  • When a patient is pronounced brain dead, they are medically and legally dead.*
  • After pronouncing death, you must obtain a withdrawal decision from the patient's family in order to remove the endotracheal tube and discontinue ventilatory support.*
  • Which of the following are NOT consistent with brain death? (Select all that apply.)*
  • When assessing the sucking reflex in an infant, any observed sucking response is NOT consistent with brain death.*
  • I am confident in my knowledge of how to perform the physical act of conducting a brain death examination. (Please choose only one.)*
  • I am confident in my ability to prepare families to receive the news I will deliver after the determination of brain death is complete. (Please choose only one.)*
  • I am confident in my ability to prepare families to comprehend the news I will deliver after the determination of brain death is complete. (Please choose only one.)*
  • I am confident in my ability to deliver news to a patient's family that the brain death examination is complete and confirms the patient has died. (Please choose only one.)*
  • I am confident in my ability to talk with families about all aspects of the brain death examination. (Please choose only one.)*
  • Prior to initiating brain death determination, which of the following must be done? (Select all that apply.)*
  • To assess the oculovestibular reflex, which of the following are necessary? (Select all that apply.)*
  • With respect to pupillary light reflex testing, which of the following are consistent with brain death? (Select all that apply.)*
  • Which of the following responses are inconsistent with brain death? (Select all that apply.)*
  • Of the following, which are pre-requisites to performing an apnea test? (Select all that apply.)*
  • Of the following, what should be considered during the apnea test? (Select all that apply.)*
  • When determining brain death, ancillary tests are indicated when . . . (Select all that apply.)*
  • When informing the family that the brain death evaluation has confirmed death, you should: (Select all that apply.)*
  • Should be Empty: