American Academy of Neurology Code of Professional Conduct

Abstract

The American Academy of Neurology (AAN) developed the Code of Professional Conduct to formalize the standards of professional behavior for AAN members to help them in their pursuit of providing the highest quality of patient-centered neurologic care. The goal of this code is to establish the professional standards that AAN members must or should observe in their clinical, academic, scientific, and personal activities.Violations of these standards may serve as the basis for disciplinary action as provided in the AAN's Bylaws 1 and Disciplinary Action Policy. 2 The code applies to all categories of AAN membership, to the extent the AAN member is participating in the relevant activity addressed by the code. This code embodies traditional standards of medical ethics, dating from the time of Hippocrates and adapted to align with contemporary medical practice and ethical values. It is written in broad language to apply principles of medical ethics to the specific demands of neurologic practice.In this code, use of the word "must" indicates that an action is ethically obligatory for AAN members; such actions are near-absolute obligations, not matters about which AAN members may use judgment or discretion. Use of the word "should" indicates an action that is ethically permissible, preferable, and strongly recommended; such actions are subject to exceptions only under special circumstances based on the AAN member's ethical judgment and discretion, exercised on behalf of the best interests of the patient. 3 When the code uses the word "including" to refer to specific examples, the word should be understood to mean "including but not limited to." The code is intended to be generally consistent with the American Board of Internal Medicine Foundation's Medical Professionalism in the New Millennium: A Physician Charter, which is endorsed by the AAN. 4 Any reference to the law in this code is for illustrative purposes only: the statements do not describe legal obligations or the consequences of violating those obligations, both of which can vary by jurisdiction. The code is not intended to establish standards of clinical practice for use in criminal or civil proceedings. If any provision of this code conflicts with state or federal law, the relevant laws will govern in any judicial proceeding.Where relevant, AAN members are encouraged to seek guidance from documents referenced in this code.

Potential Threats and Impediments to the Clinical Practice of Brain Death Determination

“…Both the AAN and the WBDP provide practical guidance about management of BD/DNC objections (Table 2). 11,17,22 Clinician responses to BD/DNC objections vary in both accommodation and nonaccommodation states, but discontinuation of organ support after BD/DNC declaration over surrogate objection is rare, in large part because of the fear of litigation or media coverage. 20,21 Although the rUDDA could be a means to facilitate consistent legal guidance across states about how to address these objections, the ideal approach is unclear (Figure 2).…”

“…Both the AAN and the WBDP have posed the question of whether guidelines for pediatric and adult BD/DNC determination can be harmonized into a single standard while accounting for physiologic and anatomical differences. 35,42 Table 2 Guidance From the American Academy of Neurology and the World Brain Death Project on Management of Objections to BD/DNC 11,17,22 Source Guidance AAN 17,22 • There is a professional obligation to determine death in a timely and accurate manner • AAN members should be aware and respectful of BD/DNC laws in the jurisdiction where they practice and should seek expert guidance when addressing BD/DNC objections • Surrogates should be notified of the intent to perform a BD/DNC evaluation, but their informed consent is not needed • Requests for indefinite accommodation of a BD/DNC objection (continuation of organ support until death by circulatoryrespiratory criteria) should be handled by the health care team in conjunction with representatives from hospital administration and legal departments with consideration of involvement of others with mediating skills like clergy members, mental health professionals, or palliative care or ethics consultants • There is no ethical obligation to provide medical treatment to a deceased person, and the only state in the United States where indefinite accommodation of a BD/DNC objection is legally required is New Jersey • Indefinite accommodation of a BD/DNC objection could be harmful to the patient, family, health care team, and society • Transfer of a patient who is believed/known to meet criteria for BD/DNC to another facility should be considered a measure of last resort • Hospitals should establish standards that address management of BD/DNC objections World Brain Death Project 11…”

“…With this mission and values in mind, the AAN has taken numerous steps to address controversies related to BD/DNC (Figure 3) through the development of practice resources, solicitation of member feedback, conferences, education, and advocacy. 13,17,20,22,36,[42][43][44] Development of Practice Resources on BD/DNC Determination In 1995, the AAN noted (1) BD/DNC determination is not easy, (2) a perceived need for standardizing the evaluation, (3) variability in practice, (4) a controversy regarding the utilization of ancillary tests, and ( 5) government and third-party payers needed a well-defined practice parameter on determination of BD/DNC. 36 To address these issues, the AAN published practice parameters on BD/DNC determination in adults.…”

“…17 The 2021 AAN Code of Professional Conduct also affirms the importance of completing BD/DNC evaluations in an accurate and timely fashion. 22 Table 2 summarizes the AAN's guidance in these practice resources on management of BD/DNC objections.…”

“…11 Advocacy to Address Legal Controversies Related to BD/DNC The AAN supported the need for revisions to the UDDA to promote a consistent legal approach to BD/DNC throughout the country and appointed a representative to serve as an observer on the drafting committee of the ULC. 1,18 This ensures that the AAN (1) can educate the commissioners who will 13,17,20,22,36,42,44 ultimately make the decision about how to revise the UDDA and (2) has a voice in the revision process. 1 The Future of the Clinical Practice of BD/DNC Determination Ideally, BD/DNC determination should be just as uncontroversial as determination of a diagnosis of stroke, Guillain-Barré syndrome, radiculopathy, or any other neurologic condition.…”