Guidelines for supporting a pregnant patient with brain death: A case discussion and literature review

Abstract

Brain death implies irreversible cessation of brainstem function. While it is generally considered unethical and futile to support vital organs once brain death is diagnosed, patients who are both pregnant and brain dead complicate this issue. The appropriateness of continuing maternal somatic support to prolong gestation until delivery is an issue of debate. This paper reviews the literature and opens dialogue about the need for guidelines and recommendations in anesthesia care, including the ethics, legality, and cost of supporting pregnant patients who are brain dead, are in a persistent vegetative state (PVS), or are in a coma due to irreversible brain injury, in order to save the fetus. The review considers United States and international cases. Making a case for or against supporting these patients is outside the scope of this paper. Instead, this case report and literature review highlights the need for guidelines to assist health care professionals in providing care to for the pregnant patient who is brain dead.

Guidelines for the management of the social and ethical challenges in brain death during pregnancy

“…Therefore, this treatment can be considered experimental and needs to respect ethical and institutional requirements to proceed, and as such, adequate assessment of the condition of the fetus (ultrasonography examination and cardiotocography) should be evaluated for an informed decision to be made, and informed consent from the father of the child, next of kin, or family should be obtained . In order to make an informed decision, a meeting of the interdisciplinary team needs to be organized, consisting of physicians, the caregiving team, the hospital ethics committee, and members of the family . Such a meeting would involve discussion of fetal prognosis, delivery prospects, and the potential emotional and financial factors of the prolonged corporeal support, which would need to be followed up with adequate and extensive counseling .…”

“…The growing number of cases has motivated researchers to present them in systematic reviews, demonstrating in the first review 11 reported cases of brain death in pregnancy (BDP) for the period from 1979 to 2000 . The second systematic review presented 30 cases dating from 1982 to 2010, and, finally, a more recent one involved 43 cases, including two where the mother was in a vegetative state, for the period from 1979 to 2015 . Additionally, in the literature the medical and ethical management of pregnancies in a vegetative state is very often equated with the BDP.…”

“…Long‐term follow up of the surviving children has been performed for 24 months in six cases, the longest being in Croatia for 36 months; however, longer follow‐ups are also needed to draw firm conclusions about the effects of such a delivery on the child. Some technical understanding has been gained as a result of these successful cases and published literature and, from the management perspective, practical guidelines have been developed, especially in relation to medical management, corporeal (somatic) support and care, fetal nutrition, and hemodynamic provision, and even a care management algorithm …”

“…Thinking along these lines, some confusion exists in the literature between the rights of a woman who is alive and one who is dead, mainly presented as a conflict of rights between the fetus's right to life and the rights of the woman who is brain dead, in connection with the woman's right to abortion . In reality, the woman is legally dead, and there is no conflict between the rights of the woman and the fetus . Despite a diagnosis of brain death, the possibility of fetal survival is a major consideration for the continuation of corporeal support.…”

“…his chances of survival outside the womb. Furthermore, several authors have already indicated a need for up‐to‐date guidelines for the management of ethical and social challenges following BDP. Therefore, in this article the authors will seek to develop guidelines in light of the existing literature and current obstetric practice.…”