The Clinical Response to Brain Death

Abstract

The ethical and scientific literature reflects a certain amount of controversy and confusion surrounding the concept of death by neurological criteria, or brain death. The issues surrounding brain death occur with limited frequency for those working in acute critical care settings. Even so, the literature and our own experiences evidence the discomfort of caregivers and policymakers when dealing with brain-dead patients and their family and loved ones. One particular area in which there seems to be significant diversity of opinion is what should occur when death by neurological criteria is pronounced. At some hospitals, when the patient is pronounced dead by neurological criteria, the support equipment is removed from the body immediately and the body is prepared for visitation by family or is transported to the morgue. In other hospitals, support equipment is maintained for a certain limited period to allow the family to be present when the equipment is ultimately removed. In general, however, it appears that institutional guidelines and policy are vague, at best, or often silent about the issue of when, how, and, to some extent, who decides what is done with the body. This policy paper discusses the confusion of care providers as well as lay persons related to the general concepts of death by neurological criteria. In addition, alternative approaches to the withdrawal of support equipment are examined. This article may also allow nursing administrators to better understand the importance of establishing specific clinical guidelines for their staff related to patients declared dead by neurological criteria. Our conclusion is that a universal policy should be adopted whereby all institutions develop the same guidelines concerning when and how treatment modalities should be withdrawn on their brain-dead patients. Such policy guidelines may not extinguish the misconceptions, misunderstandings, and discomforts that are present with a diagnosis of brain death, but it would certainly allow for more consistent actions on the part of the caregivers. Consistency would substantially benefit caregivers, families, and society alike.

Organ support after death by neurologic criteria

“…3,7,8,16 Many respondents requested the creation of guidelines for management of situations in which families object to discontinuation of organ support after DNC. Although delaying discontinuation of organ support can give a family time to come to terms with a patient's death, 6,7,16 it can also promote confusion about the patient's status and increase the risk of complicated grief (a state of profound grief for greater than 6 months that is marked by disbelief, anger, bitterness, intrusive thoughts of the deceased, and difficulty moving on in life). 3,5,6,8,17 For clinicians and hospital personnel, ongoing treatment after DNC can be seen as a violation of a patient's dignity and bodily integrity, and a misallocation of valuable resources including an intensive care unit bed, medical equipment, medications, and health care professionals' time and energy.…”

“…3,5,6,8,17 For clinicians and hospital personnel, ongoing treatment after DNC can be seen as a violation of a patient's dignity and bodily integrity, and a misallocation of valuable resources including an intensive care unit bed, medical equipment, medications, and health care professionals' time and energy. 3,5,6,8,9,16 These situations are emotionally taxing for both clinicians and families. 3,8,18 Our findings suggest that guidelines for management of these situations should address the following controversial aspects of care after declaration of DNC: (1) the specific scenarios in which physicians should/can continue organ support; (2) the timeframe for continuation of organ support; (3) continuation and initiation of vasopressors, hormones, nutrition, and antibiotics; and (4) code status.…”

“…If moral objection to DNC were to be accepted throughout the United States as a reason to continue organ support after DNC, it would be necessary to clearly define moral objections. American culture places a high value on individualism, respect for autonomy, religious freedom, and privacy, 5,16 but hospitals provide facilities for the living to receive necessary medical care, not for the dead to be maintained, 6 and it is ethically precarious to allow a negotiated standard for determining death. 8 Furthermore, equity dictates that patients who are DNC should be treated the same as patients who are dead by cardiopulmonary criteria.…”

“…8 Furthermore, equity dictates that patients who are DNC should be treated the same as patients who are dead by cardiopulmonary criteria. 6 Practice surveys have limitations. Our results represent the opinion of respondents, but do not necessarily reflect the opinions of all members of the AAN.…”

“…1 The American Academy of Neurology (AAN) advises that organ support be discontinued after declaration of DNC unless donation is planned, 2 but families sometimes request continuation of support. [3][4][5][6][7][8][9] Four states have legal accommodation exceptions. [10][11][12][13] New Jersey's statute states that DNC cannot be declared in violation of a patient's religious beliefs.…”