[gwenith]

As you will be aware and speaking in a broad clinical sense there are two aspects of consciousness wakefullness and awareness (sometimes called arousal and cognition). Broadly wakefullness is the property of the brainstem or rather hindbrain whereas awareness is the function of the forebrain or cerebrum. (Apologies for being simplistic here)

It is possible for people to "wake" and recount EVERYTHING that was said at the bedside if they have had a primary brainstem insult and it has happened. (Darned embarrassing when it does let me tell you - they will remember everything including who was dating who as an overheard conversation). Conversely and more frequently it is possible for people to be awake but unaware (how many times have you heard "Lights are on but no-body is home)

I hate to disabuse anyone of their opinions but there are more than one defintion of death and as The Intensive Care Manual by T.E.Oh states - there is no deistinction made between brain stem death and brain death. This is an Australian text Hickey (The Clinical Practice of Neurological and Neurosurgical Nursing) is American and it states that there must be absence of brain stem and coritcal activity whilst Lindsay Bone and Callander (Neurology and Neurosurgery Illustrated) is English and only outlines testing for brain stem function. Certainly in Australia and as far as I know England, we do NOT perform routine EEG's when testing for brain death. America, from the texts, this is standard practice. (I am unsure about Canada maybe someone will enlighten me LOL).

Even though we only test for brain stem function it is agreed that abscence of brain stem function is incompatable with life.

I know Hickey does have a section discussing the research that shows alteration in vital signs of comatose severely head injured patients when family and vistors have spoken to them but at the moment I can't remember where in that darn booK I saw this.

Yes hearing IS the last sense to be affected and so we nurse all neuro patients as if they can hear - as for talking to the brain dead patient - I have been there with many many brain dead patients and at that point I always consider that I am nursing the family more than the patient. My role shifts from care of patient to care of family because we have to get that family to accept social death before actual death. The normal events of life are actual death followed by social death as the family and society come to accept loss. My interactions therefor are guided by the relatives. If there is a difficulty with them accepting brain death I will encourage the family to say the last goodbyes but not address the patient directly myself. If however the family are more accepting I will join them in talking to and about the patient. I will talk to the patient when the family is not present as once again it shows respect and you never know - the spirit may be watching.





Why then do we not make a distiction between brain death and brain stem death???

[earle58]

Originally Posted by gwenith

As you will be aware and speaking in a broad clinical sense there are two aspects of consciousness wakefullness and awareness (sometimes called arousal and cognition). Broadly wakefullness is the property of the brainstem or rather hindbrain whereas awareness is the function of the forebrain or cerebrum. (Apologies for being simplistic here)

It is possible for people to "wake" and recount EVERYTHING that was said at the bedside if they have had a primary brainstem insult and it has happened. (Darned embarrassing when it does let me tell you - they will remember everything including who was dating who as an overheard conversation). Conversely and more frequently it is possible for people to be awake but unaware (how many times have you heard "Lights are on but no-body is home)

I hate to disabuse anyone of their opinions but there are more than one defintion of death and as The Intensive Care Manual by T.E.Oh states - there is no deistinction made between brain stem death and brain death. This is an Australian text Hickey (The Clinical Practice of Neurological and Neurosurgical Nursing) is American and it states that there must be absence of brain stem and coritcal activity whilst Lindsay Bone and Callander (Neurology and Neurosurgery Illustrated) is English and only outlines testing for brain stem function. Certainly in Australia and as far as I know England, we do NOT perform routine EEG's when testing for brain death. America, from the texts, this is standard practice. (I am unsure about Canada maybe someone will enlighten me LOL).

Even though we only test for brain stem function it is agreed that abscence of brain stem function is incompatable with life.

I know Hickey does have a section discussing the research that shows alteration in vital signs of comatose severely head injured patients when family and vistors have spoken to them but at the moment I can't remember where in that darn booK I saw this.

Yes hearing IS the last sense to be affected and so we nurse all neuro patients as if they can hear - as for talking to the brain dead patient - I have been there with many many brain dead patients and at that point I always consider that I am nursing the family more than the patient. My role shifts from care of patient to care of family because we have to get that family to accept social death before actual death. The normal events of life are actual death followed by social death as the family and society come to accept loss. My interactions therefor are guided by the relatives. If there is a difficulty with them accepting brain death I will encourage the family to say the last goodbyes but not address the patient directly myself. If however the family are more accepting I will join them in talking to and about the patient. I will talk to the patient when the family is not present as once again it shows respect and you never know - the spirit may be watching.





Why then do we not make a distiction between brain death and brain stem death???

gwenith, i'm not sure i understand your question. if there is no activity in the brain stem, where are most primal functions originate, then yes, the entire brain would be incompatible with life.....is that disputed?

leslie

[gwenith]

No mate it is not it is just that there is a difference that here we do not do EEGs because we are uninterested in finding out if there is any residual cortical activity whereas, from what I gather some areas of the US an EEG is required to ensure that there is no brain activity in any part of the brain.

[Tweety]

I've never taken care of a brain-dead patient. Those patients are donor cases and I don't get to care for them.

However, I always talk to unresponsive or comatose patients. I let them know who I am and what I'm doing.

[earle58]

Originally Posted by gwenith

No mate it is not it is just that there is a difference that here we do not do EEGs because we are uninterested in finding out if there is any residual cortical activity whereas, from what I gather some areas of the US an EEG is required to ensure that there is no brain activity in any part of the brain.

yes that is an absolute esp. before removing from life-sustaining equipment.

[Gompers]

Yes, I always talk to them. In the NICU, these are usually babies who had some kind of injury during the birthing process and are asphyxiated. Others are preemies with horrific head bleeds that eventually cause the destruction of most of their brain tissue. True, these kiddos don't always have a completely flatline EEG, but oftentimes are pretty darn close. Even though they don't understand language, being newborns, I always talk to them. More than that, when these types of babies are taken off life support and hang on for a few hours or days, we try to ensure that they are held as much as possible. When their families aren't there, we always find someone to rock the babies and talk to them, sometimes play lullabye tapes in the background. We dress them in baby sleepers and wrap them up with warm blankets, and just try to give them the best environment possible. Babies or adults, I think each just needs to be treated with respect and dignity and recognized as a human being, even if they aren't aware of their surroundings.

[Kyriaka]

I dont know about "brain dead" but if someone is in a coma state..please talk to them.

I have been in a coma and I heard people around me. Now I cannot tell you who they were but yes I knew people were talking to me. I still on occasion ask "did so and so come to visit me when I was in the hospital" because their voice sounds familiar.

I dont know if my experiance is unusual. But I dont think it is.

Perhaps those people who have a negative attitute to talking to an unresponsive person have an easier time believing the person is an object. They arent.

[talaxandra]

Thank you all for your comments, especially so many in such a short period of time! When I rotated through ICU as a student, the concept of brain death seemed relatively straightforward; now that I've done more research, it's much less clear - isn't that so often the way! What is clear is that there's a lot of confusion around the subject - as Gwenith pointed out, definitions and diagnostic tools vary from country to country, and the concept doesn't even exist in Japan.
Your comments so far mirror the spectrum of opinions that I've heard in my preliminary research - some people don't do it all; some people (including me) talk to all patients, including the dead, for spiritual and/or respectful reasons; some aren't convinced that brain death is equivalent to somatic death.
Death work might sound goulish, but it's really interesting

[earle58]

it depends on the condition we're talking about. being in a coma is not synonymous with a persistent vegetative state, albeit both have brain function.

[NeuroICURN]

Originally Posted by earle58

yes that is an absolute esp. before removing from life-sustaining equipment.

Actually Earle, an EEG is NOT a must before removing support. Perhaps in your facility it is, but not in mine.

As Gwenith stated, we're not interested in cortical function. And actually...what's needed to prove brain death is any three of the possible brain death criteria tests. For example, cold calorics, apnea testing, dolls eyes, absence of protective reflexes, blood flow studies, etc.