Neuro ICU - Do you talk to brain-dead patients?

[talaxandra]

I'm about to begin a Masters research project about ICU nurses talking to brain-dead patients (oh the joys of ethics approval committees!). My interest in this started when I read 'Rethinking life and death' by ethicist Peter Singer - he described observing nurses in ICU talking to brain dead patients as though they were alive, and from that decided they did it because they didn't understand that the patients were clinically dead.

I think that nurses who talk to their brain dead patients do it for a variety of reasons, which may included (but are not limited) to issues about reconciling the apparently living body (sensory knowledge) with knowledge about brain death (intellectual knowledge). I don't work in ICU, though I do work on a nero unit; I always talk to the unconscious, and sometimes talk to patients who have died.

I was at a conference in the UK last year, and an ICU nurse educator said that she not only never talks to brain dead patients, she corrects any students who do. However, one of the anaesthetists there always speaks to his brian dead patients. They're ruining my research!

What do you all think? This isn't something that will make it into my thesis, BTW, but I'm interested in what you think about the project idea, and about your own practice.

[nckdl]

I was rereading previous posts and, after my father was declared "brain dead" by the neurosurgeon, the vultures (nurses) swarmed my mother with requests to eliminate the ventilator, that we are making him suffer, and that we needed to get a grip because he was soon to be dead, All before the neurosurgeon had actually done any tests to prove he was unconsious and not brain dead. Yes, i know i called the nurses vultures, even though i am a nurse, but to me at that time, that is what they were and it felt like all they wanted was the bed free. I realize now that dr. shouldn 't have spoke to us about brain death before doing the tests, and I think the nurses should have taken our concerns about my father when we said He moves his head back and forth everytime we talk to him and they say, oh you are just imagining things because he can't do that. Some hospitals are more like bandaid stations. And my father said after recovery to "never send me to that hospital again". So i'm wondering what else besides the family talking to him, did he hear while being unconsious?????

[leslie :-D]

I was rereading previous posts and, after my father was declared "brain dead" by the neurosurgeon, the vultures (nurses) swarmed my mother with requests to eliminate the ventilator, that we are making him suffer, and that we needed to get a grip because he was soon to be dead, All before the neurosurgeon had actually done any tests to prove he was unconsious and not brain dead. Yes, i know i called the nurses vultures, even though i am a nurse, but to me at that time, that is what they were and it felt like all they wanted was the bed free. I realize now that dr. shouldn 't have spoke to us about brain death before doing the tests, and I think the nurses should have taken our concerns about my father when we said He moves his head back and forth everytime we talk to him and they say, oh you are just imagining things because he can't do that. Some hospitals are more like bandaid stations. And my father said after recovery to "never send me to that hospital again". So i'm wondering what else besides the family talking to him, did he hear while being unconsious?????

what a horrible experience for you and your father. sadly yes, these situations have happened but thankfully they are the exception and not the rule.

i'm very pleased to hear your dad is ok.

leslie

[LTC_LPN]

In our nursing home, I am often the nurse at the bedside when a resident passes (DNR) under "comfort care only" orders. Tho they may be unconscious and appear unreachable, I always speak to them as if they can hear me... and I comfort them as best I can. No one knows what actually goes on when we die; what we see, what we hear, what we feel...and I seem to think of it as a matter of respect for that person whom I've cared for for days or even years: to continue to treat them with the kindness that they so deserve.

Many times the family has no idea how to react at the moment of death - some are distressed, some are releived, but all are concerned of how we view their reactions to the situation. When a resident is at that "point of no return", unconscious, but near death, many times the family wants to speak to them but feel ashamed or afraid to approach the bed. If it's a family I personally know, I'll reassure them that it's ok to talk to them...although they may be in "their own little world" we never know just what they see, feel, or hear. Words of encouragement and love at that time can never be wrong. At least, that's my small and humble opinion.

[NeuroICURN]

I agree that when a person is NEAR death that it can be helpful to the family and to the pt. to speak to the pt. I encourage family to tell them that they love the them, that it's ok to let go, or whatever is appropriate in that situation. I truly believe that they hear us in whatever way. Let's face it, we've all seen the people that are near death and they either wait for their family to get there, or they wait for them to leave before they die. My father was one who waited for us to leave....actually I had been at his bedside for hours with him (and my mom) and he waited until just after I left, and my mother had dozed off.....we truly believe he heard her snoring and then let go....that's just the type that he was. He wouldn't have wanted me to be there when he actually died. I realize that now, but I was only a teenager then.

Hmmmm....now there's a thread that would be interesting. I might have to start that one.

[OHmom2boys]

Once again we have to make a difference between brain dead and comatose and there is a big difference. Brain death the actual clinical full manifestation is a condition for which there is no recovery. I am glad your father was merely unconscious and am happy that he did recover.

Please, Please those of you who do not work in this field and do not work with these cases it hurts us to have to hear this "Well we were told it was worse than it was and now it isn't so bad so you were wrong" type posts. I will ask all of you who make this accusation one question - How would you feel if we had not painted the picture so black??

You always expect the worst but hope for the best.

?

Because in Neuro more than any other field the outcomes are highly, grossly, completely variable we HAVE to give relatives a "worst case scenario" however this is often misconstrued to mean that we do not have faith in the recovery of the person - we do.

Just wanted to say,

THANK GOD there are people in Ohio who believe in and take care of their patients as you seem to. My youngest son suffered an anoxic brain injury from a near drowning and I was told after the first EEG to expect him to never recover. I was told to prepare myself for the possibility of removing life support. Even the Dr's notes said "dismal prognosis....supportive measures only" and blah, blah, blah......yes, I was also given the worst case scenario...now I understand why, at the time I didn't.

Yes, he was without O2 for approx 30-45 min...I've even been told up to 60 min by one EMT on the scene....his core temp upon arrival at Children's Hosp was 78 F....after at least one hour of re-warming...I really can see why they prepared me for him to die that night...really. But as another poster said, "Miracles Do Happen".

There was one doctor who looked at me and said "He's in God's hands now, there's nothing else we can do." I still remember that....not many "old time docs" will say that directly to a mom. Also, Jacob was never declared brain dead officially....but his first EEG was nothing...they did tell me he was "neurologically devastated", and told me to prepare..but he was never declared brain dead.

I guess I don't know why I'm even posting this, except I can relate to so many posts here. Also, maybe because for some reason, even though it may not "MESH" with other people's, you KNOW your stuff and you have your beliefs and you stick to them, and I like that....as a mom and a nurse. :)

Thankfully, Jacob has worked his way from a CGS of 3 to a rotten boy. No, he's not the same boy, but he's my boy....and he's here. He's had a long, hard fight and still has a life time of fighting to go, but he was given back for a reason....especially under such miraculous conditions. People tend to forget just how much of a miracle he is when he's out of control behaviour-wise due to his brain injury....including myself. But I do try to make myself stop and remember what could have been. And what I BEGGED for......for him to be back to his rotten self. :)

Just want to say thanks to you for being compassionate and firm in your beliefs......

Kim

[OHmom2boys]

Thank-you Tweety I guess this is one area that is a little tender for me as so many, and the media in particular seem to love this "Look at how wrong you all were" type of scenarios and for every one of those you look around the ward at the 20 or 30 who were not miracles, who never will get better who will live for ever in a shattered world. You see the gradual loss of hope in the families the slide into despair at ever seeing an improvement, they hold out such hope, the patient twitches and they start to beleive that this is the start of recovery only to have you tell them that it was only reflex. So, so sad. No matter how black the picture you paint, no matter what information you have given them they continue to hope and it is these people who stick in your mind when you talk to the relatives, trying once again not to give false hope because you know how hard the road ahead is.

This is yet another reason I posted to you before. You are awesome......

I promise NOT to post again if I run into another of your very compassionate and "EXACTLY WHAT A NURSE IS SUPPOSED TO BE" posts... :)

[Head Trauma]

More times than I have counted, have I noticed on a (BDP) brain dead patient's telemtry monitor, their heart rate increases with some verbal stim.

[Jellibum]

.... i think that nurses who talk to their brain dead patients do it for a variety of reasons, which may included (but are not limited) to issues about reconciling the apparently living body (sensory knowledge) with knowledge about brain death (intellectual knowledge)...i was at a conference in the uk last year, and an icu nurse educator said that she not only never talks to brain dead patients, she corrects any students who do.

i'm a student who has been 'told off' for talking to the departed by several educators. only one nurse has ever joined the conversation.

i've come into contact with many who are dying and those who have. i talk to them all. why? because i'm nuts! it's bad habit? well maybe both but it's because i don't know what this person believed about their spirtuality or their view on "an afterlife".

i was speaking to one gentleman who was dying whilst trying to make him more comfortable,after several hours of saying nothing and me floating in and out of the room talking to him at every oppotune momment, he said "why do you keep talking to me, as if i'm going to be here tommorrow to answer you?"

i said that it wasn't to make him uncomfortable but the make him realise that just becasue he's dying doesn't mean that his any less of a person.

it's the same for the dead. there are those that call the person in bed 2 - the corpse - just becasue they died 2 min's ago.

whether i think that there spirt can 'hear' me or not - i talk to comfort, ease confusion etc. this idea of talking to the dead for me stemed from the books "on death and dying" & "when a baby suddenly dies".

"on death and dying" speaks about this topic briefly by stating that in many cultures and beliefs that when the body dies, the soul is confused and then transends into whatever the culture believes - heaven/hell, limbo, another body/rebirth/reincarnation, happy hunting ground, the dreamtime etc. many cultures also tak to their dead with prayers that help guide the soul to the place of rest etc.,

good luck with the research - i think it's a great topic!

~ jelli

p.s. i talk to anyone ... dead, alive, comatose, a brick wall, my hubby! :chuckle

[Good_Queen_Bess]

Interesting topic.

I think the subject has wandered off-track a little. People seem to be misunderstanding one another about whether other people mean by coma/pvs/brain dead/brain-stem dead/dead.

I think the question really boils down to, "do you talk to people when they are dead?"

Yes, sometimes I do. What's wrong with that? Just because this person no longer exists physically, does not mean that I treat them like a piece of meat. Yes, it might well be my way of coping with death, but that's my choice. Some nurses don't talk to their dead patients and that's their business too.

Where I work, when someone dies, we wrap them up in a sheet and I always say "goodnight " before I cover their faces.

I would hope when my time comes, someone treats me with respect too.

[talaxandra]

Hi Bess.

So far in my research I've found that all the nurses who speak to their brain dead patients also speak to their dead patients, and the one nurse I (accidentally) interviewed who doesn't speak to brain dead patients doesn't speak to dead patients either. To me this suggests that nurses who speak to the brain dead do so for reasons other than thinking they're still alive.

The reason I focused the question on brain death is that it was this behaviour (speaking to the brain dead) which was identified as an example of ICU nurses' misunderstanding of the brain death concept.

[CCU NRS]

Ok Mandy....first of all the reason I quoted you was this. If someone is brain dead, then they are dead. Completely dead. Bought the farm. It is no different than if they are asystolic. At the point of brain death, organs may be harvested. Just because the heart has not stopped does not mean they are still alive. So there is no "coming back" from that. However, yes, patients may come back from a comatose state. But honestly, I have yet to ever see one that remembers things from the comatose state.

Now back to the subject at hand. Yes, I do talk to my patients. I don't think I have to explain why I talk to the alive and comatose ones. I don't always talk to the brain dead ones. As for why I occasionally talk to the brain dead ones....well, I guess it's more of a habit. You know, as an ICU nurse, you just get used to talking about what you're doing as you do it. But I don't talk to them as if they were alive....because they're NOT!

As for the ICU educator who always corrects students for doing that...well that's wrong. She should educate them that brain death IS death, but if they want to talk to the patient, then that is their right...no matter what their motive may be.

Also....no, the (true) definition of brain death does not vary from place to place....the term is just misused at times!

I've probably already done more brain death criteria testing in my short career in nursing, than other nurses have in 30 years!!! So if anyone has any questions, please feel free to ask.

I agree with your points. I also work CCU/ICU and Brain dead is dead. However we recently had an issue that involved our speaking to Pts in this state. Many nurses as you mention do talk to Pts out of habit and explain what they are doing. I am one of these. I also explain to families what I am doing. We had a case recently where the family felt they were recieving conflicting messages. Brain death was explained and they were informed of their family members brain death, but nurses continued talking to the Pt which made the family feel that nurses still felt hope or felt there was cognition. I no longer talk to brain dead pts I speak directly to family if present and I explain that the soul if you like has already departed and the body is an empty shell at this point. I always say my regular prayer of loss over brain dead pts just as I do over any pt that dies in my presence.

This my be where the instructor is coming from because I hear there were major cases concerning speaking to brain dead Pts causing families to feel hope.

[Good_Queen_Bess]

Hi Bess.

So far in my research I've found that all the nurses who speak to their brain dead patients also speak to their dead patients, and the one nurse I (accidentally) interviewed who doesn't speak to brain dead patients doesn't speak to dead patients either. To me this suggests that nurses who speak to the brain dead do so for reasons other than thinking they're still alive.

The reason I focused the question on brain death is that it was this behaviour (speaking to the brain dead) which was identified as an example of ICU nurses' misunderstanding of the brain death concept.

I agree. IMO, whoever thinks that nurses who speak to brain dead patients means that we misunderstand brain death, are patronising and insulting.