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

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???

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.