Neuro ICU - Do you talk to brain-dead patients? - page 6

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... Read More

  1. by   NeuroICURN
    Quote from talaxandra
    I'm sorry if I misrepresented the authors' position in this article, or my own - the point was not that these were case where brain-dead patients became "un-brain-dead" (for want of a less clumsy phrase). Rather it is that determinations of brain death are sometimes made when patients don't fit the criteria. In the cited cases, these reasons may have included inevitable somatic death (or perceived inevitable somatic death), a viable recipient in the wings, or perhaps even financial aspects (this last is not explicit in the text).
    I agree with you, NeuroICURN, that these cases describe patients who are not brain-dead - that was the point of the article. The reason I posted it is that, if relatives are told that a patient is brain-dead and s/he isn't, or isn't yet, or is brain damaged, then this muddies the waters for everyone. The term 'brain dead' is thrown around a lot, and as we can see from the discussion thus far, informed and interested health professionals are not always any clearer about it than lay people. For example, on my unit (which incorporates neurosciences), staff refer to patients as being 'brain dead' when they mean unconscious, unresponsive or hypoxically brain damaged, although they know that part of the definition of brain death is that the patient is ventilator-dependant.
    About the third case: although van Norman does not specify that the patient had been declared brain dead, she does say: "On the day of anticipated organ collection..." and "Vital organ collection was canceled..." These phrases seem to indicate that organ collection was planned, timed, rather than related to withdrawal of treatment. It is possible, of course, that treatment was planned to be withdrawn that day, with post-mortem organ retrieval, which would seem to be premature. However, as the article is specifically about declaring brain death, I think it's safe to presume that the third patient had been declared brain dead like the other two.
    Oh, ok. Well, there again, I think it all comes back to the fact that perhaps it is the MDs that need a lesson in what brain death is and how to accurately declare it! I certainly wouldn't want my OB-GYN declaring brain death any more than I would want a neurosurgeon doing a C-section on me!

    It also seems that perhaps RNs need education too if they're throwing the term around, when the patient is actually only brain damaged or in a comatose state.

    So, if these docs are declaring brain-death, when in fact, a person has not properly met the criteria for brain-death, then YES, that's very scary! :uhoh21: I guess that's why I consider it part of my job to know what the criteria are, what's to be done, what to look for and to be present when it's done....because it's my job to be that patient's advocate!

    Just my humble opinion!

    NeuroICURN
    Last edit by NeuroICURN on May 24, '04
  2. by   txspadequeenRN
    Hearing is the last to go . Brain dead patients deserve the same dignity and respect that you would give to any other patient .




    Quote from 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.
  3. by   teeituptom
    Yes I talk to the brain dead patients

    but I always talk

    I even talk to republican attorneys

    is there a difference
  4. by   Ashera
    Absolutely! It comforts me...and I somehow feel they hear. Until that 'spark' leaves the body - there is some essence of life there no matter how or under what means it is hanging on.
    Clinically - we may know. But there are many other areas we are yet to be made knowledgeable on. Go with what your heart is telling you. That's a big part of being a nurse.
  5. by   Dixiedi
    Quote from teeituptom
    Yes I talk to the brain dead patients

    but I always talk

    I even talk to republican attorneys

    is there a difference
    Yes, there is a difference. Attorneys don't listen to anyone speaking and your brain dead pt just might be.
    Notice I didn't choose between Dem and Rep attorneys since they are all alilke in that respect!
  6. by   nckdl
    Quote from 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.
    This past january, my family was told that my father would never "wake up" after having a quadruple bypass. The neurologist said it was a lost cause and the icu nurses told my mother that we should consider pulling the plug and i did not once see them talking to him, until....... we kept talking to him for hours and hours every day and low and behold he AWOKE. My my, that was a quick trip from brain dead to alive and well huh!!! To make a long story short, Doctors do not know everything, and we as nurses should make a point of ALWAYS talk to the patient, no matter what the condition. And yes, my father remembers hearing voices and could recognize our voices but could not really understand what we were saying.
  7. by   stevierae
    Quote from NeuroICURN
    Often brain dead people are in the ICU because that's where they progressed to brain death (it sometimes takes a while to happen)...or they may be there to be stabilized and prepared for the OR for organ donation. Brain dead patients can be the MOST unstable patients you've ever had to deal with (Think about it, their most basic brain functions are no longer working...I've had times where the patient is SOOOO unstable that 2 nurses were assigned to a single patient). Anyway, certain things have to be in order before they go to the OR.....For instance, we use the rule of 100s (SBP above 100, UO above 100, etc). They have to be a certain body temperature (not only to be declared brain dead, but also to go to the OR) and certain lab values have to be within certain limits. It's not unusual for it to take care of these people for 12, 16 hours or more to stabilize them before taking them to OR.

    I realize it's hard to understand this if you've never been a Neuro/Trauma ICU nurse that's involved in the process....but it's really a complicated process. There again, if anyone has any questions, feel free to PM me.

    NeuroICURN
    Oh, I guess I should have clarified: What I meant to say is, I can't understand why brain dead persons who are not going to be organ donors are still in the ICU. I know that kidney donors have to be maintained on all kinds of drips, etc. and that renal perfusion has to be esentially perfect before we proceed--I have had more than one scheduled donor nephrectomy cancel at the last second to try to make things perfect.

    I just wondered why, when someone has already been declared brain dead by whatever criteria is used in that facility to determine absence of cortical function, they could not be moved to a quiet, private room perhaps in med-surg, kept on the ventilator until the family has said their good-byes and taken as much time as they needed, and then disconeected when they are ready, and then allowed to stay as long as they needed to--however long it took the heart to stop beating--and even longer, should they choose to do so.

    To those who insist that brain dead does not necessarily mean "dead-" If they were not dead, we would not be taking their organs. To do so would be murder.
  8. by   stevierae
    Quote from stevierae
    Oh, I guess I should have clarified: What I meant to say is, I can't understand why brain dead persons who are not going to be organ donors are still in the ICU. I know that kidney donors have to be maintained on all kinds of drips, etc. and that renal perfusion has to be esentially perfect before we proceed--I have had more than one scheduled donor nephrectomy cancel at the last second and rescheduled for later, to try to make perfusion as perfect as it can reasonably be expected to get, or while we waited for ciritical labs (Hepatitis screening, etc.) to come back.

    I just wondered why, when someone has already been declared brain dead by whatever criteria is used in that facility to determine absence of cortical function, they could not be moved to a quiet, private room perhaps in med-surg, kept on the ventilator until the family has said their good-byes and taken as much time as they needed, and then disconnected when they are ready, and then allowed to stay as long as they needed to--however long it took the heart to stop beating--and even longer, should they choose to do so.

    To those who insist that brain dead does not necessarily mean "dead-" If they were not dead, we would not be taking their organs for implantation into another human being. To do so would be murder.
    I feel like people are confusing chronic vegetative state and coma with brain death. They are comparing apples and oranges. People in chronic vegetative state and coma are very much alive. Of course one should talk to them.
    Last edit by stevierae on Jun 3, '04
  9. by   NeuroICURN
    Quote from stevierae
    I feel like people are confusing chronic vegetative state and coma with brain death. They are comparing apples and oranges. People in chronic vegetative state and coma are very much alive. Of course one should talk to them.
    LOL....I was just going to post the same thing!

    As the previous poster said, her father was on the ventilators and they suggested that they remove medical support....HOWEVER, she did not say anything about her father being declared brain dead (which obviously he wasn't). THESE ARE TWO DIFFERENT THINGS PEOPLE! Just because one is in a coma does NOT mean that they are brain dead!!!
  10. by   tinnekke
    Quote from NeuroICURN
    But honestly, I have yet to ever see one that remembers things from the comatose state.
    I came back from a coma nine years ago. I was comatose for about a month, I guess. That's what I'm told. I can remember weirds bits of conversation that happened around me. It's very disjointed. And yes, I did check with the people I thought I heard, and I did hear aright. I can remember bits of my roommate (RL not hospital) apologizing for causing the accident that put me in the hospital. I can remember hearing my best friend's voice. At the time of the accident, he was 500 miles away at school. When I came to, he was not there. He came to see me while I was in the hospital. They said he spent four days in my room, and the only thing that took him away was having to go back for finals. I thought I was seriously out of it that I had heard his voice until my roommate said, yes he'd been there. I even remember hearing an announcer of some kind issue a tornado watch. That one I was sure was some weird dream, but that was real, too. The last place I could remember being was the middle of Kansas, but when I came out of it, I was at a hospital in New Orleans. Don't ask me how. The last I knew it was January. It was February, and there had been a tornado watch in New Orleans while I was in my coma, and my friends had been watching tv in my room and heard the announcement. All very strange for me, but yes, there are people who remember hearing stuff. Like I said, it's all very weird and disjointed, maybe not everyone mentions it because it'll sound nuts. I know it sounded nuts to me, but I asked. I didn't have alot of inhibitions for a long time after the injury, and I just said what was on my mind.
  11. by   zrjlatour
    I am a nursing student, and this is an ongoing controversy between some of my fellow classmates and our instructors. My group ALWAYS speaks to our comatose patients, no matter what their prognosis is for recovery. We just don't feel that anyone can know without a doubt that they cannot process what you are saying on some level.
  12. by   PQRST
    As an icu RN I have had the honor of working with brain dead pt's and their families. I am not talking about brain injured pt' whom have little chance for a meaningfull recovery. There is a huge clinical differance in how we care for these pts and any one who has worked closely with organ donation can attest to this. The brain dead pt is truly dead. The body will follow and is trying very hard to follow the body. This is a very busy pt and a challenging pt to care for. I have personally never been involved in a case where there was even a question as to fitting criteria. In my experience either the pt is declared or is not, and the ball does not start rolling untill after criteria is met. (although we do make organ donation aware of the pt) Everyone is very careful and cautious, and empathetic. I believe this so strongly from my experiences that i am a registered organ doner with my state organ donation program. I have had the experience of families believing we are talking about brain death and in fact we were not. In any case, Yes I do talk to my brain dead pts. I do believe they are dead and there is no missconception about it. I talk to them when we are alone in the room and not in front of the family. I do this because on a spiritual level I have personal beliefs the spirit is not able to move on untill the body follows. I don't believe I talk to the pt so much as the spirit. I will thank them for the gift of life they are about to give, I will pray for them to be in peace and even ask them to hang on untill we go to the or. Some times other nurses, assistants, RT will talk in the room about the pt. I do ask them not to. Some think I am crazy some laugh and even more feel the same way i do. I find it very rewarding and beauitful that while one life which we cannot save will save another. The last pt I cared for was a young man in his 20's who was hit by a bus. We could not save him but through donation he saved the lives of many including two people who shared his liver, his heart and both kidneys. I hope this helps some of you understand why those of us who choose to do this do.
    Last edit by PQRST on Jun 3, '04
  13. by   gwenith
    Quote from Kyriaka
    Perhaps the organ procurement agency was a little overzealous in your case, I can't say because I wasn't there. But usually they don't talk to the family unless the docs, RNs, etc. feel there isn't any hope of meaningful recovery. Maybe there was a small miracle in your case.
    _____________
    Part of the problem here was having no concept of cultural differences. You would never ever approach an Orthodox family about this. The organ people pretty much were asking my family was it ok to mutilate my children (and me). And make money at the same time!

    Are they given no training in cultural differances? Religious beliefs??
    Absolutely we do have training in these things and there is follow up every step of the way but here donation is voluntary and the organ transplant teams are part of the health care system - they are on the health care payroll and no money ever exchanges hands - EVER!!!!

    Ask me again why I am such an advocate of nationalised health care.

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