Ruptured AVM

[Mommy_of_3_in_AL..RN]

I am a student in my last semester of school. I am working on my preceptorship in a local SICU, and had an extremely upsetting case yesterday. A young lady came in a few nights ago after being found unresponsive. She was intubated by paramedics and brought to the ER where it was found she had a massive hemmorhage, likely due to a ruptured AVM. On her CT you cannot even make out the ventricles because her head is so full of blood. Her pupils are 9mm in size, fixed and nonresponsive. SHe is unresponsive to painful stimuli. GCS of 3. She is in full pulmonary edema, as well as renal failure. Her vent tubing is being changed every few hours because it continues to fill with blood. She is on full vent support. She is maxed out on Levo, Vasopressin, and Dopamine. She had a flat EEG, and failed the ear canal ice water test, corneal reflex test, and apnea test. She has been declared brain dead. However, the family continues to hold out false hope that after three days she will magically recover and walk out of the hospital. Today is day three with no change. The family is still insistant that there will be a miraculous change. My question is, am i being realistic in knowing that there is no coming back from this. Am i being too negative because i think this is totally irrational and cruel to the patient, to continue to hold out this hope? I try to put myself into this family's position and think what i would do if this is my family member, but i cant see holding out such hope for long. What do you all think is the appropriate time frame in a case like this, and am i destined to be a bad ICU nurse because i just cant bring myself to be so positive about such a patient? This really hits hard on me, because the patient is my age, and was so young, healthy and full of like just three days ago. Any advice on dealing with this would be great!!!

[mskate]

where i work, brain dead = dead. you can turn off the monitors, etc... you do not need the families permission. its a matter of "do you want to be here when she has CARDIAC death WHEN take the tubes out?" its the same as keeping a body with cardiac death on the unit waiting for them to resurrect.

[Mommy_of_3_in_AL..RN]

That was my thought..dead is dead, no matter how sad the situation is. There is no more to be done, and although i realize the family has to deal with that in their own time, there should be some standard as to how long to keep a body lying there waiting for the family to come to that realization

[SICUTOCRNA]

Initially, I did not look at your name. Best advice i could give you is put your child in that bed--your 19 yo son or daughter who is laying in that bed through no fault of his or her own. Even as a nurse--it would be so hard. I agree the patient shouldn't be laying there for a week--but a few days? Part of being a nurse is being empathetic.

[Ciale]

However, maybe if they are that religious then a pastoral consult would be good. It may help them to hear from a pastor that although the body is there, their daughter has already gone.

I would absolutley call the pastor in to talk with them. I'm in the bible-belt here and this is a situation I am anticipating coming across several times as an ICU nurse. I am Christian but by no means well versed in Christian doctrine but I think I could do a fairly good job of explaining their loss in terms of their beliefs. I had a friend in the exact same situation as you described. She politely asked the doctor if he could break it to the family in a more religious way. He was cruel to her and exclaimed how science has nothing to do with religion. Needless to say, we have pastoral care in hospitals for this reason.

What a tough situation you were in. Don't be hard on yourself for feeling the way that you did. You were not in denial about the situation and your concern was where it should have been -- with the patient.

[Keysnurse2008]

No response to cold colourics...she unfortunately is dead. What the family needs to hear is the truth. In a quiet respectful way. They have to be told about the flat EEG etc etc. But to make it simple you need to break it down into a way that they can comprehend in this horrible time. They are loosing a young family member. They need to hear what these tests really ...realllllyyy mean. They need to hear that the part of her brain that controls the essence of "who" she was is profoundly irrepairably damaged. They need to hear that the part of her brain that controls her personality is gone, the part of her brain that controls her thoughts, memories is gone. They need to hear that the part that controlled her speech is gone. And once it is gone there is no coming back. They need to hear that you need for them to make some tough choices that you would find difficult in their situation. They need to hear that if that were your daughter lying there that you would want to " hold on " to them for YOU. That you would not want to let them go. But that eventually you would realize you were holding onto her for "yourself" and not for her...bc all the things that made her so special and unique are gone ....and that eventually you would hope that you would reach a point that you could let her go. that you would feel like letting her go would be the last "gift " you could give her. They need to hear that some families never reach a point to where they can give their family member that one last gift. The gift of being able to let them go......and that some families do reach that point to where they can give them that last final gift and it brings them peace. You need to tell them whatever their decision is you will abide by it , and that even if they cant "let them go" it will slowly be taken out of your hands as eventually the only small part of her brain that is mildly functioning ( brainstem) will cease despite your efforts. Usually.....99% of the time......my families come back and withdraw care. What I have found is that they want to hear that you see her as a person and that you realize how very special/imp he/she was to them. Once faced with this little above speech,....it is easier for them to grasp....and they do a DNR. If you allow the docs to spill out - ICP out the roof , severe brain edema,...blood pressure unstable ....futile care etc....it doesnt mean anything to them....but if you break it down .....to what is important to them that they can grasp at this emotional time it sinks in. Like the part of her brain that controlled her speech is gone.....the part here ( point to the CT) that controls her memory is calle dthe temporal lobe....it is as you can see gone. These things make it "click". Hope this helps.

[wanderlust99]

Hmm...if a pt is declared brain dead, they are dead. Either the team is trying to keep their other organs going for donation or we're just waiting for all the family members to get there before we turn everything off.

Maybe the physicians weren't clear with the family.

[bellafea]

this article in the Nytimes may provide some insight

http://www.nytimes.com/2009/03/18/health/research/18faith.html?scp=2&sq=end%20of%20life&st=cse

[bellafea]

maybe it can be applied to the family as well

[RevolutioN2013]

I am not religious, and for me it would take an explanation of the science along with a healthy dose of statistics to help me understand. Since they are the kind that religious dogma trumps science it sounds like it would be helpful if you could offer to have them get their preacher in to say a prayer with them and then pull him aside and let him know what is really going on. Maybe he could help them understand. Would doing that violate anything in the ethics code?

[KenRN]

OK, sorry of this sounds crass, or blunt. In NC we treat brain death the exact same way as you would treat the situation if you were taking care of someone who's heart suffered fatal cardiac arrest. Once they are declared the family is given time for visitation, we often will wait for a relative to come if it's reasonable. We wouldn't wait on someone to get a visa to visit but might wait on a relative flying from California. But, the doctor right's his/her death pronouncement note in the chart and the patient is eventually removed from life support and turned over to the family as appropriate. Brain death sets forth a scenario that offers some additional opportunities, in NC anyone admitted witha Glasgow Coma Score of 5, or if a patient's Glasgow Coma Score drops below 5 must be referred to the state's organ procurement agency. Upon brain death declaration they must be given an opportunity to request organs and tissue for donation. Aside from all this clear concise information and teaching must be given to the family up front. This situation is often easier if the family is actually part of the care team, involved in rounds etc... Keeping the family out of the loop and in the waiting room serves no ones best interests. Family participation in patient rounds, codes, and daily care routines are a must for the patient and the family. Many times when a catastrophic events strike a family member there is a fair amount of secondary trauma to the family, they have to work through the information and be shown that the injury is real and then be educated toward what the medical teams expectations are for recovery. We have the occasional family who swears almighty Jesus, or Jehovah, or Abraham, or Allah will perform a miracle and raise their family member up from the sick good as new. Some times if they refuse to come around we just have to politely explain that they have been declared dead in accordance with the recognized medical standards, and state law, and we are very sorry but we have to turn the machines and the medicines off now.....click. Yeah Chaos and madness usually follows, but then they begin to realize what they refused to after a few minutes, and they leave after a bit and things keep humming along. All be it a very rare occurrence, it has happened to me twice in 12 years in the Neuro ICU. Not a pleasant experience for anyone involved.

[sistersledgehammer]

To SICUTOCRNA

"i am not sure if you have children--but that gives you a different perspective. sometimes in the morning when i come on to the unit and i see organ donation--i get a pit in my stomach--i think the vultures are circling!! (even though i am an organ donor and think they do wonderful work.) i think what if that was my son or daughter--if they were in an accident and i saw organ donation i would tackle them and tell them to get away from my child--but then again--i would need time :) "

Organ donation is another choice in end of life care. Transplant coordinators are not "vultures". They are called in when the person is being evaluated for brain death. Donation often gives the family a sense that their loved ones' death was not in vain. On the flip side, what if it were your son or daughter waiting on the transplant list? Organs aren't pulled off of some shelf. They are generous gifts from brave donor families. Calling them vultures undermines the important work they do for both donor families and transplant recipients. It's disrepectful and rude.

[JeanettePNP, MSN, RN, NP]

To SICUTOCRNA

Transplant coordinators are not "vultures". They are called in when the person is being evaluated for brain death. Donation often gives the family a sense that their loved ones' death was not in vain. On the flip side, what if it were your son or daughter waiting on the transplant list? Organs aren't pulled off of some shelf. They are generous gifts from brave donor families. Calling them vultures undermines the important work they do for both donor families and transplant recipients. It's disrepectful and rude.

Yes, I think the poster realizes this, that the transplant team are not "vultures." She was speaking to the emotional aspect of it--your loved one has just been declared dead and here is a team of people circling in with the intent of carving up the body to portion out the organs to more fortunate recipients. As much as you might realize the benefit of organ transplant in a "saner" moment, most people aren't fully able to feel that way right when dealing with the shock of death, particularly sudden death (as most organ donors tend to be). This is not to diminish the important life-saving work that transplant teams do, but they need to remember to do so with the utmost sensitivity and appreciation to the family of the donor.