Brain death and refusal to remove life support

subee, MSN, CRNA · Nov 25, 2017

Disagree. The family is not our patient.

Castiela · Nov 25, 2017

Disagree. The family is not our patient.

I don't disagree. Unfortunately in practice, the family members are the ones who sue not the patient, so the doctors will prolong the amount of time the patient is ventilated. I don't mind when the family wants a day or two to come to terms with a sudden death, or so all family can be present. However, without any set end goal, it becomes ethically dubious because the patient is legally dead.

subee, MSN, CRNA · Nov 25, 2017

There's not enough information in the original scenario to make any conclusion. In my 40 years, most families who needed a few days for the inevitable to percolate, permitted vent to be turned off. As nurses, we know it's all in the presentation. But, I can forsee real pain for all as the business practice of healthcare becomes more predatory and families will probably get the rush job to unplug. IMHO, this will cayse more people to dig their feet in and insist on futile care. Hope I'm wrong, but 45 years in the field ....cynicism is rarely proved wrong.

MunoRN, RN · Nov 25, 2017

There is no such thing as "life support" in a dead patient, so there's no quandary about when to remove life support. We often continue to maintain organs in a dead body after brain death, but there is no life to support. There sometimes families who might prefer that we enable the denial phase of their grieving, but that would be unethical and more prone to a successful lawsuit.

LovingLife123 · Nov 25, 2017

Brain death is death. The patient is legally declared dead. I would look up and learn the difference in cardiac and brain death.

The only time they don't come off of mechanical ventilation is when donor network is in involved.

I've never had a family want to hold on because the patient is dead. There are no miracles once you are dead. And maybe our docs are just good at explaining it, but once a brain flow study is done and it is determined that the patient is dead, that's it. The doctor signs the death certificate and once the family says their goodbyes we pull the patient off of mechanical ventilation. The family saying goodbye is just for the family as the patient cannot hear them. This isn't a terminal wean where it may be possible the patient can hear. They are dead.

That's why I'm saying you need to understand brain death. There is no ethical issue here. The patient gets declared dead at the time the brain flow study is completed, not when the ventilator is removed. The ventilator is doing every ounce of the work.

LovingLife123 · Nov 25, 2017

There's not enough information in the original scenario to make any conclusion. In my 40 years, most families who needed a few days for the inevitable to percolate, permitted vent to be turned off. As nurses, we know it's all in the presentation. But, I can forsee real pain for all as the business practice of healthcare becomes more predatory and families will probably get the rush job to unplug. IMHO, this will cayse more people to dig their feet in and insist on futile care. Hope I'm wrong, but 45 years in the field ....cynicism is rarely proved wrong.

But we are talking about brain death, not a terminal wean. Don't confuse the two. The patient is dead. There are no miracles to happen. I completely understand a person who is so sick that they need to be terminally weaned, and it's obvious to us, but the family is in denial. They can hold out hope, and to be honest I can see it. I may react that way with my loved ones. I hope not, but if was my husband, I can't say I would pray for a miracle.

But death is death and it's permanent.

Legaltrends · Nov 25, 2017

What about the case of the 13 yr old child, Ja hi McMath? She was legally declared and her family dug their heels in to keep her on life support. It seems that the patient, who had been declared, is not a factor. Which is why I think that the family is the people that we are hurting by not getting them to accept the fact that she is gone. This is why I say non-maleficience. Am I wrong still?

LovingLife123 · Nov 25, 2017

What about the case of the 13 yr old child, Ja hi McMath? She was legally declared and her family dug their heels in to keep her on life support. It seems that the patient, who had been declared, is not a factor. Which is why I think that the family is the people that we are hurting by not getting them to accept the fact that she is gone. This is why I say non-maleficience. Am I wrong still?

The factor in the jahi case is the family is not accepting that she is brain dead. They are claiming she is gradually getting better and spontaneously moving. They are also trying to pay "experts" to dispute the brain flow study.

I'm sure if you pay anyone the right amount of money, they will tell you why you want to hear. She is dead and has legally been declared dead.

Since insurance won't pay for the care of a dead person, the family has to pay out of pocket for her care.

If they want to do that, that's fine. It's theur own money and can spend it how they wish. The facility she is in is only taking her so they can get the money. They don't have to bill insurance and gethey a reduced rate. They can bill the family full price.

And I don't see it as a disservice to jahi necessarily because she is dead. She can either be dead on the ground, or in a facility. At some point, her heart will give out.

LovingLife123 · Nov 25, 2017

But also realize as a PP mentioned, it's not life support as she is dead. News articles are written by journalists, not medical people and cannot use the correct terms.

KelRN215, BSN, RN · Nov 26, 2017

The factor in the jahi case is the family is not accepting that she is brain dead. They are claiming she is gradually getting better and spontaneously moving. They are also trying to pay "experts" to dispute the brain flow study.
I'm sure if you pay anyone the right amount of money, they will tell you why you want to hear. She is dead and has legally been declared dead.
Since insurance won't pay for the care of a dead person, the family has to pay out of pocket for her care.
If they want to do that, that's fine. It's theur own money and can spend it how they wish. The facility she is in is only taking her so they can get the money. They don't have to bill insurance and gethey a reduced rate. They can bill the family full price.
And I don't see it as a disservice to jahi necessarily because she is dead. She can either be dead on the ground, or in a facility. At some point, her heart will give out.

I think they moved to New Jersey specifically because its state laws accommodate religious beliefs that do not recognize brain death. She is on NJ Medicaid.

http://www.latimes.com/local/lanow/la-me-brain-dead-girl-20170907-story.html

KelRN215, BSN, RN · Nov 26, 2017

Also, for the OP, in most situations, family consent is not needed to withdraw support from a brain dead patient. Brain death is determinant of death in all 50 states. In the case of Jahi McMath, she was not removed from support not because her mother refused to consent to the removal but because her mother went to court and filed an injunction against the hospital to stop them from withdrawing support.

When I worked in the hospital, we had a case of a small child with DIPG, a 100% fatal brain tumor. The child's parents refused to accept that she was dying and insisted on traching her. The hospital's Ethics team sided with them as a trach wasn't going to change the child's outcome. She later was declared brain dead, while vented through her trach in the ICU. Family was given a specified amount of time that they could bring in other family members to say their goodbyes and they were told that, since she had died, she would be removed from the vent.