Dead at 0252 hours. I charted, "Pronounced dead by Dr. Smith at 0252 hours. No spontaneous respirations. No visible rise and fall of the chest. Absent breath sounds. No apical heart tones audible via stethoscope. No visible signs of life." During the 45 minutes of cardiopulmonary resuscitation (CPR) on this 55-year-old woman there was no inkling of life. This was enough for the emergency department physician to determine it was time to stop resuscitative efforts. The woman's frail husband sat in a quiet room waiting to hear the status of his wife.
I spent the next couple of minutes preparing the room before bringing the husband in. The scattered wrappers from supplies used were picked up off the floor. The intubation tray removed. A fresh gown replaced the blood-stained gown and crisp white sheets were delicately draped over the woman. Only her face and neck were visible along with her left hand that I gently positioned on top of the sheet.
Standing at the foot of the bed I gave one last look at the room, and then placed my eyes on the dead woman. Taking that last look to ensure everything appeared presentable to a soon-to-be grieving husband was critical. I was ready to bring the husband to the bedside until I discovered one issue...she was not dead. Or was she? The sheets began rising and falling. I listened for an apical pulse. There was a very regular and rather strong heartbeat.
Situations like this make you wonder, how will they know when I'm dead...if I'm really dead? Will someone take my organs for donation if I'm not really dead?
In part 2 we discussed that there are two types of potential organ and tissue donors. These include:
Donation after brain death (intubated, on a ventilator, but heart is still beating)
Donation after cardiac death (heart has stopped beating)
Let's focus first on brain death, because brain death is very confusing to many. The patient will be on a ventilator, the cardiac monitor will often show a beautifully normal heart rhythm, the person looks pink, and appears like they are sleeping. If a person is brain dead by definition they have an irreversible cessation of brain function. They are not sleeping, but rather they are clinically dead. This visual of a loved one can make it difficult for family and friends to process that the person lying on the hospital bed with an often peaceful appearance is actually dead.
Determining Brain Death
The American Association of Neurology (AAN) uses three cardinal signs to define brain death and this includes:
Cessation of brain functioning including the brainstem
Coma or unresponsiveness
Apnea
Understanding the Prerequisites to Brain Death
The clinical prerequisites to consider brain death determination include:
Clinical condition incompatible with life like trauma, intracranial bleed
Neurological imaging that confirms the diagnosis like a CT or MRI
Absence of a reversible medical condition like electrolyte or metabolic abnormalities
Absence of drug induced coma
Normalized core body temperature
Evaluating Brain Death via Clinical Testing
The clinical assessment to determine brain death requires an absence of all reflexes that includes:
Corneal reflex
Pupillary light reflex
Absent reflexes in the face and maxillary areas
Absent cough and gag reflexes
Absent occulocephalic reflex known as testing for Doll's eyes
Absent occulovestibular reflex (absent nystagmus when cold water is injected into the ear)
If there is even a subtle presence of any one of these reflexes then a person is not brain dead. Once all the primitive neurological reflexes are absent, a confirmatory test can be performed to further validate brain death. Confirmatory tests are often what is needed for a family to fully understand that their loved one is brain dead.
Performing Confirmatory Testing
Two primary tests that are performed to confirm brain death are the following:
Testing for the absence of Cerebral Blood Flow with cerebral angiography
Performing an apnea test, to confirm the absence of spontaneous respirations
Determining Brain Death: Who Performs the Declaration of Death
Brain death is determined by a medical physician. The requirements for determining brain death vary by state and country. In some areas, one physician can determine brain death and in other areas two physicians are required, often one of those physicians must be a neurologist. A standard practice seen is that these two brain death exams take place six hours apart.
Determining Cardiac Death
A person can also be declared dead once there is cessation of spontaneous respiratory and cardiac function. This may occur following natural causes, cardiac arrest or, possibly a grim prognosis that leads to the withdraw of life support. Whatever the circumstance, donation of organs or tissues would never occur until after a licensed medical physician declared death.
Should you be worried about donating organs prior to death? Absolutely not...unless of course, you willingly consent to be a live donor donating a kidney or liver. Should you be worried donation after cardiac death will occur but you aren not really dead? Maybe you or your loved one are the person who will spontaneously begin to breathe and move the sheets. Don't be worried. Donation after cardiac death does not occur until a person has been declared dead for a minimum of 5 minutes. In the case at the beginning of this article, it turned out the woman was eventually determined brain dead due to anoxia from prolonged down time prior to the onset of CPR. She ultimately became an organ donor.
So dead or alive? The answer is clear as long as clinical guidelines are used to determine brain death and an adequate timeframe passes before donation after cardiac death occurs.
In part 4 of this series we will learn about donation from the perspective of a donor mother who made the decision to donate her son's organs during the most horrific time in her life.
Until next time...Embrace the Journey...wherever your journey may take you!
There has not been a single documented case of someone recovering from brain death. Articles like those posted are misleading, as they are written by persons who are not medical professionals, and frankly, have no more medical knowledge than the average person. A brain death exam is a very rigorous, clinical procedure, and many hospital policies mandate confirmatory exams. All of these patients mentioned in these dubious articles never met brain death criteria when the exam was performed. In other words, the examination was performed incorrectly.
Legally, anyone with a MD behind their name can perform a brain death exam. They could have graduated from medical school a week ago. For this reason, many hospital policies mandate the individuals that are able to perform brain death testing at that facility (I.e. one of the two people has to be a neurology attending, they have to be two separate physicians, etc.).
In short, all of the people in these questionable articles were "declared' by someone who had no business performing a brain death exam in the first place.
Thank you for your very thoughtful comments that clearly come from some great experience. Much appreciated!
I was an ICU nurse for 16 years and I've seen a lot of brain death and organ donation over the years. I have also seen what can only be described as miracles. Yes there was a lot of testing done on my nurse friend before her family was told this. She was back at work full time within 6 months, now right handed where she used to be left handed and it took a little while for her to be completely back to normal. She is now back completely to her nursing career. My sister in law had an aneurysm and my brother was told she would probably not survive it and then she started to look better. The medical team was amazed. She was responsive and was able to be extubated. She then had another bleed a few days later and the prognosis at that time was very poor. The family prepared for the worst. Today that woman is up and around. She has to struggle with some expressive aphasia but it is improving all the time and she has some issues with impulse control and memory but she has defied all the odds.
I was an ICU nurse for 16 years and I've seen a lot of brain death and organ donation over the years. I have also seen what can only be described as miracles. Yes there was a lot of testing done on my nurse friend before her family was told this. She was back at work full time within 6 months, now right handed where she used to be left handed and it took a little while for her to be completely back to normal. She is now back completely to her nursing career. My sister in law had an aneurysm and my brother was told she would probably not survive it and then she started to look better. The medical team was amazed. She was responsive and was able to be extubated. She then had another bleed a few days later and the prognosis at that time was very poor. The family prepared for the worst. Today that woman is up and around. She has to struggle with some expressive aphasia but it is improving all the time and she has some issues with impulse control and memory but she has defied all the odds.
Ellie G~.
Sounds like you have witnessed some amazing recuperations. Thank you for sharing those stories that are obviously near and dear to your heart. Wonderful that they are both doing so well.
I was an ICU nurse for 16 years and I've seen a lot of brain death and organ donation over the years. I have also seen what can only be described as miracles. Yes there was a lot of testing done on my nurse friend before her family was told this. She was back at work full time within 6 months, now right handed where she used to be left handed and it took a little while for her to be completely back to normal. She is now back completely to her nursing career. My sister in law had an aneurysm and my brother was told she would probably not survive it and then she started to look better. The medical team was amazed. She was responsive and was able to be extubated. She then had another bleed a few days later and the prognosis at that time was very poor. The family prepared for the worst. Today that woman is up and around. She has to struggle with some expressive aphasia but it is improving all the time and she has some issues with impulse control and memory but she has defied all the odds.
Are you serious.....? Telling a family there is a poor prognosis and that they are BRAIN DEAD are very different. If you were an ICU nurse who should know this better than anyone.
NurseHeart&Soul, MSN
2 Articles; 156 Posts
Thank you for your very thoughtful comments that clearly come from some great experience. Much appreciated!