Declaring death - a question...

Nalon1 RN/EMT-P, BSN, RN · Apr 25, 2014

My question is: How can one effectively declare a patient dead by only shining a light into their eyes and not checking any other functions or performing any additional testing (apnea, etc.)

not very effectively

Is it possible that she was still alive but in a severe comatose state when he called TOD?

yes

was the patient a DNR?

Fyre522 · Apr 25, 2014

No, she was not a DNR. Her power of attorney was her daughter (who was also physically disabled with RA and COPD) and was there for around the last 12 hours of the Pt's life. She did not authorize or consent to DNR for her mother, either, and was accompanied by her Granddaughter. They were told about 10 minutes before the Attending called TOD that the Pt's "time was getting close" and that they might want to "say her good-byes" to the Pt. now. 10 minutes later, he re-entered the room, shined his light into the Pt's eyes (note: she was still on the trach vent and had a pacemaker that was working just fine) and then said "She's gone" to the Pt's daughter and great-granddaughter, turned off the trach vent, and left the room.

calivianya, BSN, RN · Apr 25, 2014

That seems really sketchy. Who informed the staff about the morphine, by the way? That part seemed funny, too.

Fyre522 · Apr 25, 2014

After the Pt. was declared, her daughter mentioned something that was overheard by one of the RPNs that had come on shift a few hours earlier about that she appreciated the staff giving her mother the morphine to help ensure that her final moments weren't spent being restless or in pain. The RN had not administered any morphine (or other narcotic/opiate medications) during her shift and when she looked into the Pt's file, she noted that she had been Rx'd the morphine but never received it.

Strangely enough, when the family received the bill for services, it listed a full bottle of aspirin as a medication therapy that they were responsible for payment on. The family of course contested, being that I'm sure any one of us would pay good money to see someone who was comatose, had a feeding tube and a trach vent in swallow an entire 100-count bottle of aspirin. That error was rectified as far as I know, but the whole case seems really sketchy to me. (This hospital, btw, has a record for not so good "quality" care.)

Esme12, ASN, BSN, RN · Apr 28, 2014

Are you a nurse? were you caring for this patient? Clearly your are not the Rn who was in charge of this patient. Are you a student?

Yes a pacemaker can continue to "function" with electrical activity and the patient have no pulse. If this patient was in ICU they would have been on a monitor so the determination of death was not on pupil response alone. Whether morphine was ordered and not administered depends on the order. If it was ordered as needed...and she didn't need it...she would NOT receive it.

Pupils are used on the determination of death along with other medical evidence. If this patient was hospitalized for 4 months it is entiryly possible she was being given aspirin a day for other purposes. Yes patients are billed for their care even if the die.Nurses at the bedside have no idea what is being billed so I would assume you are a family member or a family friend.

It is IMPOSSIBLE to make judgements about a patients care without knowledge of the patients case and access to medical records.

mcubed45 · Apr 30, 2014

Brain death criteria and protocols vary from state to state. Maybe they already did the brain death testing and the official pronouncing was held off until the family was there.

This sounds like someone trying to build a legal case.

Fyre522 · May 1, 2014

Esme12 and Mcubed45, I apologize for lumping my response to you both into one reply, but I think this will sort of answer both of the questions that you have asked.

Esme, I'm fairly certain that someone on a trach vent would probably not be taking any oral meds, regardless of how long they have been in an ICU/CCU/Specialty setting. And an entire bottle (100 count) of 500mg Aspirin in the last 19 days of life to a pt. who also has been on long term Warfarin therapy to lower their PT/INR as well? (I understand that I didn't include that tidbit of information in my original writing, and apologize.) That could be detrimental, medically speaking.

I also understand that patients will be billed for services regardless of whether or not they have passed away. Bluntly speaking, living or dead, those meds/labs/tests cost money regardless. But charging someone for something that wasn't administered isn't exactly kosher.

No, I am not a Nurse. I'm fairly versed in various aspects of medical care. However, when it comes to topics and procedures in conjunction with final palliative care or hospice/end of life situations and protocol, I admit I know very little on those two things.

I have the ability to access the Pt's medical file/history, which is how I knew about the Aspirin ordeal. She had not been given anything oral - medication or otherwise - for close to 3 weeks prior to death, and was in a comatose state for her final 16 hours. Had she already passed and the Physician was simply waiting for the family to arrive before calling TOD, that would mean that there would have been approximately 12 hours that she was deceased in the hospital before anyone called it. That, in my opinion, isn't very likely because based on ethic/morals alone, letting family members sit bedside with a deceased Pt and leading them to believe that she was still alive in the duration of that time is just mean - and wrong, no matter how you slice it.

Mcubed45 - I am most definitely NOT trying to build a legal case. These questions I have asked has nothing to do with any legal proceedings or for any sort of financial gain. I do not believe in profiting from tragedies or pain at the expense of other people. This Pt. died on January 21, 2003. That is far too long ago to do anything about, even if I wanted to. No, these inquiries are for my own peace of mind and to help me understand exactly what should have happened compared to what actually did happen. Not to mention that any legal ramifications that could have possibly been compiled or imposed against those who were taking care of her medical necessities are pointless because no matter what any court or medical board would decide, it still wouldn't bring her back to life.

Oh, and of the two family members that were at her bedside - the Daughter and Great-Granddaughter of the Pt - I am the Great-Granddaughter.

mcubed45 · May 1, 2014

Thank you for clarifying. Lay people often have a very hard time understanding the concept of "brain death". It's harder to understand b/c it's not like cardiac death where there is no longer a beating heart.

Brain death is part of a continuum of brain damage. People can have severe brain damage but not be "brain dead". Actual brain death is when the most basic function of the brain stem are no longer active. It can be a gradual process in the case of someone with a head bleed or similar injury. It's not like cardiac death where it's pretty obvious when the patient is dead. Brain death is determined clinically, by checking certain reflexes and functions.

Medical staff may have a pretty good idea that a patient is already brain dead, but the actual declaration of death may be delayed for a variety of reasons. In my state once brain death is declared, the hospital has 4 hours to move the body to the morgue (as with cardiac death). Therefore if family is waiting for others to say goodbye we will not initiate brain death testing until they are ready. My state also requires 2 physicians and the testing to be done twice, a certain number of hours apart. Therefore there are some logistics involved and we would not have a doctor come in in the middle of the night to do brain death testing and pronounce. Instead the testing may be performed during the day at a time that works for the staff/family. Brain death testing on a patient that has been slowly progressing towards brain death is hardly an urgent matter.

As far as your med question, trach/vented patients typically have either an NG/OG or PEG tube for administration of oral medications and tube feedings.

I'm very sorry for your loss, but is there a reason you're digging through the medical files of a loved one that passed away over a decade ago? That's a very long time to still be holding on.. Have you sought counseling or therapy?

mcubed45 · May 1, 2014

As far as the ethics of keeping a brain dead patient on the floor, it's not quite the same as cardiac death. With cardiac death the body in its entirety is dying. Every organ and cell in the body is breaking down and decomposing d/t lack of oxygen. Things start to smell and turn ugly pretty quickly. We don't keep those on the floor for very long.

With brain death, the body is still functioning (though the brain is not). The heart is beating and we use machines to breathe for the patient. They can be sustained in this manner for a fair amount of time until the dead brain tissue starts affecting the rest of the body.

Case in point - Jahi McMath. That horrible case was all over the news a couple months ago. The girl was brain dead but the family refused to accept this and instead used legal interventions to force the hospital to keep the body alive. This was an absolute failure of the legal system and only helped to further cloud the general public's understanding of brain death.

Fyre522 · May 4, 2014

Mcubed45,

Thank you for your response and explanation. I know there's a difference between clinical (aka cardiac/respiratory death) and brain death. Clinical, you have the possibility of being revived. With brain death though, when you're dead, you're dead. There's no coming back from that.

That being said, how can the body still function (for lack of a better term) without activity in the brain? I know the SA node helps control the electrical pulses in the heart, and when that fails the responsibility rolls over to the atrioventricular node. When that fails, there's the option of an implanted pacemaker. This can keep the heart beating for awhile after brain death, from what I gather.

But - I thought that the brain controls the basic function of all other organs in the body. That's why when you begin to die or are experiencing a severe massive illness/disease, the other organs begin to shut down first so that the body can try to conserve its energy (fuel, so to speak) for the brain in an effort to at least attempt to make it through whatever medical dilemma your body is experiencing at that point in time. But if the brain is no longer functioning, then wouldn't that contradict the body's built-in self-preservation response, rendering all other organs inconsequential and thus causing full arrest of all other organs as well? Or am I "off" on my understanding there?

It's not that I am "digging through medical files" of a loved one that passed away 11 years ago - interestingly enough, the night I posted the original thread, I had been watching some documentary program on TV (I don't remember the name of it...) and during that show, the protocol of declaring death in a patient was discussed. Hearing what the general criteria was, it made me think back to when my Great-Grandmother passed and wondering if the Doctor who pronounced her was foregoing the additional steps on the checklist because meeting one or two of the listed criteria was sufficient enough without continuing the tests to make sure someone is actually dead, or if he was just a moron. The facility that she was at has been known to screw things up majorly. I.e.. amputating the wrong limb, removing a gull bladder instead of an appendix, administering medications that a patient was allergic to, etc. Shoot, I went in for a surgery back in March 2012 where I was supposed to stay for 24 hours after the surgery for observation, and ended up finally being able to go home 87 days later after an additional 2 surgeries because they screwed up the first one. Like I said, not exactly the brightest bunch over there.

And it's not that I'm trying to hold on, as you put it. It's not like any additional information or clarification that I receive is going to change what happened. Pretty sure she's not going to pop up out of the ground saying she needs a shower and a cheeseburger. :-) It's just that after seeing that documentary the other day, it made me wonder and I figured a message board such as this one might be able to shed some light on the whole situation for me. This was just for my clarification and peace of mind. My Great-Grandmother and Grandmother (her daughter, who subsequently passed in November 2004) meant the WORLD to me. They were the ones who raised me. And they are on my mind quite often - especially since my GGM passed away on 21 Jan 2003, and my daughter was born 21 Jan 2004. That makes it kind of a bittersweet day for me. Happy it's my daughter's birthday, but saddened because it's the anniversary of the death of a woman who I would have taken a bullet or jumped in front of a train for.

My apologies for this long-winded response - just wanted to clarify some of the method behind the madness, and follow-up on your explanation of what happens with brain death.

mcubed45 · May 7, 2014

Thanks for clarifying. It makes it much easier to answer these kinds of questions when we know the situation and where you're coming from.

As far as what happens to the body after brain death, with modern medicine we can keep things going for quite awhile. We breath for the patient. We give medications to maintain homeostasis. We keep the heart beating and maintain organ perfusion. It is ultimately a losing battle but it can be a veryyyy long time until the body progresses to cardiac death if we choose to use all our tools. Of course it's extremely unethical to keep a brain dead body alive for that long for purposes other than organ donation or giving family time to say goodbye.

That Jahi McMath case is a perfect example of what modern medicine is capable of when we choose to misuse it. Her body could quite possibly still be slowly rotting to death at that unnamed facility right now. She's been brain dead for nearly 6 months.