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

psychomachia · May 20, 2004

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.

Brain dead patients??

Aren't they all...

When I do talk to them, I make sure to tell them they are my favorite patients.

MandyInMS · May 20, 2004

I always talk to unresponsive pts..because even with the technology we have today, the mind/brain still has much that is NOT understood..so I always explain what I am going to do with/to them..treat them as if they CAN hear/understand me..how many times have you heard of a pt who was in a coma/brain dead that has eventually 'come back' and recalled many things..not often..but on rare occasions..I'd like that pt to remember staff/family talking to them and treating them respectfully..that's just me :)

caroladybelle, BSN, RN · May 20, 2004

Yes.

But then I have been known to talk to patients while doing post mortem care.

leslie :-D · May 21, 2004

Yes.
But then I have been known to talk to patients while doing post mortem care.

dig that carol....always. the soul never sleeps.

leslie

UK2USA · May 21, 2004

I always fins myself talking to brain dead patients, but a colleague of mine brought up an interesting theory a few weeks ago.

As we all know the term 'brain dead' differs in definition depending on where you practice... my colleague suggested that those nurses that talk to their BD patients perhaps do not understand or believe the finality of the situation they are in :uhoh3: .

elkpark · May 21, 2004

I have done so when in that situation (which hasn't been all that often), just as a gesture of respect to the person (and family, if present), and because I just don't KNOW what may or may not be going on inside the person. The research I have read indicates that hearing is the last sense to "go" when one is dying, and, although I haven't read anything about how that applies in the case of brain death, it seems like a useful thing to keep in mind.

To me, it seems like a question of practicing the principle of nonmaleficence -- if I talk to the person and s/he can't hear me, no harm is done -- but if I go in the room and treat the person like a slab of meat and s/he does still have some primitive, basic level of awareness, then I have done harm ... I try to treat patients with the same care and respect that I would want someone to show me.

It isn't that I don't understand the principle of "clinically dead" -- it's that I do understand that we don't always have all the answers, and don't always know as much as we like to think we do ... :)

NeuroICURN · May 21, 2004

..how many times have you heard of a pt who was in a coma/brain dead that has eventually 'come back' and recalled many things..not often..but on rare occasions..

Ok Mandy....first of all the reason I quoted you was this. If someone is brain dead, then they are dead. Completely dead. Bought the farm. It is no different than if they are asystolic. At the point of brain death, organs may be harvested. Just because the heart has not stopped does not mean they are still alive. So there is no "coming back" from that. However, yes, patients may come back from a comatose state. But honestly, I have yet to ever see one that remembers things from the comatose state.

Now back to the subject at hand. Yes, I do talk to my patients. I don't think I have to explain why I talk to the alive and comatose ones. I don't always talk to the brain dead ones. As for why I occasionally talk to the brain dead ones....well, I guess it's more of a habit. You know, as an ICU nurse, you just get used to talking about what you're doing as you do it. But I don't talk to them as if they were alive....because they're NOT!

As for the ICU educator who always corrects students for doing that...well that's wrong. She should educate them that brain death IS death, but if they want to talk to the patient, then that is their right...no matter what their motive may be.

Also....no, the (true) definition of brain death does not vary from place to place....the term is just misused at times!

I've probably already done more brain death criteria testing in my short career in nursing, than other nurses have in 30 years!!! So if anyone has any questions, please feel free to ask.

Koalablue · May 21, 2004

I'm only a student nurse now, but I was a nurse previously in my life (too many years ago to remember )....I only dealt with one brain dead patient in the past, and I continued to talk to them. Not because I'm too daft to understand they're dead, or because I think they might `come back' but because I'm not sure that they're not still there in the room somehow.

I don't know if I believe in an after-life or not...but if there *is* one then I want that patient to continue to know their body and soul is cared for, and about. It harms no-one, and I think it helps *me* to keep treating them that way. My way of `letting go' if you like...

Unconscious/comatose patients I will always talk to. One of our nursing educators spent 5 days in a coma and she says she can remember conversations and procedures that were done to her. She doesn't remember clearly, and certainly not everything, but it makes you think....I guess I have to believe her, I've no reason not to! So I will talk, and talk, and talk.......just because I can, and because it might make a difference somewhere, somehow.....

leslie :-D · May 21, 2004

I always fins myself talking to brain dead patients, but a colleague of mine brought up an interesting theory a few weeks ago.
As we all know the term 'brain dead' differs in definition depending on where you practice... my colleague suggested that those nurses that talk to their BD patients perhaps do not understand or believe the finality of the situation they are in .

uk2 - brain dead is brain dead. even when you're in a pvs, the brain stem is still functioning. but there are are spiritualists that continue to talk, whether dead or alive.

leslie

gwenith, BSN, RN · May 21, 2004

As you will be aware and speaking in a broad clinical sense there are two aspects of consciousness wakefullness and awareness (sometimes called arousal and cognition). Broadly wakefullness is the property of the brainstem or rather hindbrain whereas awareness is the function of the forebrain or cerebrum. (Apologies for being simplistic here)

It is possible for people to "wake" and recount EVERYTHING that was said at the bedside if they have had a primary brainstem insult and it has happened. (Darned embarrassing when it does let me tell you - they will remember everything including who was dating who as an overheard conversation). Conversely and more frequently it is possible for people to be awake but unaware (how many times have you heard "Lights are on but no-body is home)

I hate to disabuse anyone of their opinions but there are more than one defintion of death and as The Intensive Care Manual by T.E.Oh states - there is no deistinction made between brain stem death and brain death. This is an Australian text Hickey (The Clinical Practice of Neurological and Neurosurgical Nursing) is American and it states that there must be absence of brain stem and coritcal activity whilst Lindsay Bone and Callander (Neurology and Neurosurgery Illustrated) is English and only outlines testing for brain stem function. Certainly in Australia and as far as I know England, we do NOT perform routine EEG's when testing for brain death. America, from the texts, this is standard practice. (I am unsure about Canada maybe someone will enlighten me LOL).

Even though we only test for brain stem function it is agreed that abscence of brain stem function is incompatable with life.

I know Hickey does have a section discussing the research that shows alteration in vital signs of comatose severely head injured patients when family and vistors have spoken to them but at the moment I can't remember where in that darn booK I saw this.

Yes hearing IS the last sense to be affected and so we nurse all neuro patients as if they can hear - as for talking to the brain dead patient - I have been there with many many brain dead patients and at that point I always consider that I am nursing the family more than the patient. My role shifts from care of patient to care of family because we have to get that family to accept social death before actual death. The normal events of life are actual death followed by social death as the family and society come to accept loss. My interactions therefor are guided by the relatives. If there is a difficulty with them accepting brain death I will encourage the family to say the last goodbyes but not address the patient directly myself. If however the family are more accepting I will join them in talking to and about the patient. I will talk to the patient when the family is not present as once again it shows respect and you never know - the spirit may be watching.

Why then do we not make a distiction between brain death and brain stem death???

leslie :-D · May 21, 2004

As you will be aware and speaking in a broad clinical sense there are two aspects of consciousness wakefullness and awareness (sometimes called arousal and cognition). Broadly wakefullness is the property of the brainstem or rather hindbrain whereas awareness is the function of the forebrain or cerebrum. (Apologies for being simplistic here)
It is possible for people to "wake" and recount EVERYTHING that was said at the bedside if they have had a primary brainstem insult and it has happened. (Darned embarrassing when it does let me tell you - they will remember everything including who was dating who as an overheard conversation). Conversely and more frequently it is possible for people to be awake but unaware (how many times have you heard "Lights are on but no-body is home)
I hate to disabuse anyone of their opinions but there are more than one defintion of death and as The Intensive Care Manual by T.E.Oh states - there is no deistinction made between brain stem death and brain death. This is an Australian text Hickey (The Clinical Practice of Neurological and Neurosurgical Nursing) is American and it states that there must be absence of brain stem and coritcal activity whilst Lindsay Bone and Callander (Neurology and Neurosurgery Illustrated) is English and only outlines testing for brain stem function. Certainly in Australia and as far as I know England, we do NOT perform routine EEG's when testing for brain death. America, from the texts, this is standard practice. (I am unsure about Canada maybe someone will enlighten me LOL).
Even though we only test for brain stem function it is agreed that abscence of brain stem function is incompatable with life.
I know Hickey does have a section discussing the research that shows alteration in vital signs of comatose severely head injured patients when family and vistors have spoken to them but at the moment I can't remember where in that darn booK I saw this.
Yes hearing IS the last sense to be affected and so we nurse all neuro patients as if they can hear - as for talking to the brain dead patient - I have been there with many many brain dead patients and at that point I always consider that I am nursing the family more than the patient. My role shifts from care of patient to care of family because we have to get that family to accept social death before actual death. The normal events of life are actual death followed by social death as the family and society come to accept loss. My interactions therefor are guided by the relatives. If there is a difficulty with them accepting brain death I will encourage the family to say the last goodbyes but not address the patient directly myself. If however the family are more accepting I will join them in talking to and about the patient. I will talk to the patient when the family is not present as once again it shows respect and you never know - the spirit may be watching.
Why then do we not make a distiction between brain death and brain stem death???

gwenith, i'm not sure i understand your question. if there is no activity in the brain stem, where are most primal functions originate, then yes, the entire brain would be incompatible with life.....is that disputed?

leslie