Refusal of Brain Death exam??

Justhere, BSN, RN · Dec 19, 2008

Sounds like this poor family just don't want to hear the truth that their loved one is gone. So many people see the heart still beating and still believe that they are alive, even when told that their is no brain activity.

Prays go out to this family, and maybe soon they will come to the realization that it is time to let their loved one go.

nrsang97, BSN, RN · Dec 19, 2008

Sounds like this poor family just don't want to hear the truth that their loved one is gone. So many people see the heart still beating and still believe that they are alive, even when told that their is no brain activity.
Prays go out to this family, and maybe soon they will come to the realization that it is time to let their loved one go.

Exactly. They don't believe they are dead because they still see a heart rhythm on the monitor, and they are still breathing (even though it is only with the help of the vent). I have had many famlies that we are trying to get them to withdraw care and believe the pt will get better. I have seen famlies go as far as shaking their loved one and screaming at them to wake up when they have a GCS of 3. I work neuro ICU so I completely understand where you are coming from.

RN1982 · Dec 19, 2008

Some people don't want to let go. I had a patient shot in the head and when we did the apnea test, some of the family members flipped out and thought we were withdrawing care. We explained what the test was for. We waited 10 minutes, patient's BP dropped, not a single respiration. The patient was brain dead. He became a Gift of Life patient that night. But I guess some of the family members still didn't accept their relative's fate because his sister called the next day to ask how he was doing and if he was improving.

ILoveRatties · Dec 19, 2008

This is not a matter of 'not letting go--poor family'. Sorry, but dead is dead. You don't have to ask a family if their loved one is dead. Brain death = dead. Period. Why have to check twice? And you don't have to get a family permit for brain death criteria.

Why would this be allowed to go on? Is it a tiny hospital in the boondocks, or something?

A family doesn't have to agree with you about this. You tell them: 'so-and-so is dead. I am very sorry.' You tell them to say their goodbyes. You turn off the monitors and vent. You do not need permission for this.

It is not a Terry Shiavo situation. The patient is dead.

It's best to be a broken record: "He is dead." Never differentiate between brain death and death. They are the same thing.

I have found that when the medical professionals don't have this straight in their own heads/minds/heart, it can be very confusing for families who are looking for the last little bit of hope.

nrsang97, BSN, RN · Dec 19, 2008

I had pt that was already Gift of Life and the family was getting ready to leave and one of the family friends looked at me and asked what her chances were of her getting better. I told her that her brain was not functioning any more and she wouldn't get any better. She said she understood the medical stuff and wanted to know if I thought she would get better. I told her "No, She will not get better." I also asked her if she was aware of the family decision and she said she was. I just don't understand some people.

We didn't do a apnea test we did a brain death protocol on that patient. We did the exam where we squirt ice water in the ears and she went for a nuc med scan.

I think the apnea test is for DCD (donation after cardiac death ) right?

RN1982 · Dec 19, 2008

I'm not sure. I know that the patients usually go to nuc med to see if they still have perfusion to the brain. My patient was brain dead though, he had brain matter oozing from his wound. His heart was ok at the moment.

ILoveRatties · Dec 19, 2008

A patient can have brain matter oozing from a wound and NOT be brain dead.

There are specific criteria used to determine brain death. Response to ice calorics, apnea test, brain blood flow scan, EEG. Definitive is no brain blood flow.

You do not have to get permission for any part of the brain death determination.

This is not an ethics issue. Now, if the patient is found to be NOT brain dead, then there is the issue of what to do, withdrawal of treatment, etc., etc. which is more suited for ethics input.

The situation you describe is extremely unfair to the family.

RN1982 · Dec 19, 2008

A patient can have brain matter oozing from a wound and NOT be brain dead.

Ya don't say.

Aneroo, LPN · Dec 19, 2008

A patient can have brain matter oozing from a wound and NOT be brain dead.
There are specific criteria used to determine brain death. Response to ice calorics, apnea test, brain blood flow scan, EEG. Definitive is no brain blood flow.
You do not have to get permission for any part of the brain death determination.
This is not an ethics issue. Now, if the patient is found to be NOT brain dead, then there is the issue of what to do, withdrawal of treatment, etc., etc. which is more suited for ethics input.
The situation you describe is extremely unfair to the family.

If they're not brain dead but have matter coming out, they're screwed regardless.

The OP's SN is PICNICRN- PICU and NICU RN? If so, then there are the parents making those decisions. While I'm thankful I'm not in that situation, if my daughter were the one brain dead and some medical professional came up to me and said "Sorry, she's dead, we're pulling the plug", without doing everything they could to verify this, I'd need to be escorted out by the hospital police. When it's your own child, logic goes out the window. There are too many stories people can google now where someone was declared brain dead but then woke up, and I am sure some families fear this and understand our medical science is not 100% accurate 100% of the time.

ILoveRatties · Dec 19, 2008

You are thinking of persistent vegetative state. That is not brain death.

People do not 'wake up' from brain death.

You do not 'diagnose' brain death. You verify it. The criteria are strict. It is not gray--it is black and white.

Of course, nobody would go to a parent and say, 'I, ummm, think your kid is brain dead, We are going to pull the plug.' You do the criteria. If the child is brain dead, you tell the parents that the child is dead. And of course, this would have included a blood flow study. My point is that you don't need permission from a family member to do the blood flow study if the other tests indicate brain death.

If the child is dead with a beating heart and on a vent, you ask about organ donation if it is an appropriate option. If the family does not want to donate, then you tell the family that you will be turning off the ventilator and the monitors, and proceed to provide end of life care to the patient and to the family.

I speak as a person who had a nephew suffer brain death after a MVC, went throught the whole thing. I have been a transplant coordinator and have worked with families and donors for years. I have been a CC nurse for a very long time.

A lot of these posts show that there is a lack of knowledge in this area of brain death = death. If a patient came into the ER DOA, you wouldn't even think about going out after failed resuscitation and giving the family false hope, saying that he's sort of dead but maybe the heart will start to beat again, we just have to give it more time. The family may want that. That doesn't mean you do it.

You may protest, saying, well death is clearcut, brain death isn't. That's just plain false. Deal with brain death the way you do with cardiac death.

Medic09, BSN, RN, EMT-P · Dec 19, 2008

Hey, you all, there are indeed cultures or subcultures where brain death is not sufficient determination for them. Cessation of heartbeat and/or respirations is required. This can have profound consequences. This was touched on just a bit in this thread: https://allnurses.com/forums/f8/question-about-judaism-organ-donation-post-mortem-103500.html#post3237637.

It isn't just a question of 'is the patient dead'? It is a question of what is the spiritual, moral, religious import of what we do or do not do with that patient. There was a recent case in Manitoba where doctors wanted to remove a Jewish man from life support. The family objected not on emotional grounds, but on the grounds that by well-established Jewish criteria, the patient wasn't dead and removing what sustained him could constitute murder according to Jewish law.

The discussion of Brain Stem Death among authorities of traditional Jewish Law is an undecided one. BSD is relatively new, historically, compared to the millenia long discussion and requirements about the dignity of the living and the dead in Judaism. Some rabbinic authorities accept the notion of BSD, some do not. So a lot depends on where the patient is from, and what guidance they receive from an authority in Jewish law. Not so hard to grasp, but the implications are great, indeed.

In Israel, where about 25% of the population are traditional Jews (as compared to those whose religious beliefs or practices vary from that), and more subrscribe to traditional notions about things like death and dying, the law takes this into account. That's why there is a Dying Patient Law that addresses these issues (reviewed in the October, 2008 issue of Jewish Medical Ethics: A Journal of Jewish Medical Ethics and Halacha).

I use that just as an example, because it is what I am familiar with. There certainly may be other cultures/religions out there that have articulate notions about death and dying that include determination of death criteria.

Just and FYI.