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

[talaxandra]

I'm about to begin a Masters research project about ICU nurses talking to brain-dead patients (oh the joys of ethics approval committees!). My interest in this started when I read 'Rethinking life and death' by ethicist Peter Singer - he described observing nurses in ICU talking to brain dead patients as though they were alive, and from that decided they did it because they didn't understand that the patients were clinically dead.

I think that nurses who talk to their brain dead patients do it for a variety of reasons, which may included (but are not limited) to issues about reconciling the apparently living body (sensory knowledge) with knowledge about brain death (intellectual knowledge). I don't work in ICU, though I do work on a nero unit; I always talk to the unconscious, and sometimes talk to patients who have died.

I was at a conference in the UK last year, and an ICU nurse educator said that she not only never talks to brain dead patients, she corrects any students who do. However, one of the anaesthetists there always speaks to his brian dead patients. They're ruining my research!

What do you all think? 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.

[gwenith, BSN, RN]

No mate it is not it is just that there is a difference that here we do not do EEGs because we are uninterested in finding out if there is any residual cortical activity whereas, from what I gather some areas of the US an EEG is required to ensure that there is no brain activity in any part of the brain.

[Tweety, BSN, RN]

I've never taken care of a brain-dead patient. Those patients are donor cases and I don't get to care for them.

However, I always talk to unresponsive or comatose patients. I let them know who I am and what I'm doing.

[leslie :-D]

No mate it is not it is just that there is a difference that here we do not do EEGs because we are uninterested in finding out if there is any residual cortical activity whereas, from what I gather some areas of the US an EEG is required to ensure that there is no brain activity in any part of the brain.

yes that is an absolute esp. before removing from life-sustaining equipment.

[Gompers, BSN, RN]

Yes, I always talk to them. In the NICU, these are usually babies who had some kind of injury during the birthing process and are asphyxiated. Others are preemies with horrific head bleeds that eventually cause the destruction of most of their brain tissue. True, these kiddos don't always have a completely flatline EEG, but oftentimes are pretty darn close. Even though they don't understand language, being newborns, I always talk to them. More than that, when these types of babies are taken off life support and hang on for a few hours or days, we try to ensure that they are held as much as possible. When their families aren't there, we always find someone to rock the babies and talk to them, sometimes play lullabye tapes in the background. We dress them in baby sleepers and wrap them up with warm blankets, and just try to give them the best environment possible. Babies or adults, I think each just needs to be treated with respect and dignity and recognized as a human being, even if they aren't aware of their surroundings.

[Kyriaka]

I dont know about "brain dead" but if someone is in a coma state..please talk to them.

I have been in a coma and I heard people around me. Now I cannot tell you who they were but yes I knew people were talking to me. I still on occasion ask "did so and so come to visit me when I was in the hospital" because their voice sounds familiar.

I dont know if my experiance is unusual. But I dont think it is.

Perhaps those people who have a negative attitute to talking to an unresponsive person have an easier time believing the person is an object. They arent.

[talaxandra]

Thank you all for your comments, especially so many in such a short period of time! When I rotated through ICU as a student, the concept of brain death seemed relatively straightforward; now that I've done more research, it's much less clear - isn't that so often the way! What is clear is that there's a lot of confusion around the subject - as Gwenith pointed out, definitions and diagnostic tools vary from country to country, and the concept doesn't even exist in Japan.

Your comments so far mirror the spectrum of opinions that I've heard in my preliminary research - some people don't do it all; some people (including me) talk to all patients, including the dead, for spiritual and/or respectful reasons; some aren't convinced that brain death is equivalent to somatic death.

Death work might sound goulish, but it's really interesting :)

[leslie :-D]

it depends on the condition we're talking about. being in a coma is not synonymous with a persistent vegetative state, albeit both have brain function.

[NeuroICURN]

yes that is an absolute esp. before removing from life-sustaining equipment.

Actually Earle, an EEG is NOT a must before removing support. Perhaps in your facility it is, but not in mine.

As Gwenith stated, we're not interested in cortical function. And actually...what's needed to prove brain death is any three of the possible brain death criteria tests. For example, cold calorics, apnea testing, dolls eyes, absence of protective reflexes, blood flow studies, etc.

[gwenith, BSN, RN]

WE actually have a legal minefield when it comes to brain death because the only piece of legislation that even mentions it is the transplantation and anatomy act. I have seen life support withdrawn when the patients CPP entered near negative figures and stayed there - it was obvious he was no longer perfusing the brain. Severe incompatable with life head injury unresponsive and ICP >40 - we were not winning that day. I imagine that the criteria will probably vary from state to state across America as it does here.

But apart from the occasional instance quoted above we use the "british criteria" to test for brain death.

[Kyriaka]

It is a very confusing issue.

At what point is there no return. At which point is there no hope?? Sometimes this is very unclear.

My parents were asked if they wanted to donate my organs when I died (which they assumed would happen--the funeral was put on hold for me).

My parents attitude was "you dont know our daughter. She has a strong will and we will give her more time".

Well, here I am. Despite all. I did have a NDE in which I was given a choice to return.

What has scared me is that I wonder if I had had an organ donation card would I be alive today. Would they have tried everything or would I have been "worth" more dead??

There were some hospital personel who were deceptive with the organ donation issue telling my parents that my husband had agreed to organ donation (on another family member--he had not).

[Energizer Bunny]

I'm just a student, but I most certainly can see myself talking to a brain dead patient (or a corpse for that matter) because I talk to everyone all the time and can't stand silence. I also think I would feel the need to show some sort of repect to them by talking to them.

[gwenith, BSN, RN]

It is a very confusing issue.

At what point is there no return. At which point is there no hope?? Sometimes this is very unclear.

My parents were asked if they wanted to donate my organs when I died (which they assumed would happen--the funeral was put on hold for me).

My parents attitude was "you dont know our daughter. She has a strong will and we will give her more time".

Well, here I am. Despite all. I did have a NDE in which I was given a choice to return.

What has scared me is that I wonder if I had had an organ donation card would I be alive today. Would they have tried everything or would I have been "worth" more dead??

There were some hospital personel who were deceptive with the organ donation issue telling my parents that my husband had agreed to organ donation (on another family member--he had not).[/QUOTe]

To be an organ donor the patient has to neet certain specific criteria and bleieve me there is no coming back it the patient meets these. Usually the patient also shows other signs such as loss of temperature control, alteration in vital signs and a steady pulse rate that is unvarying etc.