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

Kyriaka · May 22, 2004

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.

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It is true that you have to meet certain criteria. However, they (the hospital and some of the staff) had already made up thier minds that I would eventually meet those. That was a HUGE assumption.

stevierae · May 22, 2004

I'm about to begin a Masters research project about ICU nurses talking to brain-dead patients (oh the joys of ethics approval committees!).

Brain dead is DEAD. Period.

I am confused as to why a brain dead patient would even be in an ICU, unless it was just long enough to allow their family to come to grips with their status, make a decision about organ donation, and let go. Yes, those families might find it comforting to "talk to" that loved one, and say their final good-byes, but--why would health care professionals do so? Pray for their souls; yes, please do, but dead people do not hear!

There is a huge difference between talking to a patient in coma or chronic vegetative state than talking to one that is brain-dead. Those people have a chance to "come back," and no one knows what or even if they hear-- but we hope they do, and hope that talking to them will stimulate them and help them "come back" if there is the slimmest chance to do so.

To be brain dead, an EEG has confirmed that there is no longer any electrical activity in the brain. As others have stated, the EEG can be waived--there is other diagnostic criteria, especially in the case of anoxic brain injuries. I know that sometimes just disconnecting from a ventilator for a specified time, to see if any spontaneous breathing will occur in that time, is used. In those cases, an EEG would not tell anyone anything that they do not already know.

However, often organ transplant programs require the EEG to definitively confirm brain death, probably for legal reasons. Also, that EEG report makes it a bit easier for the families to accept that, yes, this loved one REALLY IS DEAD--there will be no coming back. It's at that point that they allow themselves to let go.

The brain controls the autonomic nervous system. If a brain dead person is disconnected from a ventilator, the heart will also stop. All that was keeping that person "alive", or more accurately, his organs perfused, was that ventilator.

leslie :-D · May 22, 2004

Brain dead is DEAD. Period.
I am confused as to why a brain dead patient would even be in an ICU, unless it was just long enough to allow their family to come to grips with their status, make a decision about organ donation, and let go. Yes, those families might find it comforting to "talk to" that loved one, and say their final good-byes, but--why would health care professionals do so? Pray for their souls; yes, please do, but dead people do not hear!
There is a huge difference between talking to a patient in coma or chronic vegetative state than talking to one that is brain-dead. Those people have a chance to "come back," and no one knows what or even if they hear-- but we hope they do, and hope that talking to them will stimulate them and help them "come back" if there is the slimmest chance to do so.
To be brain dead, an EEG has confirmed that there is no longer any electrical activity in the brain. As others have stated, the EEG can be waived--there is other diagnostic criteria, especially in the case of anoxic brain injuries. I know that sometimes just disconnecting from a ventilator for a specified time, to see if any spontaneous breathing will occur in that time, is used. In those cases, an EEG would not tell anyone anything that they do not already know.
However, often organ transplant programs require the EEG to definitively confirm brain death, probably for legal reasons. Also, that EEG report makes it a bit easier for the families to accept that, yes, this loved one REALLY IS DEAD--there will be no coming back. It's at that point that they allow themselves to let go.
The brain controls the autonomic nervous system. If a brain dead person is disconnected from a ventilator, the heart will also stop. All that was keeping that person "alive", or more accurately, his organs perfused, was that ventilator.

there are some of those who continue to talk with the dead; it's a matter of their faith and belief. some believe in absolute nothingness whereas others don't. there's absolutely nothing wrong with talking w/the brain dead.

stevierae · May 22, 2004

there are some of those who continue to talk with the dead; it's a matter of their faith and belief. some believe in absolute nothingness whereas others don't. there's absolutely nothing wrong with talking w/the brain dead.

I did not mean to insinuate that it was WRONG. I only meant that it was ineffective--they are dead, and cannot hear. I have certainly stood and prayed, either silently or out loud, when I had brain dead patients in surgery, while preparing for organ donation.

talaxandra · May 22, 2004

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). 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??

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.

There's a disturbing article I read by an anaesthetist (Gail van Norman, for those wanting to follow this up :)), who described cases where patients did not meet brain death criteria (in all cases had not been appropriately assessed, and in one case was spontaneously breathing) but were in theatre for organ collection - in those cases, an anaesthetist intervened, but I imagine this is not always the case.

My understanding is that the criteria are more consistently applied (ie two assessors, well-separated assessments) in Australia than in the US. However it may just be that Australia under-reports. In any case, while it is perfectly possible that the organ donor liaison staff were a little zealous (or trying to introduce the concept early), I think that Kyriaka is right to be at least cautious, if not downright sceptical about the execution, if not the practice, of diagnosing brain death. Hmm. On re-read, 'execution' was a poor word choice!

For those of you who believe that brain death is equivalent to somatic death (ie that you are just as dead as if your heart had stopped beating for, say, five minutes without intervention), is it your understanding that somatic death will follow? If so, in what kind of time frame?

Tweety, BSN, RN · May 22, 2004

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.

EEGs are required here prior to donating a persons organs to assure they are truly dead.

However removing life support is a totally different matter. If a patient is in a terminal condition removing life support is an act of courage in my opinion. Here's where living wills come in handy.

At the point life support is removed if they continue to breath, we move them to a private room on a medical unit, so the family can be with them. I always talk to these patients, up until the end.

stevierae · May 23, 2004

EEGs are required here prior to donating a persons organs to assure they are truly dead.
However removing life support is a totally different matter. If a patient is in a terminal condition removing life support is an act of courage in my opinion. Here's where living wills come in handy.
At the point life support is removed if they continue to breath, we move them to a private room on a medical unit, so the family can be with them. I always talk to these patients, up until the end.

And doing so makes sense. Those people are not yet dead. They are dying, and they deserve any comfort measures possible--tactile stimulation, being talked to, light, music etc. right until the very moment they are actually gone. The family deserves to take as much time as they want to to stay with them, talk to them, etc. even after death has been officially pronounced.

Of course, this is true with brain dead patients, as well. Once disconnected from the ventilator, the family should be allowed as much time as they need to stay with them and talk to them, assuming organ donation is not pending, as time is critical; their heart will soon stop. Normally, they have been well-prepared for this event, and have said their goodbyes already. Still, families often walk to the OR with their brain dead--DEAD--loved one, whose organs are now being perfused with oxygen delivered via ambu bag. The difference is, the brain dead patient will not hear those final thoughts and prayers, or be cognizant of comfort measures, while the dying patient, we assume and hope, will.

Kyriaka · May 23, 2004

My understanding is that the criteria are more consistently applied (ie two assessors, well-separated assessments) in Australia than in the US. However it may just be that Australia under-reports.

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this could be the case. Since we have individual state laws than can possibly differ.

After my experiance (they wanted my organs. period. ) those relatives that would have thought about donating changed their minds under the impression that I would now be dead if I had been an organ doner and perhaps one day they might be in the same situation.

Kyriaka · May 23, 2004

I think what is very obvious is that with today's medicine things are not as clear cut as they used to be.

And miracles do happen.

Life & death can be a very blurry line.

purplemania, BSN, RN · May 23, 2004

I have not worked in ICU, but I have done palliative care for terminally ill patients. Talking to them helps me remember there is a person in the bed, not just a series of tasks to perform. Whether or not they awaken does not matter. I would like to think they knew I cared for them as an individual.

StephanieMc · May 23, 2004

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.

14 years ago, after a liver transplant that went terribly wrong, my 15 y/o son was diagnosed brain dead. After making the decision of taking him off of the vent, we moved him into a private room whre we could stay with him until the end and it was much quieter. His HR would be well over 120 in the ICU but when moved to a private room, I would lay on the bed with him, stroke his hair and talk very softly to him. His HR would drop to 76-80. Then if someone would come into the room with a loud mouth (such as some nurses) or make a loud noise in the hall his HR would jump back up to 110-120. So yes, after this experience I ALWAYS talk to my brain dead or comatose patients. You will never convince me they do not hear you.

Energizer Bunny · May 23, 2004

Oh man, Stephanie...I am so sorry for your loss. I am one of those that thinks that whether brain dead or not, there is a part of them still there that can hear and feel what is going on somehow.