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.

[stevierae]

Oh, I guess I should have clarified: What I meant to say is, I can't understand why brain dead persons who are not going to be organ donors are still in the ICU. I know that kidney donors have to be maintained on all kinds of drips, etc. and that renal perfusion has to be esentially perfect before we proceed--I have had more than one scheduled donor nephrectomy cancel at the last second and rescheduled for later, to try to make perfusion as perfect as it can reasonably be expected to get, or while we waited for ciritical labs (Hepatitis screening, etc.) to come back.

I just wondered why, when someone has already been declared brain dead by whatever criteria is used in that facility to determine absence of cortical function, they could not be moved to a quiet, private room perhaps in med-surg, kept on the ventilator until the family has said their good-byes and taken as much time as they needed, and then disconnected when they are ready, and then allowed to stay as long as they needed to--however long it took the heart to stop beating--and even longer, should they choose to do so.

To those who insist that brain dead does not necessarily mean "dead-" If they were not dead, we would not be taking their organs for implantation into another human being. To do so would be murder.

I feel like people are confusing chronic vegetative state and coma with brain death. They are comparing apples and oranges. People in chronic vegetative state and coma are very much alive. Of course one should talk to them.

[NeuroICURN]

I feel like people are confusing chronic vegetative state and coma with brain death. They are comparing apples and oranges. People in chronic vegetative state and coma are very much alive. Of course one should talk to them.

LOL....I was just going to post the same thing!

As the previous poster said, her father was on the ventilators and they suggested that they remove medical support....HOWEVER, she did not say anything about her father being declared brain dead (which obviously he wasn't). THESE ARE TWO DIFFERENT THINGS PEOPLE! Just because one is in a coma does NOT mean that they are brain dead!!!

[tinnekke]

But honestly, I have yet to ever see one that remembers things from the comatose state.

I came back from a coma nine years ago. I was comatose for about a month, I guess. That's what I'm told. I can remember weirds bits of conversation that happened around me. It's very disjointed. And yes, I did check with the people I thought I heard, and I did hear aright. I can remember bits of my roommate (RL not hospital) apologizing for causing the accident that put me in the hospital. I can remember hearing my best friend's voice. At the time of the accident, he was 500 miles away at school. When I came to, he was not there. He came to see me while I was in the hospital. They said he spent four days in my room, and the only thing that took him away was having to go back for finals. I thought I was seriously out of it that I had heard his voice until my roommate said, yes he'd been there. I even remember hearing an announcer of some kind issue a tornado watch. That one I was sure was some weird dream, but that was real, too. The last place I could remember being was the middle of Kansas, but when I came out of it, I was at a hospital in New Orleans. Don't ask me how. The last I knew it was January. It was February, and there had been a tornado watch in New Orleans while I was in my coma, and my friends had been watching tv in my room and heard the announcement. All very strange for me, but yes, there are people who remember hearing stuff. Like I said, it's all very weird and disjointed, maybe not everyone mentions it because it'll sound nuts. I know it sounded nuts to me, but I asked. I didn't have alot of inhibitions for a long time after the injury, and I just said what was on my mind.

[zrjlatour]

I am a nursing student, and this is an ongoing controversy between some of my fellow classmates and our instructors. My group ALWAYS speaks to our comatose patients, no matter what their prognosis is for recovery. We just don't feel that anyone can know without a doubt that they cannot process what you are saying on some level.

[PQRST]

As an icu RN I have had the honor of working with brain dead pt's and their families. I am not talking about brain injured pt' whom have little chance for a meaningfull recovery. There is a huge clinical differance in how we care for these pts and any one who has worked closely with organ donation can attest to this. The brain dead pt is truly dead. The body will follow and is trying very hard to follow the body. This is a very busy pt and a challenging pt to care for. I have personally never been involved in a case where there was even a question as to fitting criteria. In my experience either the pt is declared or is not, and the ball does not start rolling untill after criteria is met. (although we do make organ donation aware of the pt) Everyone is very careful and cautious, and empathetic. I believe this so strongly from my experiences that i am a registered organ doner with my state organ donation program. I have had the experience of families believing we are talking about brain death and in fact we were not. In any case, Yes I do talk to my brain dead pts. I do believe they are dead and there is no missconception about it. I talk to them when we are alone in the room and not in front of the family. I do this because on a spiritual level I have personal beliefs the spirit is not able to move on untill the body follows. I don't believe I talk to the pt so much as the spirit. I will thank them for the gift of life they are about to give, I will pray for them to be in peace and even ask them to hang on untill we go to the or. Some times other nurses, assistants, RT will talk in the room about the pt. I do ask them not to. Some think I am crazy some laugh and even more feel the same way i do. I find it very rewarding and beauitful that while one life which we cannot save will save another. The last pt I cared for was a young man in his 20's who was hit by a bus. We could not save him but through donation he saved the lives of many including two people who shared his liver, his heart and both kidneys. I hope this helps some of you understand why those of us who choose to do this do.

[gwenith, BSN, RN]

Perhaps the organ procurement agency was a little overzealous in your case, I can't say because I wasn't there. But usually they don't talk to the family unless the docs, RNs, etc. feel there isn't any hope of meaningful recovery. Maybe there was a small miracle in your case.

_____________

Part of the problem here was having no concept of cultural differences. You would never ever approach an Orthodox family about this. The organ people pretty much were asking my family was it ok to mutilate my children (and me). And make money at the same time!

Are they given no training in cultural differances? Religious beliefs??

Absolutely we do have training in these things and there is follow up every step of the way but here donation is voluntary and the organ transplant teams are part of the health care system - they are on the health care payroll and no money ever exchanges hands - EVER!!!!

Ask me again why I am such an advocate of nationalised health care.

[gwenith, BSN, RN]

This past january, my family was told that my father would never "wake up" after having a quadruple bypass. The neurologist said it was a lost cause and the icu nurses told my mother that we should consider pulling the plug and i did not once see them talking to him, until....... we kept talking to him for hours and hours every day and low and behold he AWOKE. My my, that was a quick trip from brain dead to alive and well huh!!! To make a long story short, Doctors do not know everything, and we as nurses should make a point of ALWAYS talk to the patient, no matter what the condition. And yes, my father remembers hearing voices and could recognize our voices but could not really understand what we were saying.

Once again we have to make a difference between brain dead and comatose and there is a big difference. Brain death the actual clinical full manifestation is a condition for which there is no recovery. I am glad your father was merely unconscious and am happy that he did recover.

Please, Please those of you who do not work in this field and do not work with these cases it hurts us to have to hear this "Well we were told it was worse than it was and now it isn't so bad so you were wrong" type posts. I will ask all of you who make this accusation one question - How would you feel if we had not painted the picture so black???

Because in Neuro more than any other field the outcomes are highly, grossly, completely variable we HAVE to give relatives a "worst case scenario" however this is often misconstrued to mean that we do not have faith in the recovery of the person - we do.

You always expect the worst but hope for the best.

[Tweety, BSN, RN]

Once again we have to make a difference between brain dead and comatose and there is a big difference. Brain death the actual clinical full manifestation is a condition for which there is no recovery. I am glad your father was merely unconscious and am happy that he did recover.

Please, Please those of you who do not work in this field and do not work with these cases it hurts us to have to hear this "Well we were told it was worse than it was and now it isn't so bad so you were wrong" type posts. I will ask all of you who make this accusation one question - How would you feel if we had not painted the picture so black???

Because in Neuro more than any other field the outcomes are highly, grossly, completely variable we HAVE to give relatives a "worst case scenario" however this is often misconstrued to mean that we do not have faith in the recovery of the person - we do.

You always expect the worst but hope for the best.

Good post Gwen. People need to know that dead is dead. Comatose has a whole wide variety of outcomes from people who years later have no deficits to those who stay that way for many years, to those that slip into death quickly.

It's not an exact science predicting the outcome. Someone always comes up with a family member or a friend of a friend of a friend who was told to prepare for the worst and they came out of it.

I'm dealing with a family and their 19 year old head injured son. He opens his eyes spontaneously to voice. But that's it. They hold out the hope he obeys commands and the we should provide a sitter to talk to him continously for stimulation, that eventually he'll snap out of it and walk out of there. Docs have tried to be realistic that the area and extent of this kids injuries makes that unlikely.

People hear only what they choose to hear. I do talk to him btw. :)

[gwenith, BSN, RN]

Thank-you Tweety I guess this is one area that is a little tender for me as so many, and the media in particular seem to love this "Look at how wrong you all were" type of scenarios and for every one of those you look around the ward at the 20 or 30 who were not miracles, who never will get better who will live for ever in a shattered world. You see the gradual loss of hope in the families the slide into despair at ever seeing an improvement, they hold out such hope, the patient twitches and they start to beleive that this is the start of recovery only to have you tell them that it was only reflex. So, so sad. No matter how black the picture you paint, no matter what information you have given them they continue to hope and it is these people who stick in your mind when you talk to the relatives, trying once again not to give false hope because you know how hard the road ahead is.

[Energizer Bunny]

Once again we have to make a difference between brain dead and comatose and there is a big difference. Brain death the actual clinical full manifestation is a condition for which there is no recovery. I am glad your father was merely unconscious and am happy that he did recover.

Please, Please those of you who do not work in this field and do not work with these cases it hurts us to have to hear this "Well we were told it was worse than it was and now it isn't so bad so you were wrong" type posts. I will ask all of you who make this accusation one question - How would you feel if we had not painted the picture so black???

Because in Neuro more than any other field the outcomes are highly, grossly, completely variable we HAVE to give relatives a "worst case scenario" however this is often misconstrued to mean that we do not have faith in the recovery of the person - we do.

You always expect the worst but hope for the best.

Thank you Gwenith! You know I am "only" a student, but man! some of these posts were even frustrating me! I find it's best when I don't know about the situation to keep my mouth shut (most of the time :rotfl: ) This is such a serious subject and I think a very important one. I have stated before that I talk to my coffee pot so I am sure I'll be talking to brain dead patients. Comatose ones, of course, but that's an entirely different thing as has been stated numerous times.

[NeuroICURN]

Once again we have to make a difference between brain dead and comatose and there is a big difference. Brain death the actual clinical full manifestation is a condition for which there is no recovery. I am glad your father was merely unconscious and am happy that he did recover.

Please, Please those of you who do not work in this field and do not work with these cases it hurts us to have to hear this "Well we were told it was worse than it was and now it isn't so bad so you were wrong" type posts. I will ask all of you who make this accusation one question - How would you feel if we had not painted the picture so black???

Because in Neuro more than any other field the outcomes are highly, grossly, completely variable we HAVE to give relatives a "worst case scenario" however this is often misconstrued to mean that we do not have faith in the recovery of the person - we do.

You always expect the worst but hope for the best.

I couldn't have said it better myself! Once again, you've eloquently said what we've all been trying to get across.

I think it's hard for people to really understand the difference between comatose and brain death when you don't work with them.

I fully understand about painting a bleak picture for the family, but as you said...it's better for us to do that and have it come out better, rather than painting a rosey picture and have it come out terribly. I often explain to my patient's family that all of us could have the same injury to our brains and while some things we can predict, we're all going to react differently.

Well....this horse is dead...so I guess it's time to dismount!

[chris_at_lucas_RN, RN]

History is replete with postmortem evidence of our error in assessing when death has actually occurred.

There is too much we cannot know--why assume? Hasn't been that long since we thought anesthetized patients couldn't hear us....

And so what if we do talk to them, what's lost? More importantly, what might be gained by talking to the braindead--for the patient it might not be so easy to assess, but what about for the family in attendance, or for the nurse him/herself? There's a study to be done--differences in care or attitude or level of job satisfaction, versus treating all patients as if they were sensient.

Somebody needs to find that researcher who "concluded" the nurses talking to their dead patients didn't comprehend the meaning of "dead," and give him a good smack!