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

stevierae · Jun 26, 2004

I came upon this good article today, authored by an RN. Thought it would prove very intersting to some and help to alleviate some of the confusion about brain death and organ donation.

Authored By: Mary-Ellen Anton RN, MHN, CCRN, CPTC

The purpose of this article is to provide a basic overview of the organ and tissue donation process and stresses the importance of a collaborative effort between the Organ Procurement Organization (OPO) Coordinator and the bedside nurse.

*This article does not meet the HCFA requirement for Designated Requestor training.

Objectives:

Identify the six steps in the organ donation process

Discuss recent changes in regulations enacted by the Health Care Finance Administration (HCFA)

Describe three important facts that a family must be aware of before they make a decision about donation

Describe examples of the collaborative relationship between the OPO and the nurse

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The telephone rings in the middle of the night. For many, this is always an ominous sound. Something has happened...someone is ill...maybe someone has died. Thousands of families each year receive these phone calls and hurry to local hospitals and trauma centers to find their loved ones have been victims of accidents or have suffered other types of injury to their brains. Each year in the United States, approximately 15,000(1) people, despite all of the heroic efforts to save their lives, are pronounced brain dead. A third of these patients, about 5,000, through the generosity and compassion of their surviving family members, become organ donors and give the Gift of Life to strangers.

The organ donation process is a series of six steps (referral, consent, evaluation, maintenance, surgical rescue and Aftercare) that begins with a phone call from the referring hospital to the local Organ Procurement Organization (OPO). In all but the last step (Aftercare), the nurse plays a crucial role and is a vital partner in the donation process.

The Referral

The identification and referral of a patient as a potential organ donor is the first step in the process of donation, procurement and transplant. Health care professionals, including both doctors and nurses, are an integral part of this process. They are relied upon to identify a potential donor and to make the referral to the local Organ Procurement Organization (OPO). Frequently it is the nurse who makes this referral call; the nurse who is at the bedside acting as the patient and family advocate. It is the bedside nurse who is with the family, comforting them, re-explaining tests and terminology. Often it is the nurse who has been trained as a Designated Requestor who is the first to bring up the option of organ and tissue donation.

Early referral is strongly encouraged by most OPOs. An initial phone referral by the nurse on patients who may be approaching brain death, including a history, status report and review of systems is often very helpful to the Procurement Coordinator. In fact, HCFA regulations now require that all deaths and immanent deaths be called to the local OPO for evaluation. Often a Procurement Coordinator is called to approach or assist the trained Designated Requestor* with approaching a family (*some states require that only the procurement coordinator approaches the family) with the option of organ and tissue donation. Medical management of the potential donor according to procurement protocols, however, does not begin until after the patient has been pronounced medically and legally dead utilizing brain death criteria and consent has been obtained.

Brain Death(6)

Brain death is a medical and legal definition of death, and is defined as the total and permanent cessation of the entire function of both the brain and brainstem(2). Brain death legislation, the Uniform Determination of Death Act, was enacted in 1978 and revised in 1980. Although this law defines death, it did not include specific neurological criteria for determining brain death. In 1981 the President's Commission(3) provided the criteria and standards now used to diagnose brain death at the bedside. In the 'Guidelines for Determination of Death', the consultants presented standards that include:

Two separate evaluations

Clinical evaluations that include induction of painful stimuli, responses of pupils to light, apnea testing and oculovestibular testing

Confirmatory tests (eg: electroencephalograms (EEG), cerebral angiograms and brain flow studies) are not mandatory but may be included as part of the evaluation

Although most state statutes state that brain death can be pronounced on clinical evaluation only, many hospitals and health care facilities may ask (via written policies) for further confirmatory testing before brain death is pronounced. In addition, brain death must be pronounced and documented by two different physicians (neither to be associated with the procurement or transplant teams) whereas cardiac death is usually pronounced by a single physician.

The Consent

Consent is the next step in the donation process, and it is obtained from the patient's legal next of kin, according to state statutes. Consent usually can be obtained in person, by telegram, by fax or by telephone depending on the policies in place in your institution. A properly executed and signed donor card, although legal consent, is viewed by many OPOs as simply the patient's intent or documentation of his wishes. Even though some state statutes(2) say that "an anatomical gift made by an adult is irrevocable and does not require the consent of concurrence of any person after the donor's death" the patient's family is usually asked to make this decision. For this reason it is always important that people who designate themselves as organ and tissue donors (on a donor card or on their driver's licenses) also make a point of discussing their decision with their families. Even in the presence of a signed donor card, most OPOs will follow the wishes of the patient's family if they voice an opposition to donation. Proceeding with a donation against the surviving family's wishes, would not be worth the negative publicity that could be generated or the added emotional strain that would be put on the family.

Required Request Legislation was enacted in 1986 (The Omnibus Reconciliation Act) to ensure that all families are given the option of organ and tissue donation at or near the time of death of their loved one. In 1998, HCFA enacted a regulation that mandates a relationship between the hospitals and their local OPO. It also mandates that all deaths, or immanent deaths, be called to the OPO for evaluation for donation and that the family is approached by an OPO representative or an OPO trained Designated Requestor. This law intends to assure that the family is presented their option in the correct manner, at the correct time and by the right person, with compassion and respect. The optimal situation is one where the OPO Coordinator approaches the family with the support and collaboration of the bedside nurse.

In order to be able to give consent for organ and tissue donation, a family must be given the information that they need to make an informed consent. There is some basic information that is important for family to have and understand if they are to deal effectively with making a decision about their option of donation.

There is no cost to the family or to the patient's estate for donation. The OPO pays for all costs associated with the evaluation of the organs, maintenance of the donor, and the surgical rescue of those organs.

There is no deformity after the surgical rescue of organs and tissues. An open casket viewing remains an option after organ, eye and/or bone donation.

The patient will not have pain or suffer. A brain dead patient does not have the capacity to feel pain.

The patient is brain dead and not in a coma.

An understanding of what 'brain death' means is also very important. Seeing their loved one in a bed with warm skin, a beating heart and 'breathing' with the ventilator can represent as a very confusing picture for the family because the brain dead patient does not usually look dead to the family. For this reason, the meaning and significance of brain death may need to be reinforced over and over again. It is often very difficult for the health care professional to deal with the concept of brain death and it can even be more difficult for these families who have suddenly found themselves immersed in a confusing scenario of grief and disbelief.

The family of a potential donor is usually a family in acute crisis. Often they are facing the death of a loved one who, hours or days before, was alive and healthy. Suddenly, through trauma, an accident, an undetected aneurysm, stroke or other cause this family is forced to deal with unexpected death. Even in this, their darkest hours, they are asked to make several last and final decisions. Organ donation is often one of those decisions. Despite their grief, pain and overwhelming sorrow, many families are able to reach beyond the devastation and embrace donation. Many see donation as an opportunity to have something positive come out of a most tragic situation.

The way in which a donor family is presented with the option of donation may have a direct impact on their response(7,8,10) . When approached in a professional, caring, compassionate manner and given the information to make an informed decision, a family is much more likely to respond in a positive way.

Donor Maintenance(4)

After brain death has been pronounced and documented, and the consents obtained, the objective of care of the potential organ donor switches from therapies that try to save the brain (eg: diuretic administration, vasospasm protocols) to care that focuses solely on keeping the organs adequately perfused, oxygenated and viable for transplant . With the death of the brain and brain stem, the autonomic regulatory controls of the brain are lost. Subsequently, the caregivers of brain dead patients may see a variety of patient care problems that may include hypotension, tachycardia, diabetes insipidus, electrolyte imbalances and hypothermia.(4,5)

The Critical Care Nurse is usually working hand in hand with the Organ Procurement Coordinator in managing the care of the organ donor. This partnership ensures that potential issues and trends that could be detrimental are identified and thwarted before they become actual threats to the patient. Knowing that a particular problem or manifestation is common in the brain dead patient will assist the critical care nurse in anticipating these complications and seeking corrective therapies before a crisis situation arises.

There are many common clinical issues that arise in the management of the brain dead organ donor. Most are caused by the effects of the loss of autonomic control; loss of the parasympathetic and Sympathetic systems. Profound hemodynamic instability, for example, is often evident after brain death. Brain death results in an absence of vascular tone which precipitates vascular dilatation and a reduced venous return. This in turn produces hypotension. Loss of the Vagus nerve (cranial nerve X) can result in tachyarrhythmias. Hypovolemia also further complicates the hemodynamic picture and can be caused by pre-brain death medical management of the head injured patient (eg fluid restrictions and diuretics), hemorrhage or diabetes insipidus. The treatment for this hypotension is large volume fluid replacement with crystalloid, preferably dextrose 5% in water (D5W, D5 1/4 NS, D5 ½ ND) or lactated Ringers. The rate of replacement can be as much as 200-500 cc/hr, but is given based on central venous pressure or pulmonary catheter pressures, intake and output, and physical assessment. Generally IV normal saline (NS) is discouraged due to the detrimental effect that high serum sodium levels can have, post transplant, on the liver(9). High serum sodium levels are sometimes seen in organ donors and may be due to a variety of factors including pre-death fluid resuscitation with NS and hypernatremia caused by diabetes insipidus. The use of vasopressors such as dopamine, levophed, dobutamine and colloids , such as normal serum albumen, may also be useful in helping to raise the blood pressure to a level greater than 100 systolic until fluid deficits are corrected.

The administration of T4 (levothyroxine) has gained much popularity with procurement agencies in the last few years for the treatment of hemodynamic instability after brain death. T4 is used to help decrease the amount of vasopressors required and to prevent cardiovascular collapse.

Diabetes insipitus (DI) is caused, in the brain dead organ donor, by the cessation of the secretion of the antidiuretic hormone vasopressin from the posterior pituitary gland and often is the cause of electrolyte and fluid imbalances. DI can cause polyuria and dehydration with resultant hypernatremia, hypokalemia, hypophosphatemia, hypocalcemia and hypomagnesemia. The treatment for DI consists of replacing the hourly urine output cc for cc and with the administration of desmopressin acetate (DDAVP) or with vasopressin (pitressin). Additionally, the critical care nurse must closely monitor electrolyte laboratory results and provide replacement of depleted electrolytes as indicated.

Hypothermia is another management issue that frequently arises in the care of the donor. It can be caused by the loss of hypothalamic temperature control, systemic vasodilatation and by large volume fluid replacement with unwarmed fluids. It is estimated that 85% of referred donors exhibit hypothermia(4). If left untreated hypothermia can cause cardiac arrhythmias, such as ventricular tachycardia, and have adverse effects on the liver and kidneys as well(4). Warming the body with heating blankets is an effective treatment, and when ever possible care should be taken to administer warmed IV fluids.

Managing A Potential Donor:

Common Clinical Issues In The Brain Dead Donor

Hypotension tachycardia

Diabetes insipidus

Electrolyte and fluid imbalances

Hypothermia

In all other aspects, the general the care of the donor is quite similar to the care of any other patient. Stability of hemodynamic status must be assured as well as oxygenation and ventilation. It is important to remember that organs must be continually perfused and oxygenated to remain viable for transplantation. Intake and output must be closely monitored, along with laboratory values, blood gas results and general status. The crucial role of the bedside nurse in assessing, monitoring, anticipating problems and initiating treatment can not be understated.

Simplified Goals of Donor Care

Systolic blood pressure of greater than 100

Urine output greater than 100

Oxygen saturation of approximately 100%

Evaluation and Organ Placement

Evaluation of the patient (to determine which organs and tissues are suitable for transplant) and organ placement (matching available organs to potential recipients) actually take place simultaneously with the donor maintenance phase of the donation process. Each organ donor is evaluated on an individual basis for donation. All potential donors are evaluated, and because of the ever growing disparity between the number of organs available and the number of people waiting (and often dying ) on the waiting lists, the acceptable criteria for donation is ever expanding and becoming more liberalized . Fifteen years ago a patient might have been turned down as a potential donor because of a history of hypertension or diabetes, or because he/she was over the age of 55. Today, coordinators 'never say never' without evaluating each donor on an individual basis. Older patients, some well into their 80's, are now often considered as potntial donors, as are patients with hepatitis C, systemic lupus erythematosus (SLE) and those with diabetes and hypertensive histories. Some transplant centers are even considering transplanting HIV+ recipients with organs from HIV+ donors.

Evaluation is done on each organ that may be used for transplant. The heart is evaluated by physical assessment, cardiac enzymes, ECG, echocardiogram and if necessary, even by cardiac catheterization. The lungs are evaluated through physical assessment, chest x-rays, ABGs , bronchoscopy and cultures /gram stain results. Likewise, other organs, including the liver, pancreas and kidneys are evaluated through physical assessment and appropriate laboratory testing.

An in depth and accurate history is essential for all organ and tissue evaluations. This includes both surgical and medical histories as well as a social history. Risk factors are assessed, including previous history of multiple sex partners, exposure to sexually transmitted diseases, use of non-prescribed or controlled drugs, prison/jail interment, recent tattoos, etc., as well as smoking and drinking habits. Serology testing is completed on all potential donors during the evaluation phase and may include HIV, HTLV I, Hepatitis B (antigen and core/surface antibodies), Hepatitis C, Epstein Barr Virus (EBV), and Cytomegalovirus (CMV). Throughout this evaluation phase of the donation process the role of the bedside nurse focus' on assuring patient hemodynamic stability and supporting the family.

Organ Placement and Procurement

When the Organ Procurement Coordinator has determined which organs are suitable for transplant purposes, the search for potential recipients begins. The United Network for Organ Sharing (UNOS) is notified and given donor information which includes height, weight, blood type, serology results, tissue typing information, age and sex. UNOS is a non-profit organization that maintains the national computerized potential recipient lists, and is also responsible to see that equitable allocation of organs occurs. Computerized lists for each transplantable organ are requested by the procurement coordinator and then faxed by UNOS to the coordinator at the donor hospital location. A lengthy series of phone calls then ensues. The recipient center (usually a transplant hospital) for the first recipient on each organ list is called and a full report on the donor is given. This report can be very time consuming, as it includes lab work and ABG results, radiology reports, past and present medical histories and current status, medications and vital signs. The recipient center then evaluates the information it has been given and determines whether or not this organ is acceptable for their recipient. The recipient center has one hour to accept or reject the organ offer.

Why an Offered Organ May be Rejected For Transplant

The potential recipient has already been transplanted

The potential recipient has died

The potential recipient is infected/ not able to be transplanted

The potential recipient can not be located or is refusing the transplant

Size incompatibility between donor and potential recipient

Unacceptable history or medical condition of donor

When all transplantable organs have been accepted by the appropriate recipient centers, the surgical procurement is scheduled in the donor's hospital. The scheduling of O.R. time is carefully choreographed so that the surgical recovery teams coming from their various recipient hospitals arrive at precisely the right time to procure their particular organ and rush it back to their respective Transplant Center and the awaiting recipient. The room in surgery where the procurement is taking place is often very crowded with the different surgical recovery teams rescuing the organ that they have come for. The patient is draped, prepped and a 'y' shaped midline incision is performed. After surgery the incision is neatly closed as it is with any other surgical procedure. When surgery is completed the patient's body is prepared for the Medical Examiner (if applicable) or the funeral home. Throughout the entire donation process, the donor is always treated with the utmost respect and dignity.

The rescued organs are packaged carefully in ice and rigid containers according to federal guidelines. The organs are then generally placed in ice chests/coolers and immediately transported to their respective recipients' transplant centers. As with the O.R. timing, transportation (eg ambulances, helicopters and/or small jets) for the various surgical teams is also meticulously orchestrated to ensure that the rescued organ remains viable and reaches the recipient in the least amount of time possible.

Aftercare

A few OPOs across the country offer 'aftercare' to the families who decide to allow their loved ones to provide the 'Gift of Life' through organ and tissue donation. These programs provide emotional support to the family in the hours, days and sometimes years after the donation has occurred. Involvement is voluntary, and may consist of support groups specific to donor families needs, literature, grief counseling, or maybe just a shoulder to cry on. Procurement Coordinators often provide the initial link to the program through the offering of general information about the program, an Aftercare brochure, a phone number, and/or a pamphlet designed to help the family answer some of the immediate questions and concerns surrounding funeral plans, the role of the Medical Examiner and obtaining a death certificate.

The Aftercare program director will send the donor family further information over the course of several weeks and reinforce the program's availability. Families usually have an option as to whether they wish to utilize the program or not. Families are never aggressively pursued or pressured into participating. The goal of Aftercare is to gently assist the donor family through the grieving process and beyond.

In the end...

For many families and health care providers, organ and tissue donation does help to make sense out of the often senseless tragedies that result in the death of a patient. Donation, of course ,provides the 'Gift of Life' to countless individuals who would have died had not a life saving organ transplant become available. Donation, however, also provides benefits to those left behind. When all attempts to save a patient's life have been exhausted and brain death has been pronounced, organ donation may provide some comfort and solace not only to the surviving family members(12), but also to the staff who so diligently cared for that individual and his family.

Organ and tissue transplantation of hearts, lungs, pancreas, liver and kidneys is no longer considered experimental. It provides a viable treatment modality for patients who may otherwise have no other alternative except for death. Transplant recipients can go on to live healthy, productive and normal lives. For transplant recipients, organ donation is truly the 'Gift of Life'....a gift that they may never have gotten if it were not for a process that started with a simple referral phone call from a nurse.

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References

United Network For Organ Sharing (UNOS), Richmond, Virginia 3/98

Florida State Statutes 382.009 "Recognition of Brain Death Under Certain Circumstances", FS 732.912 "Rights and Duties at Death"

Medical Consultants on the Diagnosis of Death to the Presidents Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Guidelines for the Determination of Death. JAMA. 1981; 246: 2184-2186.

Boyd G.L., Phillips, M.g., Henry, M.L.. Cadaver Donor Management. In: Phillips M.G., ed. Organ Procurement, Preservation and Distribution in Transplant. Richmond, VA.:UNOS; 2nd Edition, 1996: 81-98.

Burt, A.M., Neuroanatomy, International Edition, Philadelphia, PA: W.B. Saunders Co.; 1993: 132-155.

Culpepper, M.I., The Legal Aspects of Organ and Tissue Procurement and Transplant. In: Phillips, M.G.,ed. Organ Procurement, Preservation and Distribution in Transplant. Richmond, VA: UNOS; 2nd Edition, 1996: 23-38, 83-84.

Noury,H., Carre,P., Auger,E.., Le Sant, J.N., Pinault, M.F., Jacob,F. Preliminary Results of a survey on the Information of Families of Organ and Tissue Donors, Transplantation Proceedings, April 1995, 27:2,1660- 1661

The Partnership for Organ Donation, A Study of Donor and non-Donor Families and the Hospital Request Process: A Report to the Division of Transplantation , September 30, 1995.Boston MA

Figueras, J., Busquets, J., Grande, L., etal The Deleterious Effect of Donor High Plasma Sodium.. Transplantation, Vol 61, 410-413, Feb 15, 1996.

DeJong,W., Franz, H.G., Wolfe, S.M., etal, Requesting Organ Donation: An Interview Study of Donor and Non Donor Families. American Journal of Critical Care . January 1998, Vol 7, No 1.pages 13-23.

University of Miami Organ Procurement Organization Aftercare Program, Miami, Florida 1998

talaxandra · Jul 11, 2004

There is a book that I just bought that I am almost done with that you all should read "Stiff, The curious lives of human cadavers," by Mary Roach.

Thanks for your recommendation - I ordered "Stiff" a couple of weeks ago and it just arrived. I'm looking forward to reading it, and want to thank you for your recommendation.

I've been a little quiet on the feedback front (o! the never-ending joy of ethics committees and academia in general) but I want to take this opportunity to thank you all for your interesting and thought-provoking participation :)

Tara

Karen30 · Jul 25, 2004

I think it has been said before, but I'll say it again as it is what I believe. Even with todays technology, no-one can say for certain what "brain dead" or unresponsive patients can and cannot hear, which is why I always chat with any patient, responsive or unresponsive, let them know what the weathers doing, what day it is etc. Maybe future advances in science will reveal those patients who are "brain-dead" can hear, who knows.

As for talking to those patients who have sadly passed away...yes I do it, it's a coping mechanism and enables me to cope with their death and also who knows whether the soul/spirit can hear people? Maybe, maybe not but who knows anything for definite in this day and age?

chris_at_lucas_RN, RN · Jul 25, 2004

If it was me that was the patient, and I could not communicate or outwardly respond in any way, I'm sure I would be seriously anxious (meds notwithstanding) and probably a bit ticked off.

If someone talked to me like I mattered, if someone reassured me that they cared, that might be all I could get. And compared to nothing, that would be quite a lot.

For me as care giver, who am I to say where consciousness ends? The fact is we have "known" so much that has turned out to be wrong. Makes me think of that old starfish washed up on the beach story: I cannot save them all and maybe it doesn't matter on the grand scale one way or another, but to the one I am helping, to that one it means quite a lot.

If I care about my patients, then while they are in my care, nothing matters except how I treat them.

To me it is not about science at all. But it is hugely about nursing.

jeepgirl, LPN, NP · Jul 25, 2004

as a student, i worked part time in onc/pallitive care...

i always talked my dead people as i prepared them. i always told them what i was about to do to them, ect. i think i freaked out one of my coworkers one time though... as we were transferring one woman post code to the morge (sp?) I accidentally hit the head of the bed on the door... so i said, "Oh, "Jane" (not the patients real name - but i did say it when this actually happened), we'll be more careful! I didn't mean to bounce your head like that!"

the other CNA looked at me like i was crazy!!

i don't know if it is healthy or not. but it made me feel better.

chris_at_lucas_RN, RN · Jul 25, 2004

Sounds very healthy to me. It would be a different story if you were annoyed that "Jane" didn't answer you!

NeuroICURN · Jul 26, 2004

I think it has been said before, but I'll say it again as it is what I believe. Even with todays technology, no-one can say for certain what "brain dead" or unresponsive patients can and cannot hear, which is why I always chat with any patient, responsive or unresponsive, let them know what the weathers doing, what day it is etc. Maybe future advances in science will reveal those patients who are "brain-dead" can hear, who knows.
As for talking to those patients who have sadly passed away...yes I do it, it's a coping mechanism and enables me to cope with their death and also who knows whether the soul/spirit can hear people? Maybe, maybe not but who knows anything for definite in this day and age?

Ok...it's fine if you say that you're talking to the soul....but what I think that some people are missing is the fact that brain death is NO DIFFERENT than if a patient went asystole!!!!! BRAIN DEAD = DEAD!!! At the point of brain death, a death certificate is issued!!!!!

I can understand why people would be "confused" about if this is really death because the heart continues to beat. However, just because the heart is beating DOES NOT mean they are alive!!!!!

NeuroICURN · Jul 26, 2004

If it was me that was the patient, and I could not communicate or outwardly respond in any way, I'm sure I would be seriously anxious (meds notwithstanding) and probably a bit ticked off.
If someone talked to me like I mattered, if someone reassured me that they cared, that might be all I could get. And compared to nothing, that would be quite a lot.

If you have anxiety or were aware of anything, then you would NOT be brain dead!!!!! That is a TOTALLY different story; I talk to comatose patient's all the time.

Brain death = completely DEAD!!! Please see my previous post.

chris_at_lucas_RN, RN · Jul 26, 2004

For me as care giver, who am I to say where consciousness ends? The fact is we have "known" so much that has turned out to be wrong. Makes me think of that old starfish washed up on the beach story: I cannot save them all and maybe it doesn't matter on the grand scale one way or another, but to the one I am helping, to that one it means quite a lot.
If I care about my patients, then while they are in my care, nothing matters except how I treat them.
To me it is not about science at all. But it is hugely about nursing.

I do think you are missing some points here, NeuroICURN. We have asserted that just because someone is "brain dead" according to whatever technology there might be, now or at some point in the future, this does not mean that there is absolute certainty that the individual is not aware, at some level.

That is what I was responding to and what others have shared here. Please let's try to keep the tone of this thread on an "up beat."

Like I said in the portion of my post I quoted above (emphasis added), it is hugely about nursing.

BernieRN · Jul 26, 2004

I do think you are missing some points here, NeuroICURN. We have asserted that just because someone is "brain dead" according to whatever technology there might be, now or at some point in the future, this does not mean that there is absolute certainty that the individual is not aware, at some level.
That is what I was responding to and what others have shared here. Please let's try to keep the tone of this thread on an "up beat."
Like I said in the portion of my post I quoted above (emphasis added), it is hugely about nursing.

I have to say I agree here. It wasn't that long ago that there was a woman on Oprah with a small girl who was born and died and she had been holding the child for, I think, an hour and the baby started breathing. This baby had been tested and brain dead, etc. When reading the original post of this thread, my thought was that although modern medicine can say a person is BD, they have no clue about the soul and readily admit that. Too many statements by the medical community over the years have been found to be false as technology advances. The opinion of the medical community can be that brain dead is dead, but there is no way to know for sure in the respects of what a patient can hear since they have no answers for the soul. It can't be carved in stone. The thread was about what they hear when you talk to them, not what the clinical definition of dead was.

NeuroICURN · Jul 26, 2004

I stand behind my responses. If you reread my posts, I stated that if she was talking to the soul, then I felt that that was fine.....If that is what someone needs to do to deal with the current situation, then fine, I'm all for it. I merely stated a fact....that at the point of brain death, a death certificate is issued.

However, the point that I was making was that MANY people do NOT realize that brain death is the equivalent of death where someone is asystolic. People sometimes have a hard time realizing that someone is dead, just because the heart continues to beat.

After all, isn't this what this post was about??? It wasn't about talking to living people, it's about talking to DEAD people. I'll state it again, I talk to my comatose people all the time and encourage my families to do so. My responses are based on my personal experience. I work with this stuff, day in and day out.

gwenith, BSN, RN · Jul 27, 2004

Although the term "brain dead" in ICU and especially in NeuroICU refers to a specific and leagal defintion of death it is a term that is sadly misused. We hear all the time of people diagnosed as "brain dead" but in fact the tests that determine this state were either never carried out or the patient did not fit the criteria.

I have even used the term "brain dead" to refer to myself after night duty!!:)

However there is one point I would like to refute in the ascertion that "dead is dead". Unless an EEG is used in the test criteria then all we are determining is brain stem death NOT full cerebral death.

Why do we only test for brain stem death???

1) I wouldn't want to be the patient trapped in a mind with absolutely no outlet and

2) death from asystole will occur within 1-3 weeks of brain stem death. The mechanism is unknown

The underlined portion of my text is from Oh's Intensive Care Manual by Dr T.E. Oh. fourth edition Butterworth's Sydney (Sorry if I have any part of the reference wrong I am doing it from memory)