Are my pts "brain dead"?

[smartnurse1982]

I apologize if I am sounding stupid now,but I am just curious. We have all heard about the case in California with the 13 yr old,and how she is brain dead. Of course,she is on a vent,and the family wants her to get a trach and gtube.

I have several pts that are "unresponsive" meaning they don't talk, blink their eyes, nothing, no purposeful movement, nothing. All but one is on a vent, and all have trach and gt. At least one doesn't even use a gtube. She has been on Tpn for 1.5 years now for all her nutritional needs. One boy is a Dnr order, but with the understanding that we are to rescucitate him using the Ambubag, but if his heart stops, we do nothing. (I haven't seen a Dnr order like that before, and this is the first one I've seen like that)

It also says "at parents discretion", meaning that they could change their minds and make us do chest compressions. (according to nursing supervisor). This same boy had an EEG,and it shows no activity.

Anyway,I'm not seeing the big issue with the California case as I have several kids with vents, trach, and gtubes that are well...I'm not saying the words.

[KelRN215, BSN, RN]

I did very early,when starting out as a new grad,turn down a job with Planned Parenthood.It was for "religious reasons".I knwo for sure I would have told women the "bad" of getting abortions. I don't think I would have been fair

Now I'm seriously curious as to why you would have applied for this job in the first place.

[smartnurse1982]

Now,there is another case that involves brain death.Finlay Boyle was declared brain dead but when I read the article,it seemed she was breathing on her own and had a feeding tube????How can they insert a feeding tube in someone declared brain dead?Someone help me out with that story.

[Rose_Queen, BSN, MSN, RN]

Now,there is another case that involves brain death.Finlay Boyle was declared brain dead but when I read the article,it seemed she was breathing on her own and had a feeding tube????How can they insert a feeding tube in someone declared brain dead?Someone help me out with that story.

CNN is using the terminology vegetative state. Parents accuse Hawaii dentist of leaving daughter with brain damage - CNN.com

(CNN)

-- The parents of a 3-year-old in a "vegetative state" are suing a Kailua, Hawaii, dentist, alleging negligence and dangerous conduct that left the girl with massive, irreversible brain damage.

Unfortunately, those writing for the media are:

-looking to sell papers; sensationalism sells

-not educated in medical terminology

Both of these are going to lead to misuse of terminology and confusion in those without a medical background.

[LadyFree28, BSN, LPN, RN]

Nowthere is another case that involves brain death.Finlay Boyle was declared brain dead but when I read the article,it seemed she was breathing on her own and had a feeding tube????How can they insert a feeding tube in someone declared brain dead?Someone help me out with that story.[/quote']

Brain damage does NOT equal brain dead...

Finlay is brain damaged, in layman's terms; similar to the pts you work with.

[JustBeachyNurse, LPN]

Nowthere is another case that involves brain death.Finlay Boyle was declared brain dead but when I read the article,it seemed she was breathing on her own and had a feeding tube????How can they insert a feeding tube in someone declared brain dead?Someone help me out with that story.[/quote']

Only the Huffington Post declared her brain dead. Not a physician. She had extensive brain damage and was in a deep coma due to the delay in responding to cardiac arrest during an in-office dental procedure. She died Friday night (no ventilator as she had brain stem function) at a Hawaiian hospice facility. The mother, a nurse, had a full grasp on her daughter's condition and prognosis. She was not brain dead. Never was diagnosed as such by anyone with medical authority. She had massive brain damage and was in a deep coma/vegetative state. The headline was written by an author seeking to increase readership & interest.

[KelRN215, BSN, RN]

Now,there is another case that involves brain death.Finlay Boyle was declared brain dead but when I read the article,it seemed she was breathing on her own and had a feeding tube????How can they insert a feeding tube in someone declared brain dead?Someone help me out with that story.

Ok, first, the media doesn't know the difference between brain death and brain damaged. That child was NOT brain dead. (She is now, as she died last night, but when they published these articles she wasn't.) Anything you're reading outside of a medical journal needs to be taken with a grain of salt. People who write for CNN or the HuffPost or wherever you read about her in the first place simply don't know what brain death is. I mean, you can see how they wouldn't, right? You are a nurse for 9 years and admitted you didn't know what it was.

Prior to her death last night, she was breathing on her own and intermittently opening her eyes. Brain dead persons don't do these things. She probably had an NG tube placed when she was brought to the hospital before they knew what they were dealing with/before the family had the time to make their decisions. Fortunately for this child, her mother is a nurse and understood what they were dealing with. The family pursued hospice care and she passed calmly last night.

[Esme12, ASN, BSN, RN]

Now,there is another case that involves brain death.Finlay Boyle was declared brain dead but when I read the article,it seemed she was breathing on her own and had a feeding tube????How can they insert a feeding tube in someone declared brain dead?Someone help me out with that story.

Have you read ANYTHING in this post? It has been mentioned SEVERAL TIMES that by US standard which is in accordance with international standard, except for the UK, that for brain death to be determined ONE of the NECESSARY criteria is apnea....for the layman, NO SPONTANEOUS RESPIRATION'S ARE PRESENT

American Academy of Neurology Guidelines for Brain Death Determination

Many of the details of the clinical neurologic examination to determine brain death cannot be established by evidence-based methods. The detailed brain death evaluation protocol that follows is intended as a useful tool for clinicians. It must be emphasized that this guidance is opinion-based. Alternative protocols may be equally informative.

The determination of brain death can be considered to consist of the following steps:

I. The clinical evaluation (prerequisites).

A. Establish irreversible and proximate cause of coma.

The cause of coma can usually be established by history, examination, neuroimaging, and

laboratory tests.

Exclude the presence of a CNS-depressant drug effect by history, drug screen, or, if available, drug plasma levels below the therapeutic range. Prior use of hypothermia (e.g., after cardiopulmonary resuscitation for cardiac arrest) may delay drug metabolism. The legal alcohol limit for driving (blood alcohol content 0.08%) is a practical threshold below which an examination to determine brain death could reasonably proceed.

There should be no recent administration or continued presence of neuromuscular blocking agents (this can be defined by the presence of a train of 4 twitches with maximal ulnar nerve stimulation).

There should be no severe electrolyte, acid-base, or endocrine disturbance. Achieve normal core temperature.

In most patients, a warming blanket is needed to raise the body temperature and maintain a normal or near-normal temperature (36°C).

B. Achieve normal systolic blood pressure.

Hypotension from loss of peripheral vascular tone or hypovolemia (diabetes insipidus) is common; vasopressors or vasopressin are often required. Neurologic examination is usually reliable with a systolic blood pressure 100 mm Hg.

C. Perform 2 neurologic examinations

Legally, all physicians are allowed to determine brain death in most US states. Neurologists, neurosurgeons, and intensive care specialists may have specialized expertise. It seems reasonable to require that all physicians making a determination of brain death be intimately familiar with brain death criteria and have demonstrated competence in this complex examination. Brain death statutes in the United States differ by state and institution. Some US state or hospital guidelines require the examiner to have certain expertise.

The clinical evaluation (neurologic assessment).

A. Coma.

Patients must lack all evidence of responsiveness. Eye opening or eye movement to noxious stimuli is absent. Noxious stimuli should not produce a motor response other than spinally mediated reflexes. The clinical differentiation of spinal responses from retained motor responses associated with

B. Absence of brainstem reflexes.

• Absence of pupillary response to a bright light is documented in both eyes.
  
• Absence of ocular movements using oculocephalic testing and oculovestibular reflex testing. Movement of the eyes should be absent during 1 minute of observation. Both sides are tested, with an interval of several minutes.
  

• Absence of corneal reflex. Absent corneal reflex is demonstrated by touching the cornea with a piece of tissue paper, a cotton swab, or squirts of water. No eyelid movement should be seen.
  

• Absence of facial muscle movement to anoxious stimulus.
  

• Absence of the pharyngeal and tracheal reflexes. The pharyngeal or gag reflex is tested after stimulation of the posterior pharynx with a tongue blade or suction device. The tracheal reflex is most reliably tested by examining the cough response to tracheal suctioning. The catheter should be inserted into the trachea and advanced to the level of the carina followed by 1 or 2 suctioning passes.
  

C. Apnea Test

• Absence of a Respiratory Drive.
  Absence of a breathing drive is tested with a CO2 challenge. Documentation of an increase in PaCO2 above normal levels is typical practice. It requires preparation before the test.
  

Prerequisites:

1. normotension
   
2. normothermia
   
3. euvolemia
   
4. eucapnia (PaCO2 35–45 mm Hg)
   
5. absence of hypoxia
   
6. no prior evidence of CO2 retention (i.e., chronic obstructive pulmonary disease, severe obesity).
   

Procedure:

1. Adjust vasopressors to a systolic blood pressure _100 mm Hg.
   
2. Preoxygenate for at least 10 minutes with 100% oxygen to a PaO2 _200 mm Hg.
   
3. Reduce ventilation frequency to 10 breaths per minute to eucapnia.
   
4. Reduce positive end-expiratory pressure (PEEP) to 5 cm H2O (oxygen desaturation with decreasing PEEP may suggest difficulty with apnea testing).
   
5. If pulse oximetry oxygen saturation remains_95%, obtain a baseline blood gas (PaO2, PaCO2, pH, bicarbonate, base excess).
   
6. Disconnect the patient from the ventilator.
   
7. Preserve oxygenation (e.g., place an insufflations catheter through the endotracheal tube and close to the level of the carina and deliver 100% O2 at 6 L/min).
   
8. Look closely for respiratory movements for 8–10 minutes. Respiration is defined as abdominal or chest excursions and may include a brief gasp.
   
9. Abort if systolic blood pressure decreases to _90 mm Hg.
   
10. Abort if oxygen saturation measured by pulse oximetry is _85% for _30 seconds. Retry procedure with T-piece, CPAP 10 cm H2O, and 100% O2 12 L/min.
    
11. If no respiratory drive is observed, repeat blood gas (PaO2, PaCO2, pH, bicarbonate, base excess) after approximately 8 minutes.
    
12. If respiratory movements are absent and arterial PCO2 is _60 mm Hg (or 20 mm Hg increase in arterial PCO2 over a baseline normal arterial PCO2), the apnea test result is positive(i.e., spports the clinical diagnosis of brain death).
    

If the test is inconclusive but the patient is hemodynamically stable during the procedure, it may be repeated for a longer period of time (10–15 minutes) after the patient is again adequately pre-oxygenated.

Ancillary tests

In clinical practice, EEG, cerebral angiography, nuclear scan, TCD, CTA, and MRI/MRA are currently used ancillary tests in adults (see below).

Common confirmatory tests in Brain Death

Cerebral angiography

• Contrast medium under high pressure in both anterior and posterior circulation injections
  
• No intracerebral filling at the level of the carotid or vertebral artery entry to the skull
  
• Patent external carotid circulation
  
• Possible delayed filling of the superior longitudinal sinus
  

Electroencephalography

• Minimum of eight scalp electrodes
  
• Interelectrode dependencies should be between 100 and 10,000
  
• Integrity of the entire recording system should be tested
  
• Electrode distances should be at least 10 cm
  Sensitivity should be increased to at least 2 µV for 30 minutes with inclusion of appropriate calibrations
  
• High-frequency filter setting should be at 30 Hz, and low-frequency setting should not be below 1 Hz
  
• There should be no electroencephalographic reactivity to intense somatosensory or audiovisual stimuli
  

Transcranial Doppler ultrasonography

• Bilateral insonation.
  
• The probe is placed at the temporal bone above the zygomatic arch or the vertebrobasilar arteries through the suboccipital transcranial window•
  
• The abnormalities should include a lack of diastolic or reverberating flow, small systolic peaks in early systole, and a lack of flow found by the investigator who previously demonstrated normal velocities
  

Cerebral scintigraphy (technetium Tc 99m hexametazime)

• Injection of isotope within 30 minutes of reconstitution
  
• Static image of 500,000 counts at several time intervals: immediately, between 30 and 60 minutes, and at 2 hours.
  

Information based on: Evidence-based guideline update: Determining brain death in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology Eelco F.M. Wijdicks, Panayiotis N. Varelas, Gary S. Gronseth and David M. Greer 181e242a8 Neurology 2010;74;1911-1918

Huffington Post sensationalized their headline to attract readers using irresponsible journalism

[smartnurse1982]

So,if a coworker writes that pts are "watching tv" and "sleeping" is that charting incorrectly?Also,when I told a mom one time that your baby knows and her eyes gravitate toward your voice,was that incorrect and giving false information?

[LadyFree28, BSN, LPN, RN]

Soif a coworker writes that pts are "watching tv" and "sleeping" is that charting incorrectly?Also,when I told a mom one time that your baby knows and her eyes gravitate toward your voice,was that incorrect and giving false information?[/quote']

As far as charting "watching tv"; they MAY, however it's more accurate to state "awake" as well as sleeping; due to your pts having sleep/wake cycles.

If you observed in your pt that their eyes gravitated to the sound of their mother's voice, why would that be false information; even with assessing and focused observation, if you observed it, how can that be false...unless your personal feelings were involved....

[KelRN215, BSN, RN]

So,if a coworker writes that pts are "watching tv" and "sleeping" is that charting incorrectly?Also,when I told a mom one time that your baby knows and her eyes gravitate toward your voice,was that incorrect and giving false information?

Uhhh... what? How did anything any of us said make you think this? Your patients are NOT brain dead. They may have any range of neurological injuries. Neurologically delayed/injured children very well MAY look at their mothers. We didn't assess these children, we don't know what they can or cannot do.

[Esme12, ASN, BSN, RN]

So,if a coworker writes that pts are "watching tv" and "sleeping" is that charting incorrectly?Also,when I told a mom one time that your baby knows and her eyes gravitate toward your voice,was that incorrect and giving false information?

What are you taking about? How could we possibly KNOW if a co worker that charted this was wrong...I've never assessed that child. If the kids eyes are open and they track movement in the room then they are looking at things. If the child you care for looks towards Moms voice then they are looking at Mom.

What exactly are you looking for here? What exactly do you not understand?

[Altra, BSN, RN]

So,if a coworker writes that pts are "watching tv" and "sleeping" is that charting incorrectly?Also,when I told a mom one time that your baby knows and her eyes gravitate toward your voice,was that incorrect and giving false information?

That you are unable to answer these questions indicates substandard nursing care. There, I said it.

How can we possibly answer here, when we are not assessing your patients? Your patients likely do not all have identical histories/diagnoses/levels of neurologic & cognitive function.

But your lack of/incomplete understanding of their conditions ... I have no words.

Do you not understand the importance of accurate assessment? If you have no idea, as you have indicated throughout many posts in two different threads, about the neurologic status of your patients ... how would you know if there was a change, possibly indicative of a medical emergency? Your method of obtaining resources is to post patient-specific questions on a social media site??

Unacceptable.