Are my pts "brain dead"?

  1. 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.
    Last edit by Joe V on Jan 1, '14 : Reason: spacing
  2. Visit smartnurse1982 profile page

    About smartnurse1982, RN

    Joined: Jun '08; Posts: 1,786; Likes: 1,308

    197 Comments

  3. by   MunoRN
    A "persistent vegetative state" and "brain death" are two different things medically speaking, although I'd argue neither counts as being "alive" in a practical sense.

    "Brain death" involves no reflexes and no spontaneous respirations and has absolutely no chance for recovery of any type. Recovery is possible in a vegetative state, although meaningful recovery becomes less likely over time, after 6 months recovery becomes very rare and will almost always result in significant disability in the event of recovery, after one year in a vegetative state it's referred to as a "permanent vegetative state".
  4. by   jadelpn
    We can never venture to guess what it is like for any parent to lose a child. Unless one has been there. And even then, each situation is unique.

    As a parent, it would be so very difficult to make a decision to let one's baby go, even if all of the evidence points to a body with no other evidence of life. However, it is a life, and it is a decision, and as heartbreaking as it may be to the nurses, it is beyond devastating to the parents.

    As nurses, we can only support choices. And the choices are personal and unique. And based on thought processes that are a parent's own.

    We can only keep their babies warm and dry and fed. And as comfortable and peaceful as possible. And God bless each and every one of the nurses that take care of these children. It is devastating, and it takes a special nurse. Thank you each and every one.
  5. by   smartnurse1982
    Well,yes,most are vent dependent.

    Some can breathe on their own for 1 to 2 hrs max.
    Others can be off the vent for 5 hrs max,and then breathing becomes haywire.

    So,I guess they are in a vegetative state?
    The only things I see are aw/as cycles in the charts.
    I also see "global developmental delays".

    Most have been on vents longer than 4 yrs.
    All my "kids" are under age 9
  6. by   smartnurse1982
    I guess I don't understand why the Doctors in the California case don't place the trach and gtube,and vent, and send the child home with 16 private duty nursing.

    I don't see what's so hard about that. Instead,they want to make the decision for mom,which is wrong.
  7. by   Esme12
    Quote from smartnurse1982
    Well,yes,most are vent dependent.

    Some can breathe on their own for 1 to 2 hrs max.
    Others can be off the vent for 5 hrs max,and then breathing becomes haywire.

    So,I guess they are in a vegetative state?
    The only things I see are aw/as cycles in the charts.
    I also see "global developmental delays".

    Most have been on vents longer than 4 yrs.
    All my "kids" are under age 9
    If they breathe they are not brain dean....self resps are an indicator that brain stem function exists.
  8. by   Esme12
    Quote from smartnurse1982
    I guess I don't understand why the Doctors in the California case don't place the trach and gtube,and vent, and send the child home with 16 private duty nursing.

    I don't see what's so hard about that. Instead,they want to make the decision for mom,which is wrong.
    We of course don't know the whole story. Chances are this child is on meds to keep her B/P "normal" she is probably on a hyperthermia blanket to maintain normothermia. It has been determined by several medical experts including one from outside the hospital that brain function has ceased. It is cruel and futile to "follow" the parents wishes...there is no life to save. I'd bet a hundred dollars that insurance won't pay for her to go anywhere or have anything done because she is brain dead.

    She is deceased. You cannot live without a brain. Feeding her will NOT help. A trach is unnecessary...she is legally and clinically deceased. The facility is not making a decision for the Mom...this poor child died and modern medicine has kept her body with a beating heart because she is 13 years old. Any and all decisions were made when her brain died. There are no brain transplants. There are no reversal techniques to repair the damage to her brain. She is gone.

    This family is crazy with grief and maybe guilt....for it is reported that the child had a feeling that something would go wrong and I am sure the mother said as mothers do..."Oh honey everything will be just fine" and it wasn't. My heart aches for this family.

    There seems to be no one at "fault"...it is one of the horrible things we see in medicine to remind us we don't hold all the cards nor have all the answers.
  9. by   KelRN215
    Quote from smartnurse1982
    I guess I don't understand why the Doctors in the California case don't place the trach and gtube,and vent, and send the child home with 16 private duty nursing.

    I don't see what's so hard about that. Instead,they want to make the decision for mom,which is wrong.
    Because the child in California is dead. We don't perform surgery on dead patients unless it is to harvest organs. The actions of the hospital in California are well within established ethical guidelines. Brain death is determinant of death in all 50 states and family consent is not required to withdraw support once brain death has been determined. The hospital is 100% correct when they say that they are not under any obligation to continue to provide medical care to corpse. There's no way this child would qualify for private duty nursing. She is dead, the insurance company is no longer paying for her medical care. They are not going to grant the family the maximum number of PDN hours to provide nursing care for a dead child at home.

    Bioethicist: Girl's tragic case can't change reality of brain death - NBC News.com

    http://www.csmonitor.com/USA/Justice...ilies-disagree

    Your patients are not dead.
  10. by   smartnurse1982
    Yes,they can breathe on their own(some can) but if they were left off the vent and 02 for 2.5 hrs longer,then they would die.

    I'm sorry if I sound like an idiot,but I don't understand,seeing as I take care of kids in similiar situations.

    The boy I described earlier only had an EEG;parents won't consent to other tests.
    His pupils also don't react when light is shown into them.
    Their religion also states that death occurs after the heart stops beating.
  11. by   Esme12
    Quote from smartnurse1982
    Yes,they can breathe on their own(some can) but if they were left off the vent and 02 for 2.5 hrs longer,then they would die.

    I'm sorry if I sound like an idiot,but I don't understand,seeing as I take care of kids in similiar situations.

    The boy I described earlier only had an EEG;parents won't consent to other tests.
    His pupils also don't react when light is shown into them.
    Their religion also states that death occurs after the heart stops beating.
    You do not take care of kids in similar situations.....again if they breathe at all once removed from the vent they are NOT brain dead.

    Pupils not responding doesn't conclude brain death it concludes brain damage. Not all comatose patients are brain dead.

    Are you a RN? What is so confusing.
  12. by   KelRN215
    Quote from smartnurse1982
    Yes,they can breathe on their own(some can) but if they were left off the vent and 02 for 2.5 hrs longer,then they would die.

    I'm sorry if I sound like an idiot,but I don't understand,seeing as I take care of kids in similiar situations.

    The boy I described earlier only had an EEG;parents won't consent to other tests.
    His pupils also don't react when light is shown into them.
    Their religion also states that death occurs after the heart stops beating.
    Right, they WILL die after several hours off the vent- they are not already dead. A brain dead person has ZERO brain function, including the brain stem which controls the most primitive functions. They will not take one single breath once support is withdrawn.

    The kids you take care of are not in similar situations. They are not dead.
  13. by   Esme12
    Brain death has certain protocol to determine brain activity/circulation.
    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.
    American Academy of Neurology Guidelines for Brain Death Determination | Welcome to Clinical Operations | Life Alliance Organ Recovery Agency at Miller School of Medicine

    While many patients may be in a persistent vegetative state....they will show at least some brain activity and have some brain stem function intact. A persistent vegetative state IS NOT brain dead.

    There are no wake sleep cycles. There are no purposeful movements. They will not withdrawal to pain. There maybe some spinal reflexes at first but those fade as well.
    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., supports the clinical diagnosis of brain death
    Without the brain there is no life.
  14. by   ParisAntonel
    Quote from Esme12
    Brain death has certain protocol to determine brain activity/circulation. American Academy of Neurology Guidelines for Brain Death Determination | Welcome to Clinical Operations | Life Alliance Organ Recovery Agency at Miller School of Medicine

    While many patients may be in a persistent vegetative state....they will show at least some brain activity and have some brain stem function intact. A persistent vegetative state IS NOT brain dead.

    There are no wake sleep cycles. There are no purposeful movements. They will not withdrawal to pain. There maybe some spinal reflexes at first but those fade as well.Without the brain there is no life.
    This is a great review! Thanks for sharing, I love reading from you and GrnTea my two idols

close