removal from life support question

eagle78 · Oct 22, 2011

I found this in an article from Critical Care Nursing:

"The patient should be deeply comatose, with no response to painful or verbal stimuli, including decorticate or decerebrate posturing. He or she should also have no spontaneous movement, including shivering, seizures, or respiratory movement. The single exception is movement resulting from spinal reflexes."

Determing Brain Death in Adults: A Guideline for use in Critical Care http://ccn.aacnjournals.org/content/24/5/50.full

That says to me that there can still be spinal reflexes, maybe that is what the OP saw???

ONRADAR124 · Oct 22, 2011

In the brain dead patient, myoclonus originates in the spinal cord. It is not a seizure because, by definition, a seizure originates in the brain.

Fine, then by that definition I am wrong. Thanks for the correction.

mrr5745 · Oct 22, 2011

Never seen this, but I've heard stories about it:

One of the most startling movements for family members and health care professionals is called the ‘Lazarus sign.’ It is a sequence of movements lasting for a few seconds that can occur in some brain dead patients, either spontaneously or right after the ventilator is disconnected,” Bueri said. It is named for the episode in the Bible where Lazarus is raised from the dead.

“It starts with stretching of the arms, followed by crossing or touching of the arms on the chest, and finally falling of the arms alongside the torso,” he said. “It is also a spinal reflex, but it can be disturbing to family members and others who see this.”

suanna · Oct 22, 2011

Never seen this, but I've heard stories about it:
One of the most startling movements for family members and health care professionals is called the 'Lazarus sign.' It is a sequence of movements lasting for a few seconds that can occur in some brain dead patients, either spontaneously or right after the ventilator is disconnected," Bueri said. It is named for the episode in the Bible where Lazarus is raised from the dead.
"It starts with stretching of the arms, followed by crossing or touching of the arms on the chest, and finally falling of the arms alongside the torso," he said. "It is also a spinal reflex, but it can be disturbing to family members and others who see this."

If this were to happen to a patient I was caring for who had been declared "dead" there would have to be a code called- FOR ME! At least I'd have to make a trip to the locker room for a quick change of scrubs.

I did have a patient : asystole, flat line on A line, PAP line for over 15 min start having "Agonal Respirations". He would take a long deep breath about once every 5-10 minutes. Pt was s/p trach so the sound was disturbing to say the least. Fortunately for the family he stopped before they came to the bedside to pay thier last respects. I don't think I could convince a family it was OK to take thier grandfather to the morgue if he was taking a breath or two now and then I'm sure I couldn't zip someone into a body bag if they were occasionaly doing "Pilaties" with thier upper body. CREEPY!

xtxrn, ASN, RN · Oct 22, 2011

One of my nursing student buddies came out to the desk early one shift, and asked if any of us had seen the instructor. None of us thought anything of it, and said no (someone was ALWAYS looking for the instructor). She said "well, if you see her, tell her my patient is dead" :eek: :eek: :eek: :eek: WHAT????? OK...first question- is said patient a no code (yes....ok, exhale). Someone ran off to find the instructor. I hung back with my friend (ethnic skin tone was about 4 shades lighter than normal, and I was seriously concerned about some chain reaction getting ready to start). Instructor shows up with the student who found her (that student also not looking well).:uhoh21: Instructor gets info- patient died during the bath. Was a no code- and now my friend needed to do post mortem care. (another shade paler). She asked if I'd help my friend, she'd see that my patient was taken care of.... no problem. I'd been working as a CNA during school... dead folks weren't nearly as much trouble as the breathing ones . Let's go. :up:

My friend and I go into the room (family had left) and I told her that sometimes people twitch, or the air in their lungs "empties" when they are turned. I turned around- and I was the only live body in the room. Uh...YO?.... ya still there? No answer. :cool: Looking around at ceiling, view out window, dead guy.... My friend came back about 10 minutes later (I'd been dealing with the trivial things - not tubes that she had "custody" of), and told me she needed to talk to her husband .....and that if there was any twitching going on, she was going out the window.

She survived. :clown: I think she has her PhD now. I'd love to have a day with her students to tell stories :)

Mommy&RN, BSN, RN · Oct 22, 2011

http://www.sciencedaily.com/releases/2000/01/000113080008.htm

the clinical examination includes an evaluation of overall responsiveness, brain-stem reflexes, and apnea testing. the patient should be deeply comatose, with no response to painful or verbal stimuli, including decorticate or decerebrate posturing. he or she should also have no spontaneous movement, including shivering, seizures, or respiratory movement. the single exception is movement resulting from spinal reflexes. the assessment of responsiveness and movement requires that the effects of all neuromuscular blocking agents and sedatives have worn off completely (see table[url=http://ccn.aacnjournals.org/content/24/5/50.full#t1][/url]).

http://ccn.aacnjournals.org/content/24/5/50.full

mrr5745 · Oct 22, 2011

http://www.sciencedaily.com/releases/2000/01/000113080008.htm
the clinical examination includes an evaluation of overall responsiveness, brain-stem reflexes, and apnea testing. the patient should be deeply comatose, with no response to painful or verbal stimuli, including decorticate or decerebrate posturing. he or she should also have no spontaneous movement, including shivering, seizures, or respiratory movement. the single exception is movement resulting from spinal reflexes. the assessment of responsiveness and movement requires that the effects of all neuromuscular blocking agents and sedatives have worn off completely (see table[url=http://ccn.aacnjournals.org/content/24/5/50.full#t1][/url]).
http://ccn.aacnjournals.org/content/24/5/50.full

very good point about the meds! :yeah:

just recently i did a f/u visit on a patient i hadn't met before. did a through neuro exam and her gcs was 3. i told the snf nurse not to give her pain meds as i saw no s/s of pain and she was brain dead. the next morning, her regular nurse went in for a visit after receiving report on my assessment the night before. the patient was literally walking up and down the halls because she wanted exercise. she had not received any pain meds for about 12 hours, and what a huge difference that made!!! this served as a great reminder to me that meds most certainly can mask the pt's true condition!

Laurie52 · Oct 22, 2011

Very good point about the meds!
Just recently I did a f/u visit on a patient I hadn't met before. Did a through neuro exam and her GCS was 3. I told the SNF nurse not to give her pain meds as I saw no s/s of pain and she was brain dead. The next morning, her regular nurse went in for a visit after receiving report on my assessment the night before. The patient was literally walking up and down the halls because she wanted exercise. She had not received any pain meds for about 12 hours, and what a huge difference that made!!! This served as a great reminder to me that meds most certainly can mask the pt's true condition!

As nurses we need to be careful when using the term brain dead. This patient may have been overmedicated and unresponsive but she was not brain dead. Brain death is a very specific diagnosis. It makes it difficult for nurses to discuss true brain death with a family because they remember when they were told grandpa was brain dead and then he woke up.

shhhh · Nov 2, 2011

Just last weekend, I extubated my brain dead patient. As you would expect, prior to extubation, he had no purposeful movement, no localizing, not posturing, etc. A few minutes after extubation, as his sats were dropping and he stopped breathing, it appeared to me that his entire body just tensed up severely. It looked like neuro-storming in slow motion (to me, at least).

I really wasn't expecting him to actually move at all, but what I saw didn't really shock me either. I surmised that his body was experiencing profound air hunger and the movement was the consequence of that. I pushed 10 mg of morphine, and he went asystole about two minutes later. Withdrawing care from a patient is never a walk in the park for me, and I felt very gloomy the rest of the evening.

Reading the OP's original question, I thought that perhaps what I experienced was similar. Does anyone agree with me?