What exactly is death?

azverte · Nov 16, 2003

C'mon all you reading - please help!

If a neighbor came to you for advice on making a decision regarding organ donation, what would you say regarding when the time is right? How do you get them to understand in terms they can understand?

Thank you!

Katnip, RN · Nov 16, 2003

Our state has an organ donation center that works with families about this. When we have a patient who is dying, we alert them and they come in and handle the donor part. They're awesome, and their stats show something like 87% compliance. That's with families who have not made the decision beforehand. They also deal with the families who balk against the dying person's wishes.

As far as explaining death, I had to deal with a case just recently. Doc didn't want to take away hope, pt unresponsive, couldn't breathe without a vent, total renal shutdown; everybody knows the deal. Pt was withdrawing for weeks.

The family asked if his Ca came down, would pt. wake up. I very gently, but honestly told them that their loved one was trying to let go, that they asked that we *do everything*, and we could continue to throw more drugs and fluids at the pt, but essentially *everything* had been done.

Family was very religious and they wanted a miracle. I also explained that if God wanted pt to live, the miracle would happen with or without medical intervention. Their minister, thankfully backed me up on that.

Two days later so they could gather the whole family together, the vent was removed. Pt. didn't last 2 minutes. The family, though devastated, thanked me for being honest with them.

There's an article in American Journal of Critical Care about this very subject..November issue. Interviews with families who lost loved ones, and how angry they were that medical staff refused to be totally truthful about the pt's situation.

Yes, it's hard for bot healthcare providers and families to face the truth. but families can make much better decisions with the facts once they've had time to assimilate them.

azverte · Nov 16, 2003

Thank you so much for your post Cyber! I appreciate it.

However, it is not the dying process or end-of-life-decisions about what therapies to employ. It is about how to explain the difference between comatose/ventilated/alive and dead/ventilated/should-we-call-the-transplant-team.

How do you help families understand the definition of death?

What is the definition of "dead?"

Tough one? C'mon - if we can't - who can?

breanna · Nov 16, 2003

Originally posted by azverte
What is the definition of "dead?"

Hi azverte. I am from Florida too.

Well, absence of brain waves is pretty strong. An EEG (actually 2 EEGs) is a good definition.

Inability to breathe and needing ventilator is NOT a definition of death. Christopher Reeves is very much alive as are patients under general anesthesia - so I will go with the negative brain waves.

nocngail · Nov 16, 2003

Negative brain waves....and gentle discussion re: Quality of life vs. Quantity as it pertains to the situation.

stressednurse · Nov 16, 2003

Defining Death

An EEG that shows no brain activity, a brain blood flow study that shows no circulation to the brain.

If there are no narcotics or barbituates being used then the off the vent for 2 mins with no spontaneous respirations, co2 level rises to above 60 (I think) when a blood gas is drawn at the two minutes of no spontaneous respirations.

Water caloric test is also utilized.

I have also used an Aspect Monitor for brain wave activity over a 24 hour period.

Each facility I have worked at that did brain death criteria studies required results of 2 different types of tests showing brain death.

As long as there is some basic brain activity the patient is not "dead".

Once brain death is determined a death certificate is signed, I can commend each facility in which this happened while I was working that they allowed the patient to stay on "life support" long enough to inform family of the finding and to allow them the option of being with the patient when all support is withdrawn if they choose. (I am not talking days, but sometimes hours)

If there is no reasonable possibility to expect any recovery or consciousness then terminal weaning is considered and discussed with the family.

Quality of life is also an issue.

I have seen ALS patients request terminal weaning when vent dependant for a period of time.

There are some family members who just won't accept or just don't understand, this is where an ethics committee is helpful and clergy and the social worker can help with this also.

Added interesting story, while working in a large trauma facility I did have one patients family request transfer to another facility after brain death was declared. They were sure that the other facility did "brain transplants" It took a few minutes for them to grasp what I responded with; "You will need a donor for a brain, dead people donate organs, live people have brain activity." After that didn't do it I proceeded to ask which family member was gonna offer their brain? Ah, the light came on and they accepted death. These were not mean or difficult people, they just thought medicine could cure everything.:zzzzz :confused:

EastCoast · Nov 17, 2003

I am surprised that you all have to be the ones to discuss organ donation. I believe that the United Network of Organ Sharing nearly mandates that first approach to a family be made by qualified personnel for the very reason that you are posting this question. Procurment nurses and staff are extremely qualified and do not mince words. Often they will stay with a famliy even if the family declines donation efforts. It should never be left up to a nursing staff member to brooch this subject unless she has been trained to do and actually has the right answers to the questions the family may ask.

Brain death criteria is as mentioned lack of electrical activity and absence of respirations off vent. Physical exam is often evident enough (if you also consider mechanism of death) to determine survivability.

In our region organ procurment is quite regimented:

-Potential donor identified by nurse/doc/

-Organ bank called with info

_They arrive and go over information

-They address the family first (they will usually have the nurse present as they often have a relationship with the family)

_Family thinks/talk/prays

_If okay and patient is suitable the criteria for brain death is established and if positive further testing and steps are made to start the active process

--Family continuously recieves support ffrom our organ bank staff

I would encourage strongly that you contact your local organ bank and ask that they come and do an inservice for your staff. They are more than willing to educate so that they do not miss the opportunity to procur because someone without knowledge addressed the issue with the family before they could.

Agnus · Nov 17, 2003

In talking with donnor organizations I have been told they do not even want us to approach anyone about this.

They are to be contacted in the event of a potential donnor and they will send their specially trained people to approach and talk with the family. Unless we have on staff someone who has been specially trained to do this.

If I am approached ( and some one is a candidate)I will answer general questions but I will call the donnor folks and let them answer more specific questions.

My understanding of the legal term for death is essentially NO brain wave activity at all. I have had to explain to families that ventilators beating hearts etc were not nessasairly evidence of life.

If I was discussing advanced directives and helping some one with this. I would only ask if they wanted to donate. I would not offer to discuss it unless THEY specifically asked for information. This is just me. It would violate my personal ethic to do or say anything that might be encouraging or discouraging to some one about this. Unless they ask for specific information this is one area I stay out of.

I personally have mixed feelings about donating since talking at length with the donnor folks. I used to be very pro donating but now I am kind of neutral.

Sorry I do not recall the ethical issue that I had with this but it was something that really bothered me. It was more in terms of how they handled donations as I recall.

CougRN · Nov 17, 2003

In AZ ICU nurses are required to take a class with the organ donation group. Then we are the family approach nurses. You need to be educated by professionals before approaching, IMO and I guess the state of AZ too.

JACALA_CL · Nov 17, 2003

IN MICHIGAN, "THE GIFT OF LIFE" (ORGAN DONATION) OFFERS SEMINARS AT HOSPITAL TO HELP EDUCATE NURSES IN ORGAN PROCUREMENT.

J. B. · Nov 17, 2003

I am trying to provide a link that will be helpful to all interested in this topic.

As foar as the understanding of brain death and explaining this to families...It is a hard concept to understand let along accept.

It is the greatest challange to a Organ Procurement Corrodinator.

I had one circumstance where a wife understood the concept I explained to her and acepted that her husband was dead howeveron a vent and being supported. When she said this and and I felt she was able to decide on donation or not she said something very profound to me.

She said she wasnt sure about donation even though she had discussed the possibility with her husband and had agreed that this would be what they both would want..she still had mixed feelings about going through with it. She Said she had promised her husband that if at all possible she would be there with him when he died holding his hand. Learning this I knew she wasnt fully passed the concept that he was already dead. I supported her need to be with him and told her even though he was already dead that it seemed of greater importance that she be with him when his heart stoped. I told her that this may ttake some time once the vent was turned off but being at the bedside was where she should be for the benefit of her own promises and grief process. I encouraged her not to fret over not donating and that it was OK to fulfill that promise formost (Being there at his bedside when he died. She ended up consenting to tissue donation which was recovered after cardiac death.

I believe I did the right thing by her.

JB

Retired Organ Donation Consultant

PS to explain how I explain brai death here in this forum would be a little difficult.

I hope the link is helpful

I will try to provide the link in next message