Download Brain stem Death by Dr Aden McLaughlin

Name of Disorder: Brain Stem Death
Essay Title: Brain Stem Death
Author: Dr Aden McLaughlin
Institution: Gold Coast University Hospital
Date: 27.06.2014
Brain Stem Death
Brain stem death, or more simply brain death is a terrifying and at times confusing
diagnosis. Commonly in the Intensive Care setting loved ones and family members
receive the earth shattering diagnosis on behalf of their treasured relative without any real
understanding of what this means for themselves or for their relative. Confusion with the
diagnosis often abounds, particularly when it is obvious to family that a loved one’s heart
continues to beat, skin remains pink and warm and who’s chest continues to rise and fall albeit with the aide of modern intensive care ventilators. It can be immensely difficult for
family to grasp that despite the presence of these signs that we hold to be so intimately
related to life, their loved one has suffered an injury to their brain so severe that their
condition is irretrievable. All of this of course is often thrust upon distraught relatives and
family during their most vulnerable moments in life.
Definitions of brain death have varied slightly over time and between countries. The
current legal definition of brain death in Australia is: a) irreversible cessation of all function
of the brain of the person; or b) irreversible cessation of circulation of blood in the body of
the person1. Such a diagnosis carries the immense gravity of finality and there is no room
for clinical uncertainty. For a clinician to come to the diagnosis of brain death and to
subsequently convey that diagnosis to a distraught and loving family is a process that
takes time and requires a number of specific qualifying conditions in order to eliminate all
ambiguity.
Diagnosis of brain death in Australia requires the patient to have suffered a brain injury
severe enough to be consistent with causing death1. Such injury is associated with an
increase in the pressure inside the skull which cuts off blood supply to the brain. Overtime,
this causes the entirety of the brain to die. A situation that is irretrievable. The most
common causes of such a severe injury include; trauma, stroke, and severe lack of
oxygen to the brain for example following a heart attack with prolonged cessation of
normal heart function2. Before clinical testing of brain death can be undertaken all possible
reversible causes of the patients lack of consciousness must be explored and ruled out
and the following conditions must apply1-4:
- Brain scans show sufficient brain pathology to cause death
- Body temperature is normal
- Blood pressure is normal or close to normal
- Drug effects have been ruled out
- New significant electrolyte, metabolic and hormonal conditions have been ruled out
- Nerves supplying muscles are intact and not paralysed by medications
- Brain death testing is not prevented by severe injury to the ears and eyes
- Ability to safely perform a test period off the breathing machine is available
If all of these qualifying conditions have been met, clinical testing of brain death can
proceed. Brain death is confirmed if there is a lack of brain reflex response to stimuli like
pain; lack of primitive brain stem reflexes like coughing when the patients wind pipe is
irritated; and if the patient fails to breathe when disconnected from the ventilator for a
period of time. The above tests must be confirmed by a second doctor1-4.
The diagnosis of brain death by no means implies nursing staff and medical staff will stop
caring for a patient. The patient continues to be a beloved family member that deserves
continued respectful care and attention. However the diagnosis implies that the clinical
situation for the patient is dire and nothing can be done to save their life. A great deal can
be done however to help care for the patient’s relatives and loved ones left behind in such
devastating circumstances. It may be appropriate, both culturally and medically to consider
the patient as having the potential to donate their organs to patients around the country
awaiting life-saving transplantations. The organ donation process can have therapeutic
effects for distraught family members and help bring them some degree of meaning and
peace in a time of otherwise abject tragedy. The transplant co-ordinator for a particular
health service will most likely be involved in the patient’s care from an early point in time
following the diagnosis of brain death. This is not to lead the family down the path of
transplantation, but to provide a supportive role both medically and to the family to
facilitate transplantation if that is the eventual decision.
In some instances, whether for cultural or medical reasons, patients may be unable to
donate their organs following the diagnosis of brain death. These decisions, whether made
by the patient or by the family are always explored and respected. Sensitive and timely
multidisciplinary discussions involving medical, nursing and allied health staff and the
patients relatives and family are undertaken to develop an end of life plan for the patient.
This may involve withdrawal of supportive therapy, such as the breathing machine or
continuation of such support for a clinically appropriate time so as to allow family members
to pay their last respects. Patients who have been diagnosed with brain death will continue
to be nursed and cared for throughout this process. Following withdrawal of supportive
therapy the brain dead patient will not breathe and their heart will cease not long after this.
It is conventional practice in our society to provide pain relief during this period to help
assure family members that their loved ones suffered no pain. The time of death will be
recorded as the time the diagnosis of brain death was first made.
References
[1] Statement on death and organ donation 2010, DonateLife, Viewed 21 June 2014,
<http://www.donatelife.gov.au>
[2] Berston, A and Soni, N, 2009, ‘Oh’s Intensive Care Medicine’, Butterworth Heineman
Elselvier, Philadelphia, USA
[3] Singer, M and Webb, A, 2009, ‘Oxford Handbook of Critical Care’, Oxford University
Press, Oxford, UK
[4] Greenberg, M, 2010, ‘Handbook of Neurosurgery’, Thieme Medical Publishers, New
York, USA