Photo Credit: iStock.com/Sean Anthony Eddy

Dr. Frank Brodkey explains why it is absolutely necessary for Brain Death/Death by Neurologic Criteria to be determined according to medical standards.

“All stories, if continued far enough, end in death, and he is no true-story teller who would keep that from you.”

Ernest Hemingway- Death in the Afternoon

In my last contribution, I reviewed the potential pitfalls of the determination of ‘Brain Death/Death by Neurologic Criteria (BD/DNC)’ and the reasons why families and the public at large may deny ‘Brain Death’ as ‘Death’. As previously discussed, family members may have good reasons to deny the present legal and professional medical standards for Brain Death determination and may well wish to refuse extubation and consider further aggressive medical treatments of a legally dead patient.

It is absolutely necessary, both ethically and legally, for BD/DNC to be determined according to accepted medical standards, with no doubt as to the determination. Any residual doubt amongst family should be assuaged by the passage of time, repeated examinations, and second opinions. Ancillary testing, although usually not necessary for BD/DNC determination, may still be reassuring to the family.

Families and hospital staff faced with this dilemma will require emotional support. A sense of cultural humility should be maintained among staff, consistent with ethical responsibilities. A hospital-wide ethics committee or a similar group involved with ICU care should be established to serve, in unanimity, as the hospital’s official response to this issue, demonstrating to the family the seriousness and gravity held by the hospital in this and related matters. As BD/DNC is a medical determination, it may or may not be appropriate for chaplains or attorneys to play a role in this process; however, they should be involved at the family’s request. The attending Intensivist may or may not be part of the committee, depending on the family’s and staff’s wishes and comfort levels.

A significant percentage of BD/DNC patients will spontaneously develop cardiac arrest, even while these deliberations are taking place; therefore, it is important to attempt to arrange an agreement not to accelerate treatments (eg, CPR) among them. This will often be acceptable to families, even if withdrawal of care is not. It is usually easier for families to agree not to advance therapies than to discontinue those already started.

Requests for additional time for decision are common and should be freely granted; however, extended periods (more than a few days) seem inappropriate and disrespectful to both the patient and the caregiver and should be avoided.

A family’s personal, religious, or cultural beliefs should be accepted with appropriate respect; however, there is no obligation on the part of the care team to agree with non-scientific or non-legal doctrines. Language is vitally important in these discussions, and patients, unfortunately, are properly referred to in the past tense. In addition, BD/DNC patients should always be referred to as simply ‘Dead,’ not ‘Brain Dead,’ ‘Potentially Dead,’ or ‘Probably Dead.’ Similarly, ventilators, pressors, and other supportive treatments and equipment should be referred to by name and function, and never be referred to as ‘Life Support’.

Finally, to avoid any confusion regarding goals and conflicts of interest, it is essential that potential organ donation never plays a role in these discussions unless specifically requested by the family. Of course, families also need to understand that previously authorized donations, such as those made by driver’s license notation, must be ethically and legally honored.

It is hoped that proceeding in these firm, yet deliberate and respectful, manners will result in a reasonably amicable course, free from the need for legal intervention.

Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Physician’s Weekly, their employees, and affiliates.