When Family Members Cannot Agree to Remove Brain Dead Patient What Can the Ethics Department Do
BMJ. 1999 Jun 26; 318(7200): 1753–1755.
Ethical dilemma
Discontinuation of ventilation later brain stalk expiry
Defoliation among the public over the difference between brain stem expiry and a persistent vegetative state can get in hard to obtain consent to withdraw ventilation. Clinicians who have been faced with this dilemma outline their strategies for coping with such a situation, and a neurologist and a neurosurgeon offer their opinions.
1999 Jun 26; 318 (7200) : 1753–1755.
To whom is our duty of intendance?
The concept of brain death is not ofttimes discussed in the public arena. According to the royal medical colleges in the United Kingdom and their faculties death of the brain stalk is a component of encephalon death, and brain decease is decease.ane-1 The criteria for brain stem decease are well established,1-2 and their use in intensive care units enables treatment to exist withdrawn from patients with encephalon stalk expiry without recourse to the courts. Conversely, as a result of several loftier profile cases, persistent vegetative land has been reported on frequently in contempo years. The application to the High Courtroom in 1992 to discontinue life sustaining treatment for Tony Bland, who had been injured in the tragedy at Hillsborough football ground, brought the ethical fence to the front pages of the national printing. Occasional stories of "miraculous recoveries" from comas are widely reported and may have led to an exaggeration of the pocket-sized chances that patients have of recovering from a persistent vegetative state among a public that is increasingly well versed in this status. This contrasts with the inevitable death from asystole which occurs inside a few days for patients who are brain dead.one-3
ANGELA SMITH
Nosotros accept experienced a case in which, although the patient had been alleged encephalon stem dead, the patient'southward family prevented us from switching off the ventilator. On this occasion our intensive care unit was full, and maintaining this patient on a ventilator might accept forced us to transfer any new critically ill patients to another hospital, with the associated increment in life threatening complications that this would have entailed.1-four
Case written report
An 18 year sometime girl was brought to the blow and emergency department of our infirmary. She had been found collapsed at home by her family who had begun basic life back up. After unsuccessful attempts at avant-garde life support by the paramedic crew at the scene she was transferred to hospital, where a cardiac output was achieved later on further defibrillation. Nosotros estimated that she had been without spontaneous cardiac output for at least 30 minutes. She was transferred to the intensive care unit for full ventilatory and inotropic support. Blood concentrations of tricyclic antidepressants were high, confirming the family unit's suspicion of an overdose. Activated charcoal was given nasogastrically. From the beginning of handling the family was made aware of the patient's poor prognosis and the high probability of her death.
Subsequently 72 hours blood concentrations of the ingested drug had fallen to the lower end of the therapeutic range, and ii sets of brain stem tests were performed co-ordinate to national guidelines.1-2 The family unit had been kept fully informed of the patient's condition up to this signal and were aware that encephalon stem testing was beingness performed. The significance of the tests had already been explained to them, and they had already ruled out the possibility of organ donation.
Still, afterward the proclamation of death the family refused to allow the ventilator to be switched off. We believe that a good relationship had been maintained with the family unit at all times, but they were unable to accept that the patient was dead while her heart was all the same beating. Nosotros were contacted past a lawyer acting for the family and threatened with an injunction to prevent united states from switching off the ventilator. We sought advice from the management of the hospital, the hospital'due south legal advisers, and a medical defence union. They all brash u.s. not to stop artificial ventilation. Just later on 48 hours, and later discussions with representatives of the family and their general practitioner, did the patient'due south family unit eventually agree to allow us to switch off the ventilator.
In discussing this case with colleagues we were fabricated aware of two other similar cases that had occurred in our intensive care unit in which, despite the declaration of brain death, patients were ventilated at their family's insistence until they became asystolic.
Conclusion
We believe that there is confusion among the public over the differences between brain stalk expiry and a persistent vegetative country. This, combined with high profile reporting of miraculous recoveries from comas, has led to the evolution of unrealistic expectations of the potential for recovery of patients who are brain dead. The confusion is further complicated by cultural and religious beliefs about death which may vary from the medical and legal definitions.
This case also highlights the upstanding upshot of priorities of care. For ii days we ventilated a patient who was legally dead. For about of that time our eight bed unit of measurement was full with patients who required ventilation. Had we had a request to admit a patient who required ventilation we would have been unable to take the patient and would instead have had to transfer him or her to another hospital. To whom is our duty of intendance greatest? Is it to the grieving family of a dead patient or is information technology to the critically ill patient who is placed at greater risk by an unnecessary transfer between hospitals?1-four According to Sprung et al, brain death is one of the few situations for which there are accepted medical criteria that enable the autonomy of the md to prevail over the requests of the patient's surrogate.ane-five
It is important to raise the public'due south awareness of brain stem death and its implications. The public needs to know that past definition at that place is no hazard of recovery from brain stem death, and the differences betwixt brain decease and a persistent vegetative country need to be explained. In this instance we were grateful for the involvement of the family unit's full general practitioner, and nosotros believe that general practitioners might likewise benefit from having a clearer agreement of encephalon stalk expiry. Sensitive and thoughtful explanations from medical and nursing staff combined with a amend understanding of the nature of this condition will help grieving families cope with this difficult situation.
References
1-one. Conference of Medical Colleges and their Faculties. Diagnosis of brain death. BMJ. 1976;two:1187–1188. [PMC complimentary article] [PubMed] [Google Scholar]
1-two. Criteria for the diagnosis of brain stem death: review past a working grouping convened past the Royal College of Physicians and endorsed past the Briefing of Medical Imperial Colleges and their Faculties in the United kingdom. J R Coll Physicians Lond. 1995;29:381–382. [PMC free commodity] [PubMed] [Google Scholar]
1-4. Braman SS, Dunn SM, Amico CA, Millman RP. Complications of intrahospital send in critically sick patients. Ann Intern Med. 1987;107:469–473. [PubMed] [Google Scholar]
one-5. Sprung CL, Eidelman LA, Steinberg A. Is the physician's duty to the individual patient or to gild? Crit Intendance Med. 1995;23:618–620. [PubMed] [Google Scholar]
1999 Jun 26; 318 (7200) : 1753–1755.
Policy should be counterbalanced with concern for the family
The upstanding and legal concept of brain stalk decease is still in transition in the Usa, the United Kingdom, and elsewhere.2-ane It has not notwithstanding been fully accepted by practitioners, past the general public, or past patients and their families. The concept of brain stem death as a neurological syndrome has only existed for the past 40 years or then, and as an upstanding and legal concept (that is, brain stem death is death) it has existed merely for 30 years. Many more years probably will go by until this concept reaches a high degree of medical and social acceptance.
In the clinical setting the diagnosis of encephalon stem death, the pronouncement of expiry, and the raising of problems of organ donation are usually compressed into a matter of hours or a few days. Different the persistent vegetative state—which it may accept weeks, or even months, to diagnose and constitute irreversibility—the diagnosis of the irreversible loss of brain stalk functions tin be determined with a high degree of certainty within a brusque time. Because of this, family members should exist approached in steps and so that they are able to fully comprehend the process. The starting time step should be to inform the family of the poor prognosis for recovery of neurological functions. The 2d pace should be to enhance the possibility that the patient may be brain dead; at this point families should exist told that studies are being performed to decide whether this is the case. The 3rd step should be taken when it seems fairly certain that encephalon stem death has occurred, and the family unit should then be told clearly and unequivocally that the usual practice at the hospital is to pronounce a person dead once neurological criteria have been confirmed. With this approach, a family unit should be able to fully understand that the pronouncement of decease is non their determination and that the determination of brain stem decease as expiry is a medical conclusion merely equally cardiorespiratory expiry is.
At the aforementioned time, practitioners should be sensitive to the feelings of families who are suddenly confronted with the expiry of their loved one, who may still look "alive" and who may have been a salubrious and vibrant human existence but a few hours ago. Thus, it seems reasonable and humane to give the family some fourth dimension to understand the procedure and integrate the concept. But for how long, and nether what circumstances should the time be given? There are no clear cutting answers to these questions and there never volition exist. Nether what other circumstances and for how long is it permissible to delay, or hasten, the pronouncement of death and termination of support systems? Should the pronouncement of decease be delayed, or not made at all, if the family unit is in a land of denial and completely unable to have the concept of brain stalk expiry for religious or other reasons? What should exist washed in cases in which brain stem decease has apparently been caused by the actions of the doctors providing treatment, or in cases in which the pronouncement of decease volition cause charges against an alleged aggressor to exist inverse from attempted murder to murder? Should time be taken to find family unit members to proceeds consent to organ donation? Or should the need for beds in the intensive intendance unit be considered when at that place is a shortage?
If practitioners really believe that brain stem death is death and so infirmary policies and the actions and practices of practitioners should be as uniform as possible. Pronouncements of decease should not be speeded up because of a shortage of beds in the intensive care unit nor should they be delayed unnecessarily to await for relatives to consent to organ donation.
In this example the doctors acted wisely and humanely, balancing a compatible policy on brain stem decease with appropriate concern for the family. Involving the general practitioner who knew the family unit well was also wise. Only when practitioners have more experience in treatment cases of brain stem death and when in that location is more widespread credence amid the public will these controversies diminish. Until then, dilemmas similar the one discussed past Swinburn et al will continue to ascend. Neurological and neurosurgical specialists, legal directorate, and ethics committees at individual hospitals should discuss some of these issues in advance so that they know how to handle them when they occur.
References
2-1. Youngner SJ, Arnold RM, Schapiro R, editors. The definition of death: contemporary controversies. Baltimore: Johns Hopkins Academy Printing; 1999. [Google Scholar]
1999 Jun 26; 318 (7200) : 1753–1755.
Brain stem death defines death in constabulary
The concept of encephalon death was exposed to intensive public scrutiny in 1981 following a controversial Panorama programme on television in which it was asserted that the diagnosis of brain death could exist uncertain.3-one A afterwards plan, fabricated past doctors nominated by the royal colleges, was specifically broadcast to rebut the assertions. A contempo review past the royal colleges preferred the term encephalon stem death but found that there was no demand to modify the original diagnostic criteria outlined in 1976, which require two doctors to carry out specific tests on two occasions.three-2 At that place is no possibility of diagnostic defoliation between patients who are brain stem dead and those who are in a persistent vegetative land. This should exist explained to families who may, as Swinburn et al suggest, doubt the reliability of the diagnosis of brain death because of reports of the misdiagnosis of patients in a persistent vegetative country and of the few vegetative patients who make a partial recovery.
An essential component of all formal pronouncements past the royal colleges and the Departments of Health on this subject field is that once a patient is declared encephalon dead he or she is as well legally expressionless. The departments' 1983 code of practice specifically states that the time of expiry is the time at which brain death is established and not some later fourth dimension when ventilation is withdrawn or the heartbeat ceases.iii-iii Clinicians should emphasise this when explaining the state of affairs to relatives, and they should make it clear that ventilation is not being withdrawn to let the patient dice but because continued ventilation is inappropriate for a patient who is already dead. The but justification for maintaining ventilation for a curt time is to preserve the status of organs when information technology has been agreed that they are to exist made available for transplantation.
In the United Kingdom no ane other than a doctor can decide most the provision or withholding of treatment from an adult who is unable to give consent, although practiced practice dictates that the family should exist consulted and kept informed. Parents take more rights in regard to their children. In 1992, a 19 calendar month old child was declared encephalon dead afterwards suspected not-accidental injury but an emergency protection order was granted to require the consent of those who had parental responsibility before a life back up machine could be switched off. A Loftier Court gauge declared that the kid was undoubtedly expressionless and that if the md considered information technology appropriate to withdraw ventilation this would not exist reverse to the law.3-iv
There has been much word in recent years nigh the upstanding propriety of doctors deciding, on the grounds of the off-white allotment of resources, to care for one patient rather than another because one is considered more likely to benefit. Some have challenged the appropriateness of such decisions considering they are based on the value judgments of doctors rather than on the wishes of patients. Nonetheless, even those who believe this admit that encephalon death is i of the few weather most which such an statement is non relevant.3-5 This is because in that location is no question of balancing the comparative benefits expected from treating two different patients, every bit the brain dead patient tin can derive no do good from maintaining ventilation.
References
3-one. Jennett B. Brain decease. Br J Anaesth. 1981;53:1111–1119. [PubMed] [Google Scholar]
3-2. Purple Higher of Physicians Working Party. Criteria for the diagnosis of brain stem death. J R Coll Physicians Lond. 1995;29:381–382. [PMC gratuitous article] [PubMed] [Google Scholar]
3-three. Health Departments of Dandy United kingdom and Northern Republic of ireland. Cadaveric organs for transplantation: a lawmaking of practice including the diagnosis of brain death. London: HMSO; 1983. [Google Scholar]
3-4. Re A (a minor) [1992] 3 Med LR 303-5.
3-v. Sprung CL, Eidelman LA, Steinberg A. Is the physician's duty to the private patient or to society? Crit Intendance Med. 1995;23:618–620. [PubMed] [Google Scholar]
Articles from The BMJ are provided hither courtesy of BMJ Publishing Group
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1116089/
0 Response to "When Family Members Cannot Agree to Remove Brain Dead Patient What Can the Ethics Department Do"
Post a Comment