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Brain Death Declaration: Diagnosis or Dilemma A Nursing Perspective

Brain Death Declaration: Diagnosis or Dilemma A Nursing Perspective. Mary McKenna Guanci MSN, RN, CNRN, CSRN Neuroscience Intensive Care Clinical Nurse Specialist Massachusettes General Hospital Boston , MA. Partners.

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Brain Death Declaration: Diagnosis or Dilemma A Nursing Perspective

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  1. Brain Death Declaration:Diagnosis or DilemmaA Nursing Perspective Mary McKenna Guanci MSN, RN, CNRN, CSRN Neuroscience Intensive Care Clinical Nurse Specialist Massachusettes General Hospital Boston, MA

  2. Partners We would like to thank the American Association of Neuroscience Nurses and the International Transplant Nurses Society for their support in making this webinar a success.

  3. Goal The goal of this webinar is to provide nurses with information and practice strategies used in the determination of brain death and describe the important role that nurses play throughout the process.

  4. Objectives Objectives: 1. Identify at least two tests performed during the brain death exam • Name those conditions that mimic brain death • State the nurse’s role in the management of the patient during brain death determination 4. Identify nursing strategies that will aid the family in understanding the brain death diagnosis

  5. Sound There will be a short video during the webinar. The sound will come from your computer, not over the phone. During the video, please turn up the volume on your computer or connect external speakers to enhance the volume.

  6. Disclosure The presenter has no financial relationships to disclose with any commercial entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

  7. Brain Death Declaration:Diagnosis or DilemmaA Nursing Perspective Mary McKenna Guanci MSN,RN,CNRN Clinical Nurse Specialist, Neuroscience ICU Massachusetts General Hospital Boston, Ma. mguanci@partners.org

  8. Case: Complexity of Brain Death Understanding • A 13 year old girl , post tosillectomy ,complicated by anoxic injury, diagnosed as brain dead. • Family refuses diagnosis, hospital obtains a court order for ventilator disconnection. • The family said it believes she is still alive and that the hospital should not remove her from the ventilator without its permission. She is moved on ventilator to outside facility willing to take her.

  9. Family Response • "It's wrong for someone who made mistakes on your child to just call the coroner ... and not respect the family's feeling or rights," Sandra Chatman, Jahi's grandmother and a registered nurse, said in the hallway outside the courtroom. • "I know Jahi suffered, and it tears me up." • Jahi's mom said last week the girl had feared she would not wake up after surgery.

  10. Definitions of Brain Death • Harvard Criteria- Harvard ad hoc group defined cerebral or brain death in 1968 • Uniform Determination of Death Act, 1980 • An individual who has sustained either (1)irreversible cessation of circulatory and respiratory functions or (2) irreversible cessation of all functions of the entire brain, including the brainstem, is dead. A determination of death must be made in accordance with accepted medical standards. • Allows for determination at the discretion of the physician. • American Academy of Neurology Guideline for Brain Death Determination -Neurology 1995;45:1012–1014. • American A

  11. Whole Brain Death vs. Brainstem Death Whole Brain • Death of whole brain; • including the brain stem. • Brainstem function is permanently impaired • “Never again be conscious or breathing.” • Example: Brain stem stroke Brainstem

  12. Man makes “miraculous” recovery from brain death after accident Oklahoma City, Okla., Mar 27, 2008 / 05:58 am/ Dateline NBC “ “A young man who was injured in an all-terrain-vehicle accident woke from his coma and showed signs of life just minutes before he was to be disconnected from life support “ Zack Dunlap suffered a broken collarbone, multiple skull fractures, and “absolutely catastrophic” brain injuries when his four-wheeled off-road vehicle flipped over.  • After tests revealed no blood flow to Dunlap’s brain, doctors determined he met the legal and medical requirements for declaring someone brain-dead.

  13. Quality Standards Subcommittee of the American Academy of Neurology Evidence-based guideline update:Determining brain death in adults. Neurology 2010 Conclusion. In adults, recovery of neurologic function has not been reported after the clinical diagnosis of brain death has been established using the criteria given in the 1995 AAN guide.

  14. Determination of Brain Death • “ There is marked variability in the performance of different aspects of the guidelines, including • Number of exams required • Types of physicians who could perform the examinations • Waiting periods between examinations”(Greer,2008)

  15. Factors Influencing the Determination Global influences • UK- Brain Stem Death 2008, “when the stalk (brainstem) is permantly out of action it is reasonable to disregard continuing activity elswhere because they can never be conscious or have spontaneous breathing” • US – Not generally accepted, total brain, President’s Council on Bioethics describes this as “clinically dangerous” Religious groups hold to heart cessation standard New Jersey- has legislation granting an exception to brain death on religious grounds. New York- “responses to individuals with religious or moral objections would be addressed by health care facilities at the community level”(Task Force on Life) Religious influences

  16. Clinical Criteria for Brain Death in Adults and Children • Coma • Absence of motor response • Absence of pupillary responses to light and pupils at midposition . • Absence of corneal reflexes • Absence of caloric responses • Absence of gag reflex • Absence of coughing in response to tracheal suctioning • Absence of respiratory drive at PaCo2 that is 60mmHg or 20mmHg above normal baseline

  17. Clinical Criteria in Children • Absence of sucking and rooting reflexes • Interval between exams • Term to 2 mo., 48 hr. • >2 mo. To 1 yr, 24 hr. • >1yr to <18, 12 hrs • >18 yrs, interval optional • Confirmatory testing • Term-2mo, 2 confirmatory tests • >2mos.to 1yr, 1 confirmatory test • >1yr to <18 yrs, optional • >18 yrs optional

  18. Mimics of Brain Death • Locked- In Syndrome • Guillain- Barre • Drug Intoxication- Four times the elimination half life ( Wijdicks 2001) • Hypothermia- loss of brainstem reflexes and pupillary dilation at 28-32 C.

  19. Testing the Brainstem

  20. Apnea Test(American Academy of Neurology) Procedure • Pre-requisite • Temp>97F • Sys BP>90 • Euvolemia • Normalize PO2,PCO2 if possible • Testing • Observe chest • 100% O2 via cannula • ABG at 8 minutes • Abort if BP cannot be sustained • PCO2 of 60 is considered high enough to expect respiration. • PCO2 increase >20mmHg. • PH < 7.30 from 7.4 or .02 unites /minute • If PCO2 does not rise >20mmHg. than other testing is needed Findings

  21. Confirmatory Testing • Transcranialdoppler ultrasound • Windows not always available • Small systolic peaks without diastolic flow, high vascular resistance consistant with high ICP • Cerebral angiography • No flow through the Circle of Willis • Electroencephalograhpy (EEG)- 16 channel for 30 minute • CT angio- ? • False positive CT angiography in brain death. (Greer , 2009)

  22. Flow studies • Cerebral flow study (isotope) • Technetium 99 • “Hollow Skull”

  23. Movement and Brain Death • Brainstem reflexes vs spinal cord reflex • 39% of patients had spontaneous movements including; triple flexion,toe flexion, arm leg movements(Saposnik 2000) • Lazarus sign

  24. Internet & News • “As Good as Dead” • Is there really such a thing as brain death? • by Gary Greenberg August 13, 2001 WASHINGTON, Dec. 7, 2008 Big 3 Were Brain-Dead • NY Times Columnist Says That In Order To Survive, Automakers Need New Management To Be More Competitive Are you employing the brain-dead? • http://blogs.computerworld.com/are_i_you_i_hiring_the_brain_dead

  25. Brain Death and the Media 46 Centimeters of Paralyzing Pizza Brain Death

  26. “Harvesting Organs When Brain Function is Still Present” ALEX TANGJ OHOR BAHRU, THURSDAY, AUGUST 21, 2008

  27. Ethics and Brain Death • What’s next…. Brainstem death ? • Organ donation and perceived influence on Brain Death Criteria • “waiting to see if they progress” • Family Coping • Is it appropriate to accommodate requests for interventions on patients who have been declared dead? • 19 yr old brain dead boy whose father requested the treating team administer a traditional medicinal substance after the declaration . • Time to extubation? Needs of the patient vs. family

  28. Nurse’s Influence • “ He looked tan…. He looked so good and they all kept saying that, you know, the nurses kept saying he looked so good”(Long,T.2008) • Common phrases heard include: • “Kept alive by the ventilator • “Life support”

  29. Automaticity Automaticity is the ability of cardiac cells to depolarize spontaneously, i.e. without external electrical stimulation from the nervous system. • SA node is the heart pacemaker • SAN is propagated to the rest of the heart through the His-Purkinje network, the fastest conduction pathway.

  30. Family Support“But his foot is moving!” • Establishing a relationship • Who is the patient? Role in the family. • Language, communication of all phases of care. • Knowledge • Neuroassessment techniques used • Clarification of neuro movements • Spinal reflexes –triple flexion, • Criteria • Preparation for removal of ETT • Collaboration with Organ Bank/plan for approach • Aftercare- social work, chaplaincy, bereavement groups.

  31. Thank You • mguanci@partners.org • www.stopstroke.org • Critical care

  32. References • mguanci@partners.org • Goudreau,J.(2000) Complications during apnea testing in the determiantion of brain death: predisposing factors, Neurology,55,1045-1048. • Greer,D(2008) Variability of brain death determination guidelines in leading US neurologic institutions.,Neurology 70;284-289. • Greer,D. ,Schwamm,L (2009) False Positive CT Angiography in Brain Death. NCC. • Long,T (2008) Conflict Rationalisation : How family members cope with a diagnosis of brain stem death. Social Science &Medicine,67 ,July 253-261 • Wijdicks,E (2001) The diagnosis of brain death, N England Journal of Medicine; Vol344,No 16 p1215-1221. Mary Guanci 3/10

  33. Questions You may type a question using the Q&A box located in the bottom center of your screen, directly underneath the PPT slide.

  34. Educational Credit Information The Organ Donation and Transplantation Alliance will be offering one nursing CE in addition to one Category 1 CEPTC credit for this webinar as well as a Certificate of Attendance. An evaluation form needs to be completed in order to receive the certificates. A link to the evaluation form will be sent out after the webinar. Inquisit is the provider of this activity. This activity awards 1.0 contact hour. Inquisit is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Inquisit is Iowa Board of Nursing provider 333 and 1.2 contact hours will be awarded for this program.

  35. Thank You! For more information and questions, please contact: Franki Chabalewski fchabalewski@odt-alliance.org or Roxane Cauwels rcauwels@odt-alliance.org This webinar was made possible by Grant Number UD2HS22186 from the Division of Transplantation, Health Resources and Services Administration, U.S. Department of Health and Human Services

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