Page 111 - ACCCN's Critical Care Nursing

88 S C O P E O F C R I T I C A L C A R E

informed to make choices about their treatment and to death will have occurred some indeterminate time before
maintain optimal self-determination (Value statement this but is only determined at this point. 62
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2.3). One of the nurse’s roles is to initiate discussions
with patients and families to get a true understanding Brain death cannot be determined without evidence of
of the cultural beliefs regarding end-of-life care. When sufficient intracranial pathology. Cases have been reported
the information is collected the health care team can in which the brainstem has been the primary site of
collaboratively assist the patient and family to make injury and death of the brainstem has occurred without
appropriate decisions. Building trusting relationships is death of the cerebral hemispheres (e.g. in patients with
the objective. severe Guillain–Barré syndrome or isolated brainstem
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injury). Thus brain death cannot be determined when
While most patients and surrogates agree with reasonable the condition causing coma and loss of all brainstem
healthcare recommendations to forgo life-sustaining function has affected only the brainstem, and there is still
therapy, there are times when members of either the blood flow to the supratentorial part of the brain. Whole
healthcare team or the patient’s family do not concur. brain death is required for the legal determination of
When disagreement or dissent occurs, it is prudent to death in Australia and New Zealand. This contrasts with
allow time to reconsider all elements in detail and to the UK where brainstem death (even in the presence of
proceed with caution and sensitivity. Collective agree- cerebral blood flow) is the standard. Brain death is deter-
ment should be the goal.
mined by clinical testing if preconditions are met; or
imaging that demonstrates the absence of intracranial
Conscientious Objection blood flow. The overall function of the whole brain is
In Australia nurses are empowered by the Australian Code assessed. However, no clinical or imaging tests can estab-
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of Ethics to refuse to participate in any procedure that lish that every brain cell has died. According to the US
would violate their reasoned moral conscience (i.e. Uniform Determination of Death Act, brain death occurs
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strongly held moral beliefs). In doing so, they must when a person permanently stops breathing, the heart
ensure that quality of care and patient safety are not stops beating and ‘all functions of the entire brain, includ-
compromised. In the critical care setting, such beliefs may ing the brain stem’ cease. Yet determining brain death is
impose on a nurse’s ability to care for a patient, in the a complex process that requires dozens of tests to make
case where the patient (or the patient’s family) has chosen sure doctors come to the correct conclusion. With that
to withdraw treatment, should the nurse hold strong goal in mind, the American Academy of Neurology issued
moral beliefs about the sanctity of human life. new guidelines in 2010 – an update of guidelines first
written 15 years ago, that call on doctors to conduct a
lengthy examination, including following a step-by-step
BRAIN DEATH checklist of some 25 tests and criteria that must be met
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before a person can be considered brain dead. The goal
Brain death occurs in the setting of a severe brain injury of the guidelines is to remove some of the guess work and
associated with marked elevation of intracranial pressure. variability among doctors in their procedure for declaring
Inadequate perfusion pressure results in a cycle of cere- brain death, that previous research has found to be a
bral ischaemia and oedema and further increases in intra- problem, and were developed based on a review of all of
cranial pressure. When intracranial pressure reaches or the studies on brain death published between 1995 and
exceeds systemic blood pressure, intracranial blood flow 2009. According to the guidelines, there are three major
ceases and the whole brain, including the brainstem, signs of brain death: coma with a known cause; absence
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dies. Determination of brain death requires that there of brain stem reflexes; and breathing has permanently
is unresponsive coma, the absence of brainstem reflexes stopped. Periodically, news reports will talk about a
and the absence of respiratory centre function, in the patient in a long-term coma that miraculously woke up,
clinical setting in which these findings are irreversible. In or someone in a persistent vegetative state who seems to
particular, there must be definite clinical or neuro-imaging have an inner life; one of the best known examples was
evidence of acute brain pathology (e.g. traumatic brain the Terri Schiavo case in Florida USA, which pitted the
injury, intracranial haemorrhage, hypoxic encephalopa- woman’s parents against her husband. The 41-year-old
thy) consistent with the irreversible loss of neurological Schiavo died in 2005, two weeks after the removal of a
function. 62
feeding tube that had kept her alive for more than a
ANZICS recommends clearly that whenever death is decade. But brain death should not be confused with
determined using the brain death criteria, it is certified by other conditions, such as persistent vegetative or mini-
two medical practitioners as defined by local legislation; mally conscious state, in which there is still some limited
consistent with the original intent of the Australian Law brain activity.
Reform Commission that the determination of brain
death should have general application, whether or not In a survey of 89 countries, legal standards on organ
organ and tissue donation and subsequent transplanta- transplantation were present in 55 of 80 countries (69%).
tion were to follow. Consistent with this, they also rec- Practice guidelines for brain death for adults were
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ommend that the time of death is recorded as the time present in 70 of 80 countries (88%). More than one
when the second clinical examination to determine brain doctor was required to declare brain death in half of the
death has been completed. That is, when the process for practice guidelines. Countries with guidelines all specifi-
determination of brain death is finalised, recognising that cally specified exclusion of confounders, irreversible