Brain Death Test, Is Family Consent Required? CA. teen Alex Pierce, June 2016

[ALansby]

Prof. Pope's blog references Public Education & Misinformation on Brain Death in MSM
http://medicalfutility.blogspot.com/...mation-on.html June 22, 2016

"We sought to evaluate the caliber of education mainstream media provides the public about brain death...."
"The subject was referred to as being “alive” or on “life support” in 72% (149) of the articles, 97% (144) of which also described the subject as being brain dead. A definition of brain death was provided in 4% (9) of the articles. Only 7% (14) of the articles noted that organ support should be discontinued after brain death declaration unless a family has agreed to organ donation. Reference was made to well-known cases of patients in persistent vegetative states in 16% (34) of articles and 47% (16) of these implied both patients were in the same clinical state." bbm

"Mainstream media provides poor education to the public on brain death. Because public understanding of brain death impacts organ and tissue donation, it is important for physicians, organ procurement organizations, and transplant coordinators to improve public education on this topic."

http://onlinelibrary.wiley.com/doi/1...12791/abstract

this is EXACTLY the reason that people are so confused. an article will say a person is brain dead and then say "they are being kept alive" by machines....it's crazy.

 

[al66pine]

Prof. Pope's blog, July 8: http://medicalfutility.blogspot.com/2016/07/two-brain-death-cases-consent-for-apnea.html

"Two recent court cases* posed the question whether family consent is required for clinicians toadminister an apnea test to confirm as suspected diagnosis of brain death.
One of those cases is now moot. 13-year-old Alex Pierce was transferred fromthe hospital in the court dispute (Loma Linda). He was later determined dead** at the Naval MedicalCenter San Diego."

BTW, June 4, somone set up a funding page for treatment & ongoing care, w $75,000 goal.Per pe.com link below, "The woman who set up the page for the family, Tara Jensen, posted an updatethat said continued donations would be used for funeral expenses."
________________________________________________

In case his ^ blog's links do not work:
* http://medicalfutility.blogspot.com/2016/06/five-active-brain-death-cases-in-us.html June21
** http://www.pe.com/articles/pierce-807670-life-school.html 2 pages. July 7, Updated July 10

 

[al66pine]

this is EXACTLY the reason that people are so confused. an article will say a person is brain dead and then say "they are being kept alive" by machines....it's crazy.

Yes, ^ EXACTLY. And it was done again w Alex.

The headline: "MURRIETA: Drowning victim declared brain dead, removed from life support (UPDATE)"
"Alex, who had been on life support since a near-drowning incident at a June 3 pool party at Vista Murrieta High School, was declared brain dead following a final test by doctors at the Naval Medical Center in San Diego." bbm
** http://www.pe.com/articles/pierce-807670-life-school.html 2 pages. July 7, Updated July 10

Meant to reply to this post earlier. Better late than never?

 

[ninij9]

Hi. From a "Lay persons" POV, when a dr tells a family their child is "Brain dead" they are already clouding the water. If my child's heart stopped would a Dr come out and say "I'm sorry Mrs Ninij9, your child is Cardiac dead"?
To me saying "Brain Dead" brings up connotations of Coma ( I KNOW it is NOT the same.) I'm just wondering why the terminology cannot be legally changed from "Brain Dead" to just plain old "Dead". Is it all about being able to harvest
organs? I'm sure some of you wonderful medical experts know why, I just wonder why we make such A HUGE distinction between Brain Death and every other form of death. Actually I was just thinking about L-VAD patients waiting for A Heart Transplant, being kept alive.GAHHHH. now I don't know what I mean. Sorry, giving this thread back to the pros.


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[ALansby]

Hi. From a "Lay persons" POV, when a dr tells a family their child is "Brain dead" they are already clouding the water. If my child's heart stopped would a Dr come out and say "I'm sorry Mrs Ninij9, your child is Cardiac dead"?
To me saying "Brain Dead" brings up connotations of Coma ( I KNOW it is NOT the same.) I'm just wondering why the terminology cannot be legally changed from "Brain Dead" to just plain old "Dead". Is it all about being able to harvest
organs? I'm sure some of you wonderful medical experts know why, I just wonder why we make such A HUGE distinction between Brain Death and every other form of death. Actually I was just thinking about L-VAD patients waiting for A Heart Transplant, being kept alive.GAHHHH. now I don't know what I mean. Sorry, giving this thread back to the pros.


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So your question is a valid one, and I will give you a couple different reasons from my perspectives.
#1 - cardiac death for hundreds of years when we were not sophisticated enough to establish brain death, was the ONLY type of death, so the terminology was just "dead" because no one knew there was any other option or adjective that would be required. It continues today because of habit. ALSO
#2 - brain death is tough to accept by families, and can be tough to understand. Keep in mind, every families situation, intelligence, level of denial, family dynamics are all different. If there was no distinguishable adjective "brain" versus "cardiac" in front of death - imagine the confusion it would cause to the family when, after brain death testing, and the MD's are notifying the family, the family goes back in the room and sees the patient still hooked up to IV's, heart monitor, ventilator, drugs, etc. They see their loved one's chest rising and falling - which they can even perceive as 'breathing', the level of mistrust and confusion at that point would be astronomical.
Having said that, the best case scenario (not speaking of patient outcomes of course, but of the care & education of the family in these situations) is to a) have time to process the injury, the severity of it and the gravity of the potential outcome. most of these cases are related to some kind of trauma, so often it is a relatively otherwise healthy individual, heightening the sense of denial of the family; b) have frequent, honest but caring descriptions of the patient's status, (e.g. if a nurse is checking a patient's reflexes, they should explain what they are doing while they are doing it - "Now I am checking to see if his/her pupils respond to light, if the brain is working correctly, the pupil should constrict when my light hits it", etc. brain death testing should never be "a total surprise" to the family; and c) in some cases I've been in attendance on, we have shown the family the brain flow study (if done); we have repeated the brain death testing sequence in front of the family. It is powerful to see the testing done - to see the tests that happen before the patient comes off the ventilator for the apnea test - and to see no response.
I do think getting "permission" for brain death testing is going down the wrong road.

 

[ninij9]

So your question is a valid one, and I will give you a couple different reasons from my perspectives.
#1 - cardiac death for hundreds of years when we were not sophisticated enough to establish brain death, was the ONLY type of death, so the terminology was just "dead" because no one knew there was any other option or adjective that would be required. It continues today because of habit. ALSO
#2 - brain death is tough to accept by families, and can be tough to understand. Keep in mind, every families situation, intelligence, level of denial, family dynamics are all different. If there was no distinguishable adjective "brain" versus "cardiac" in front of death - imagine the confusion it would cause to the family when, after brain death testing, and the MD's are notifying the family, the family goes back in the room and sees the patient still hooked up to IV's, heart monitor, ventilator, drugs, etc. They see their loved one's chest rising and falling - which they can even perceive as 'breathing', the level of mistrust and confusion at that point would be astronomical.
Having said that, the best case scenario (not speaking of patient outcomes of course, but of the care & education of the family in these situations) is to a) have time to process the injury, the severity of it and the gravity of the potential outcome. most of these cases are related to some kind of trauma, so often it is a relatively otherwise healthy individual, heightening the sense of denial of the family; b) have frequent, honest but caring descriptions of the patient's status, (e.g. if a nurse is checking a patient's reflexes, they should explain what they are doing while they are doing it - "Now I am checking to see if his/her pupils respond to light, if the brain is working correctly, the pupil should constrict when my light hits it", etc. brain death testing should never be "a total surprise" to the family; and c) in some cases I've been in attendance on, we have shown the family the brain flow study (if done); we have repeated the brain death testing sequence in front of the family. It is powerful to see the testing done - to see the tests that happen before the patient comes off the ventilator for the apnea test - and to see no response.
I do think getting "permission" for brain death testing is going down the wrong road.

Thank you for your detailed reply. So in a nutshell, our ability to keep the heart and lungs operating after brain death causes so much enabling for families to deny, not accept their loved ones death? There is a test I have heard about regarding touching patients open eye and pouring iced water into their ear. Is this an actual part of the test?

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[ALansby]

Thank you for your detailed reply. So in a nutshell, our ability to keep the heart and lungs operating after brain death causes so much enabling for families to deny, not accept their loved ones death? There is a test I have heard about regarding touching patients open eye and pouring iced water into their ear. Is this an actual part of the test?

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BBM - yes, what you are referencing are two portions of the clinical exam of testing the cranial nerve function.
Before brain death testing there are other parameters that must be in place, for example, there must be:
a) known cause of injury
b) normothermia (normal body temperature)
c) adequate blood pressure
d) no sedatives, paralytics, or similar CNS depressing-drugs on board
e) adequate blood volume
f) adequate oxygenation
g) normal amount of blood carbon dioxide

The cranial nerves that are tested evaluate the following: ((absence of response = negative result) at any point a positive result (meaning reflexes are present) stops the exam)
1) Absence of pupillary response to a bright light is documented in both eyes.
2) Absence of ocular movements using oculocephalic testing (commonly called "Doll's eyes") and oculovestibular (commonly called "Iced calorics" reflex testing. Movement of the eyes should be absent during 1 minute of observation. Both sides are tested, with an interval of several minutes.
Iced calorics is where cold (not iced) water is injected into the ear canal. If the patient's eyes don't move, and they don't projectile vomit, it's a negative response. P.S. NEVER try this on a non-comatose patient, I understand it is excruciating)
3) Absence of corneal reflex. Absent corneal reflex is demonstrated by touching the cornea with a piece of tissue paper, a cotton swab, or squirts of water. No eyelid movement should be seen.
4) Absence of facial muscle movement to a noxious (painful) stimulus. (e.g. pinching)
5) Absence of the pharyngeal and tracheal reflexes. The pharyngeal or gag reflex is tested after stimulation of the posterior pharynx with a tongue blade or suction device. The tracheal reflex is most reliably tested by examining the cough response to tracheal suctioning. The catheter should be inserted into the trachea and advanced to the level of the carina followed by 1 or 2 suctioning passes. In a normal patient, they will cough.

A pretty good article from which I borrowed (and added to) some of the descriptions:
http://surgery.med.miami.edu/laora/clinical-operations/brain-death-diagnosis

 

[ninij9]

BBM - yes, what you are referencing are two portions of the clinical exam of testing the cranial nerve function.
Before brain death testing there are other parameters that must be in place, for example, there must be:
a) known cause of injury
b) normothermia (normal body temperature)
c) adequate blood pressure
d) no sedatives, paralytics, or similar CNS depressing-drugs on board
e) adequate blood volume
f) adequate oxygenation
g) normal amount of blood carbon dioxide

The cranial nerves that are tested evaluate the following: ((absence of response = negative result) at any point a positive result (meaning reflexes are present) stops the exam)
1) Absence of pupillary response to a bright light is documented in both eyes.
2) Absence of ocular movements using oculocephalic testing (commonly called "Doll's eyes") and oculovestibular (commonly called "Iced calorics" reflex testing. Movement of the eyes should be absent during 1 minute of observation. Both sides are tested, with an interval of several minutes.
Iced calorics is where cold (not iced) water is injected into the ear canal. If the patient's eyes don't move, and they don't projectile vomit, it's a negative response. P.S. NEVER try this on a non-comatose patient, I understand it is excruciating)
3) Absence of corneal reflex. Absent corneal reflex is demonstrated by touching the cornea with a piece of tissue paper, a cotton swab, or squirts of water. No eyelid movement should be seen.
4) Absence of facial muscle movement to a noxious (painful) stimulus. (e.g. pinching)
5) Absence of the pharyngeal and tracheal reflexes. The pharyngeal or gag reflex is tested after stimulation of the posterior pharynx with a tongue blade or suction device. The tracheal reflex is most reliably tested by examining the cough response to tracheal suctioning. The catheter should be inserted into the trachea and advanced to the level of the carina followed by 1 or 2 suctioning passes. In a normal patient, they will cough.

A pretty good article from which I borrowed (and added to) some of the descriptions:
http://surgery.med.miami.edu/laora/clinical-operations/brain-death-diagnosis

So if some of these tests are performed on a comatose vs a brain dead patient the results are expected to be different? Or could they mimic? (Thank you so much for taking time to explain this to me. It's a subject that has kept me awake at times).

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[MzOpinion8d]

So if some of these tests are performed on a comatose vs a brain dead patient the results are expected to be different? Or could they mimic? (Thank you so much for taking time to explain this to me. It's a subject that has kept me awake at times).

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Right...on a comatose patient there would still be some/total cranial nerve response to these tests due to it being a reflex. In the brain dead patient the signals simply aren't there at all.

 

[ALansby]

Yes, if the tests were performed on a person who was in a coma, but not brain dead - the results would be different. Essentially the testing works "downward" into the deeper cranial nerves, for example, someone could easily have no pupil reflexes, but very much still have a cough/gag reflex and reflex to pain.
It would be rare, though for someone to have no 'deeper' reflexes and have higher level reflexes.

That's why there is so much rigor around the actual brain death testing - to make sure that it is always done correctly.