ICU Lecture #6
Brain Death and End of Life
Christian Sonnier MD
LSU-FP Alexandria
6/25/15
Learning objectives
• Define brain death, coma and persistent
vegetative state
• Discuss management of each of the above
• Breaking bad news
• Discuss end of life care
Brain Death
• Definition:
– Total and irreversible cessation of all spontaneous
and reflexive brain functions
– Determined clinically by
• Positive coma
• Absence of all brain stem reflexes
• apnea
– Ancillary testing is not required but does include
• Cerebral blood flow study
Brain Death
• Preparation for Brain Death Assessment
– Notify LOPA
– Involve nurse and appropriate religious officials or medical
ethics personnel
– Discuss with family
– d/c sedation and paralytics
– Confirm the following
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Known and irreversible cause
Clinical and radiological evidence of CNS catastrophe
If associated with cardiac arrest re-examine q6hrs
Insure no significant electrolyte or acid base imbalance is present
r/o drugs and alcohol intoxication
Brain Death
• Clinical findings for brain death:
– Coma: no eye opening to command, no verbal response,
no purposeful movement. No withdrawal to pain
– Can not confirm brain death in presence of severe
metabolic derangements.
– Absence of brain stem reflexes
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Pupils fixed and unresponsive
No ocular movements
No oculovestibular reflex (cold water in ears with nystagmus)
No corneal reflex
No grimace or w/d from pain
Absent pharyngeal and tracheal reflexes such as gag/cough
Brain Death
• Clinical findings of brain death
– Apnea test
• Normal body temperature and adjust vent for abg that is
within following (ph 7.35-7.45) (PaCO2 35-45)
• Pre-oxygenate with FIO2 until PaO2 is over 200
• 1) disconnect from vent and provide 100% oxygen
• 2) observe for resp movements for 8 minutes
– Cyanosis, sbp under 90, significant O2 desaturation or arrhythmia
is positive for apnea and brain death and stop test
• 3) re-check abg and reconnect to vent
– If abg meets following then consider positive
» PaCO2 over 60 or increased by more than 20 from first abg
Brain Death
• If all of the above are documented and
observed then 2 licensed physicians are
required to agree in order to w/d from life
support.
Cerebral blood flow study
• http://www.nucmedresource.com/braindeath-scan.html
• This was the website I was directed to when I
spoke to the radiologist about the results.
Coma
• Definition:
– Unarousable unresponsiveness
• Etiology/pathophysiology
– Can be result of any of the following
• Diffuse, bilateral cerebral damage
• Unilateral cerebral damage causing a midline shift or compression
of contralateral hemisphere
• Supratentorial mass lesion causing herniation
• Posterior fossa mass causing brainstem compression
• Toxic or metabolic issues including overdoses
• Status epilepticus
• Apparent/pseudocoma (locked-in, hysterical rxn ect)
• s/p cardiac arrest, stroke, ICH are the most common
Coma
• Bedside eval:
– Through evaluation of cranial nerves, complete
neuro exam, history, labs, imaging, and full
physical exam
– Motor responses
Coma
• Bed side eval
– Response to pain
– Eye opening
– Pupil exam
Coma
• Bedside exam:
– Ocular motility
– Ocular reflexes
Coma
• Bed side exam
– Oculovestibular reflex
– GCS
Coma
• Conditions mistaken for coma
– Locked in syndrome
• Focal injury to base of pons usually embolic occlusion to basilar
artery
• Can be mimicked by upper spinal cord lesion, motor neuron
disease, parkinsons ect
– Akinetic mutism
• Injury to pre-frontal or pre-motor areas
• Will follow with eyes but does not obey or initate other motor
commands
• Tone, reflexes usually remain intact (including cold caloric and
postural reflexes)
– Psychogenic unresponsiveness
• Catatonia. This is a psych issue
Coma
• Diagnosis
– Work up for infection, metabolic abnl, seizures,
overdoses, surgical complications
– Cbc, cmp, abg, mag, phos, LP, cultures, urine
studies, possible LP, ct head, mri head, cta head
and neck, eeg, drug screen, thyroid and hormone
function tests
Coma
• Management
– Support ABC’s
– Support hemodynamics
– Treat any discovered underlying diseases
Coma
• Prognosis
– Coma is a transitional state between acute injury
and PVS or brain death…basically can go either
way (recovery to death)
– Use APACHE II, GCS, and FOUR points scale as well
as clinical judgment to determine prognosis
FOUR Points score
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Eye response
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Motor response
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4 = thumbs-up, fist, or peace sign
3 = localizing to pain
2 = flexion response to pain
1 = extension response to pain
0 = no response to pain or generalized myoclonus status
Brainstem reflexes
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4 = eyelids open or opened, tracking, or blinking to command
3 = eyelids open but not tracking
2 = eyelids closed but open to loud voice
1 = eyelids closed but open to pain
0 = eyelids remain closed with pain
4 = pupil and corneal reflexes present
3 = one pupil wide and fixed
2 = pupil or corneal reflexes absent
1 = pupil and corneal reflexes absent
0 = absent pupil, corneal, and cough reflex
Respiration
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4 = not intubated, regular breathing pattern
3 = not intubated, Cheyne-Stokes breathing pattern
2 = not intubated, irregular breathing
1 = breathes above ventilator rate
0 = breathes at ventilator rate or apnea
Breaking bad news
• There are many ways to go about this
however below is the model I used with this
patient’s family and it seemed to work well.
• SPIKES
Breaking Bad News
• SETTING UP the interview
• Assessing patient’s and family’s PERCEPTION
• Obtaining the patient’s and family’s
INVITATION
• Giving KNOWLEDGE and information
• Addressing the patient’s and family’s
EMOTIONS
• STRATEGY and SUMMARY
Breaking Bad News
• Setting up the interview
– Determine who needs to be there. Ask the family
who needs to be there.
• In our case it was children, nurse, myself +/- attending
– Set a time: should not be rushed let the family tell
you when they are ready
– Prepare, prepare, prepare: you want to know
everything and anticipate questions
– Must be in private place.
Breaking Bad News
• Assessing family/patient PRECEPTION
– Gather before you Give
– Patient’s knowledge, expectations and hopes
– What do they understand about the situation?
Unrealistic expectations?
– What is their state of mind? Hopes?
– Opportunity to correct misinformation and tailor your
information
this is the time to let them speak first, always
remember if the family has something to say…stop
talking
Breaking Bad News
• Obtaining patient’s/family’s INVITATION to
speak
– Again you always want to ask if they are ready to
talk before you start speaking and allow them to
change their minds as much as they want
– How much do they want to know? Very
important.
– Answer questions asked, always ask how much
detail/ information do they want.
Breaking Bad News
• Giving KNOWLEDGE
– Warning shot
– Use simple language, no jargon,
– Vocabulary and comprehension of patient
– Small chunks, avoid detail unless requested
– Pause, allow information to sink in
– Wait for response before continuing
– Check understanding
– Check impact
Breaking Bad News
• Addressing the patient’s EMOTIONS with
empathic responses
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Shock, isolation, grief
Silence, disbelief, crying, denial, anger
Observe patient’s responses and identify emotions
Offer empathic responses
Remember empathy is: The capacity to recognise
emotions that are being felt by another person you do
not have to “feel” these emotions with them.
How to express emphathy
• An indication to the patient that you recognise
what they are feeling (and why)
• Verbal and Non verbal
• Often associated with the impact of the news
rather than the understanding.
• I see that…. I appreciate …..
• Wait for response
• Clarify
Breaking Bad News
• Step 6: S – STRATEGY and SUMMARY
– Are they ready?
– Involve the patient in the decision making
– Check understanding
• Clarify patient’s goals
– Summarise
– Contract for future
Important to allow the patient’s family to make the
decision. Emphasize to them that they are in control and
you are here to advise them and implement the actions for
them. Important to emphasize that they are not locked into
any decision.
End of Life Care
• Pt in the last days/hours often have severe and
unrelieved suffering
– Physical, emotional, social
• Recognizing this kind of patient is important and
should prompt a shift from active disease
management to comfort care
• Different cultures have different definitions of a
“good death” and is entirely personal
– Important to remind patient and family that there is
no wrong answers
End of Life Care
• Place of death
– Home (+/- hospice) vs NH vs inpatient hospice vs
inpatient floor vs ICU
– Discuss this with the patient and family
– Consider burden to patient, family, financial,
providers (last one matters the least)
– Consider fears associated with each
End of Life Care
• Estimating short term prognosis
– Diagnosing dying
• Very difficult however certain clinical signs are
suggestive of death within days
End of Life Care
• Honoring preferences for end of life care
– Discuss DNR/DNI (code status with every patient both
outpatient and inpatient…should be standard
operating procedure when admitting patient)
– Discuss venue of care and make every effort to
respect these wishes
– Patient dying in the ICU
• ICU’s are designed to deliver state of the art life prolonging
care however they can do a good job at palliative care
• ICU’s have strict visitation hours and offer limited family
privacy…always consider stepping down patient to offer
more privacy
End of Life Care
• Physiologic changes and sx
– This is not an all inclusive list but the active
process of dying frequently involves
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Weakness, fatigue, functional decline
Decreases oral intake
Hypotension
Neurological derangements
Upper airway secretions “death-rattle”
Loss of sphincter tone
Inability to close or open eyes
End of Life Care
• Palliative care
– There is an entire emerging specialty devoted to
this.
– Goals are comfort care
End of Life Care
• When death occurs
– MD and or nurse needed to pronounce death and
complete death certificate
– Assess the situation and have family step out of
room if appropriate
– Assess for respirations, pulse, response to pain
and stimuli
– Coordinate with patient’s family for post-mortem
services
End of Life Care
• Resources
– Beacon project
– Hospital Chaplain or other religious services
– Uptodate.com: Palliative care: the last hours and
days of life
References:
• SPIKES – A Six-Step Protocol for Delivering Bad
News
• WF Baile, R Buckman et al.
• The Oncologist 2000;5:302-311
• Marino’s Blue ICU book
References
• http://www.nucmedresource.com/braindeath-scan.html
• Pocket ICU pg 19-1-19.4
• NEJM, 2001:344;1215
• Uptodate.com