Death and brain death

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The death of a patient is one of the most difficult situations for clinicians, especially if the patient is well-known to them or has been their patient for a long time.
It is an important clinical responsibility that requires strong communication, clinical accuracy, and an understanding of medical and legal standards.
In healthcare, death is diagnosed using either circulatory criteria or neurologic criteria, also known as brain death. Physicians are most commonly responsible for pronouncing the death of a patient.
OK, let's start with circulatory death, which is defined as an irreversible cessation of circulatory and respiratory function.
When a patient is thought to be deceased, a clinician is contacted by the healthcare team. Keep in mind that even though it is physicians who are typically called to pronounce death, other clinicians like physician assistants, nurse practitioners, nurses, paramedics, or coroners may diagnose death depending on state and institutional laws and policies.
Before entering the patient's room, the clinician should review the medical chart, identify family members and the healthcare proxy, and determine whether organ donation or autopsy discussions have already occurred.
Nurses may also provide information regarding the patient's condition and circumstances of death, as well as family needs such as pastoral care.
Upon entering the room, clinicians introduce themselves to the family and explain that an examination will be done to pronounce their loved one.
The family may stay or leave the room during the examination. The exam begins by confirming the patient's identity on their identification bracelet.
The next step is to assess the lack of movement and absence of response to verbal or tactile stimulation, such as nail bed pressure.
Using more aggressive tactile stimulation, such as a sternal rub may cause unnecessary distress to the family. Then pupils are checked, which are fixed and non-reactive.
Lastly, the absence of respirations is confirmed by observing no chest movement or breath sounds. While absence of circulation is confirmed with no carotid pulse or heart sounds.
For ventilated patients, first confirmed that no paralytic drugs were given in the last 6 to 8 hours. The patient should have no pulse, no measurable BP, or no electrical activity on electrocardiogram tracing before the ventilator is disconnected.
The remainder of the death examination is then performed as usual. After death is confirmed, clinicians should use SPIKE's guidelines for delivering bad news.
SPIKE stands for setting, perception, invitation, knowledge, empathy, and strategy, and involves creating an appropriate setting, starting the conversation with a headline, warning them that bad news is coming, using clear language, responding with empathy, and planning next steps such as patients' wishes for organ donation or autopsy.
Finally, the physician documents the examination findings, including date and time of death, presumed cause of death, and important communications with consultants, coroner, and family members.
The interdisciplinary team also assists in arranging pastoral visits and organ procurement organizations if needed. Here's a legal connection.
By law, deceased patients may need to be referred to a coroner. It varies by state, but usually patients who died within 24 hours of a hospital admission under unusual circumstances such as a sudden death or whose death was associated with trauma such as a suicide, homicide, or an accident should be referred to a coroner.
OK, let's see how this works in practice. Nurse practitioner or NP Mina is called by a nurse to pronounce the death of Miss Sebastian, a 65 year old woman with metastatic breast cancer.
She was admitted 48 hours ago with intractable vomiting and treated with anti-nausea and pain medications. During morning nursing rounds, Miss Sebastian was found not breathing and with no pulse.
She signed a do not resuscitate and do not intubate order two weeks ago when her metastatic cancer progressed and was found to be terminal despite aggressive therapy.
NP Mina begins the examination using the circulatory criteria to determine death. She notes the patient is not moving and does not respond to voice or when pressure is applied to her nail beds.
Her pupils are fixed and dilated. Her chest is still, lung sounds are absent, and she has no carotid pulse and no heart sounds.
Next, NP Mina calls Miss Sebastian's healthcare proxy. I'm sorry, Miss Sebastian has died, she says.
She avoids medical jargon and euphemisms for death such as past or is no longer with us. She provides empathy and offers space for questions.
They discuss Miss Sebastian's wishes for organ donation and autopsy. NP Mina concludes her examination by documenting the time and date of death.
Details of the death examination. And summary of her discussions with the clinical team and healthcare proxy.
Let's move on to brain death, which is the complete irreversible loss of all brain function in a patient who has cardiac activity.
It is characterized by coma and loss of brain stem reflexes and respiratory function. Diagnosing brain death is more complicated than diagnosing circulatory death.
First, the cause of brain injury must be known and irreversible, often accompanied by significant abnormalities on brain imaging like severe cerebral edema or intracranial hemorrhage.
Before brain death testing can begin, reversible conditions that can mimic or interfere with the examination like hypothermia, severe hypotension, drug intoxication, or neurologic conditions like Guillain-Barre syndrome must be excluded or treated.
Patients must be observed before brain death testing to confirm that the coma is irreversible and that sedating drugs such as barbiturates have cleared.
In adults, the observation period is at least 6 hours. However, many physicians wait longer after a noxic brain injury such as post-cardiac arrest or in pediatric patients.
The brain death examination is performed in 3 parts. The first evaluates cerebral cortex function by confirming coma, which is an unconscious state where the patient is unresponsive to noxious, visual, auditory, and tactile stimulation.
The second part evaluates brain stem reflexes, including pupillary, corneal, oculocephalic, oculovestibular, gag, and cough reflexes.
Patients with brain death do not have brain stem reflexes bilaterally. The final part is performing the apnea test, which assesses spontaneous breathing when carbon dioxide levels rise.
When discussing brain death with families, the clinical team should communicate with simple language in an empathetic way using the SIKES protocol.
Families should also be told that although their loved one's heart is beating, the patient has died because all brain and brainstem function has stopped.
Any remaining movements are due to automatic spinal cord reflexes and do not indicate consciousness or recovery. Here's another legal connection regarding brain death protocols.
For example, some states exclude treating or transplant physicians from participating in the brain death examination. Instead, 2 independent physicians are required to examine the patient, potentially an ICU or neuroscience physician.
Again, in some states, nurses can perform brain death examinations. Let's go through another case and see how brain death is pronounced.
Doctor Patel, the ICU fellow, is called to perform a brain death examination on Mr. Light, a 72-year-old man with a large intracerebral bleed due to a ruptured aneurysm.
He is unconscious and the ICU staff has not observed any changes for 2 days. He does not have any conditions that could mimic his condition or interfere with performing the brain death examination, including administration of recent sedating medications.
Doctor Patel uses the neurologic criteria to determine brain death. Assessing cerebral activity, Mr.
Light does not respond to his name being called or when pressure is applied to his nail beds. Brainstem reflexes are absent, and during the apnea test, there is no spontaneous breathing.
He then speaks to Mr. Light's healthcare proxy to inform them of his death, providing empathy and offering to answer any questions.
When asked about leg movements the family has witnessed, Doctor Patel explains that these are due to spinal reflexes and don't involve the brain.
Additionally, the ICU staff informs the organ donation team, which will carry out the conversation about potential organ donation with Mr.
Light's healthcare proxy. Finally, Doctor Patel documents the death pronouncement date and time, details of the death examination, and summary of discussions with Mr.
Light's attending physician, organ donation team, and family. All right, as a quick recap, death is diagnosed by using either circulatory criteria, which is the irreversible loss of circulatory and respiratory function.
Or neurologic criteria, which is the irreversible loss of brain and brainstem function. Clinicians are responsible for examining, diagnosing, pronouncing and documenting patient death with accuracy and compassion.
Brain death determination requires careful exclusion of reversible causes, neurologic examination, and apnea testing. Clear, empathetic communication with families and interdisciplinary collaboration is essential throughout the process.