Determining brain death

Bedside Ultrasonography of the Optic Nerve Sheath in Brain Death

Increased intracranial pressure has successfully been detected by using bedside optic nerve sheath diameter (ONSD) ultrasonography. ONSD ultrasonography has become one of the current methods used to detect potential brain death in recent years. In this study, we carried out ONSD ultrasonography for patients who were diagnosed with brain death and in comatose state. Mean ONSD values obtained from the patients with brain death were compared with ONSD values of patients in a comatose state. There was no significant difference between the mean ONSD values of the right and left eye and no significant difference in transverse and sagittal plane measurements in all groups. Mean ONSD values of Group BD were significantly higher than both Group CT (P < .05) and Group CM values (P < .05). Some of the patients with a history of intracranial hemorrhage, subdural hematoma, or traumatic brain injuries who remain in a comatose state in intensive care units may ultimately result in brain death. Therefore, it may be kept in mind that intermittent ONSD measurements of patients in deep comas might have an important role for diagnosing brain death early for purposes of cadaveric organ donation. In conclusion, transorbital ONSD measurement using bedside ultrasonography, an inexpensive, comfortable, and noninvasive test for patients in deep comas, may be helpful in determining potential brain death.

Development of the University of Wisconsin Donation after Cardiac Death Evaluation Tool

Background

Donation after cardiac death is a method by which severely neurologically injured patients not fulfilling brain-death criteria can donate organs.

Objective

To develop an evaluation tool that can be used to predict if a patient is a suitable candidate for donation after cardiac death.

Methods

The University of Wisconsin Donation After Cardiac Death Evaluation Tool assigns numeric values to observable clinical parameters to yield an overall predictive score of suitability for donation after cardiac death. This evaluation tool is typically utilized in a critical care unit to evaluate patients with a severe neurological injury, who do not meet brain-death criteria, and for whom the physician and family have chosen to terminally withdraw life support. Each patient is disconnected from a ventilator and observed for up to 10 minutes. Observations are then scored to yield a prediction of suitability for donation after cardiac death.

Results

Using the University of Wisconsin Donation After Cardiac Death Evaluation Tool, we were able to predict suitability for donation after cardiac death 83.7% of the time, within a 60-minute period and 74.4% of the time within a 120-minute period. The actual results using the tool were higher when clinical observations were included in the donation after cardiac death evaluation—an overall accuracy of 88.4%.

Information Sharing: Its Impact on Donor and Nondonor Families' Experiences in the Hospital

Objective

To illustrate the methods used to convey complicated information regarding the critical injury, and death diagnosed by means of brainstem testing, to the next of kin of potential organ donors.

Design

3-year, prospective, longitudinal study.

Participants and Setting

Forty-three family members who chose to donate their deceased relatives' organs were recruited via 4 transplant coordinating centers, and 3 family members who chose not to donate were recruited via 1 intensive care unit.

Method

Face-to-face qualitative interviews were carried out with 46 family members of 43 individuals who died between June and December 2000. Family members who agreed to donation were interviewed during and after their next of kin's admission to hospital and 3 to 5 months, 13 to 15 months, and 18 to 26 months after bereavement. Three participants who chose not to donate were interviewed on 1 occasion only. Interviews were audio-recorded, and the transcribed reports were analyzed using a comparative, thematic approach focusing on the detection of similarities and differences between cases.

Results

Participants who were offered verbal information supported by complementary methods of communication had (1) a greater understanding of the critical injury sustained by their next of kin, and (2) fewer questions over time regarding brainstem testing.

Conclusion

Better methods of communicating complicated information are needed, as the sheer load of information shared makes demands of next of kin at a time when they are cognitively and emotionally poorly equipped to respond.

Brain Death and Organ Procurement

Patients with severe brain injuries (as can result from trauma, subarachnoid hemorrhage, or brain tumor) are monitored closely by nursing staff. It's often the nurse who first recognizes clinical signs of decompensation and begins the process of determining whether the patient is a potential organ donor. When a person is declared brain dead, it's the nurse who maintains hemodynamic stability so that donor organs remain viable. It's therefore crucial for nurses to know how brain death is determined in adults and how potential organ donors are identified, and to know the major physiologic changes that occur upon brain death, as well as essential nursing interventions.

Clinical Management of the Organ Donor

There is a critical mismatch between available organs for transplant and acutely or critically ill patients with end-stage organ disease. Patients who may benefit from organ transplantation far outnumber available organs. The causes for this imbalance are multiple. One cause is family refusal to donate. A second cause is nonrecognition or delay in determination of brain death. A third cause is donor loss due to profound cardiopulmonary and metabolic instability consequent to brain-stem herniation and brain death. Family refusal may be addressed by education, public awareness, as well as close attention to social, cultural and ethical issues, and optimal communication with donor families. Brain death may be consequent to traumatic brain injury, ischemic versus hemorrhagic stroke, as well as massive cerebral anoxia/ischemic following cardiac arrest. Nonrecognition or delay in brain death determination may be addressed by clinician education and frequent clinical assessment to detect early stages of brain-stem herniation refractory to aggressive measures for control of intracranial pressure. Donor loss due to profound cardiopulmonary and metabolic instability may be addressed by aggressive, mechanism-based treatment for clinical instability based on affected body system, as well as measures to support metabolic activity at the cellular and tissue level in the brain-dead organ donor. This article explores cerebral physiology related to impending brain death and catastrophic intracranial pressure elevations. In addition, physiologic consequences of brain death are correlated with affected body systems and mechanism-based therapies to support organ function pending transplantation. Ethical/legal issues are explored as related to patient autonomy and optimal family outcomes. Effective family communication, astute clinical assessment, and optimal clinical management of the organ donor are illustrated using a case study approach, highlighting the role of the advanced practice nurse in donor management.

The problems with the validity of the diagnosis of brain death

The diagnosis of brain death as 'death' and organ transplantation have been closely historically linked since the mid twentieth century. It will be argued in this article that the development of a neurological definition of death was introduced to justify the removal of fresh viable organs for transplantation. Brain death cannot be diagnosed reliably using 'established practices'. Improved understanding of the pathophysiology of raised intracranial pressure has challenged our understanding of brain death. We need to move forward in our conceptualization of phenomenon of profound coma associated with massive brain damage. If examination for 'brain death' is to be carried out at all, there needs to be an examination and re-evaluation of practices and protocols.

Legal and ethical issues related to nonheart beating organ donation

Major breakthroughs in immunosuppressant medication and advances in surgical techniques have increased the number of successful transplantations, but the demand for organs far outweighs the supply. People continue to die while waiting for donor organs to become available. Nonheart beating organ donation is a means of increasing the supply of organs to be transplanted. It is based on cardiac cessation criteria. This article explores the ethical and legal considerations, as well as implications for perioperative nurses.

Why families deny consent to organ donation

Advances in medical practice and technology and the success of organ transplantation over the past 2 decades have resulted in an increased demand for organ donors. However, the health care community and organ procurement organisations (OPO) are faced with a worldwide shortage of donor organs. The non-consent of families is the most common reason that organs of medically suitable potential donors are not recovered. A review of published research post 1990 was conducted to primarily determine the major factors that influence a family's decision to deny consent to donation. Other objectives included providing suggestions for health care personnel to facilitate the donation request experience and to suggest strategies that would increase donation consent rates to benefit the organ procurement process. Databases predominately used in the review included CINAHL and Medline. The world wide web (www) was also accessed. The literature review indicates that the significant factors associated with denial of consent include: the misunderstanding of brain death; cultural beliefs; the specific timing of the request; the setting in which the request is made; the approach of the individual making the request; and characteristics of the deceased. Organ donation and transplantation rates could be increased by the joint involvement of medical, nursing and OPO personnel to enhance the quality of hospital care and to ensure that requests for donation are handled in a way that meets the family's informational and emotional needs. Increased consent rates have the potential to save lives and improve the quality of life for organ recipients.