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Welcome back to Behind the Knife, and I'm excited to say today is another installment of the Big T Trauma Series. My name is Patrick Georgioff, an acute care surgeon at WakeMed in Raleigh, North Carolina. And joining me today are two of my former co-fellows at the home of Big T Trauma, the University of Texas in Houston. We've got Dr. Teddy Puzio, who is currently faculty at UT and assistant PD for the Acute Care Surgery Fellowship.
And Dr. Jason Brill, who's currently living the life in Hawaii and serving with the Marine Corps unit. And part of his time is devoted to the U.S. Indo-Pacific Command as his trauma medical director. Now, we got a very serious... topic today and that's that's brain death and this is a complex situation the diagnosis of brain death adds to what is already you know an immensely complex scenario and what is
inevitably a devastating situation for family and friends. And patients and their family deserve clarity when it's needed most. And that's why a very thorough understanding of brain depth. And its diagnosis is so important for healthcare providers and so important for trauma surgeons and residents, fellows, everyone. And I should note that what we're talking about today, what we're going to discuss is brain death.
in the adult patients only there certainly are some nuances when it comes to diagnosing brain death in the pediatric population uh we should probably start off a little bit you know in the beginning with a bit on pathophysiology of brain death. So the brain injury results in brain swelling and increased intracranial pressure. This leads to compromised blood flow to the brain. And then this just
further propitiates the hypoxic injury. Once the intracranial pressure exceeds the mean arterial pressure blood flow to the to the brain it the flow completely stops entirely at that point the brain may herniate through the form and magnum is essentially how it how it works a vicious cycle patrick um yeah thanks for having us on such a light and cheery topic
I'm with you in that you really need a very good understanding of this because it's very misunderstood, I think, by the lay public and honestly even some providers. So to take Teddy's discussion of pathophysiology a step further. Normally, the brainstem is the last part of the brain to suffer irreversible anoxic injury. At least that's what you're going to see the majority of the time. And when that happens, there are also a multitude of...
homeostatic disturbances that accompany that last step that leads to the diagnosis of brain death. And you can see that in terms of hemodynamic instability, endocrinopathies, hypothermia among others. Yeah. And what's really interesting is the concept of brain death came into existence only in the 1950s. And that was after the introduction of positive pressure mechanical ventilation. So prior to that, brain death patients would rapidly succumb to hypoxic arrest.
And the first widespread clinical definition of brain death, which was known as the Harvard Brain Death Criteria, was published in 1968. And since then, there have been many definitions, protocols, and guidelines that have been created all around the world to try to manage. Again, it's a very complicated situation. Yeah, it's pretty crazy when you look back. So really in the early 1980s, 1981, the Uniform Declaration of Death Act was created by a presidential commission.
and approved by the American Medical Association and the American Bar Association. So the term UDDA states, an individual who has sustained either one... irreversible cessation of circulatory and respiratory functions or to do irreversible cessation of all functions of the entire brain including the brain stem is dead it goes on to say that determination of brain death must be made in accordance
in accordance with accepted medical standards, which leaves that interpretation, broad interpretation. Yeah, so that's the UDDA, but... Unfortunately, there is not a single nationwide code or statute that covers this. Fortunately, all states, including the District of Columbia, have adopted the UDDA. at least in the premise of how to state someone is dead via the route of brain death. I should mention though that many states have added additional regulations including
how and when this can happen, number of exams, et cetera. And we'll get into the details of that in a second. So as with a lot of the podcasts that we do in the Big T Trauma series, defer to your local regulations, hospital protocols, and state law, especially in these cases that it's not perhaps as straightforward as others. Yeah.
Yeah, and there are a few parts of the Uniform Declaration of Death Act that deserve some farther emphasis. So the first is that the brain-dead patients are just as dead as the patient whose heart has stopped beating. And that's critical. to understand. And it seems, you know, again, for good reason, that the lay public is often confused about that. And as Jason mentioned too, sometimes even within the hospital, there is some confusion.
now the second part about this is the udda states that the entire brain must be dead and this differentiates brain death from a persistent vegetative state or a minimally conscious state okay in the third This statement that the termination of brain death must be made in accordance with acceptable medical standards. This mandate introduces countless questions, right? Very gray. Right? So what exactly is the accepted medical standards? Jason, you mentioned it's...
yes, the UDDA has been accepted, but what's the medical standard? Who makes this determination? Is it the same in every state? Is it the same in every hospital? And if you look into it, the answers vary. it can vary to some significant degree, and this complicates an already complicated situation. Yeah, so fortunately there are some standards though that we can...
go back and rely on. So for a number of years now, the gold standard in the United States, this is something that was published in 2010, originally from the American Academy of Neurology or the AAN. And this document really served as the basis for hospital policies and guidelines, or at least we hope it did in most situations. That's been my experience at least. And while useful...
The AAN guidelines still have left some questions unanswered, which again, we'll go into in as much depth as we can on the podcast here. Yeah, no, it's interesting because you have national laws and... state laws that offer some clarity, but ultimately the determination of brain deaths is really left up to the individual institutions. You know, you can be at one hospital and what your guidelines for brain death are.
are totally different when you go to a different hospital. And sometimes they're left up to individual providers. And obviously that is problematic, can be problematic. In fact, there was one study of 508 unique hospital policies found the determination of brain death was still highly variable and, I quote, not congruent with contemporary practice parameters. Right.
And the determination of brain death is understandably difficult for loved ones to process, but it is definitely made more challenging when the process is mishandled. And there are countless examples of incorrect diagnoses. for communication and legal challenges that have all made their way into the media. And these stories definitely fuel public distrust. And for example, this is a clip from a production called Real Science Radio.
Today's program, Real Science Radio's list of brain-dead patients who have recovered. Brain-dead and recovered. Bob, this is going to be a great topic. These are actual patients, right, in hospitals. who have been diagnosed as brain dead and they've recovered it's supposed to be impossible it is so this list of real life examples of people who recovered after being crowned brain dead
shows that doctors and hospitals are sometimes dead wrong. Yeah, they are. All right, despite all that outrageousness, it's really, really important to know that there is not a single... documented case in which appropriate application of brain death testing led to the inaccurate determination of death and no patients had return of any type of brain function including
consciousness of any kind brainstem reflexes or even ventilatory efforts so when appropriately applied the criteria and the guidelines that we're going to talk about are extraordinarily accurate in diagnosing a patient as brain dead Okay, so let's fast forward a decade later. We talked about the 2010 AAN guidelines. In 2020, the World Brain Death Project, it's a large international multidisciplinary panel.
published a very robust consensus statement further clarifying the determination of brain death, and this guideline sought to, quote, harmonize practice and improve the rigor of brain death determination, unquote, which grosses. was very needed and still is. Yeah, I mean, and if you haven't read this, you certainly should if you work in this field. I mean, the authors should really be commended for their vigorous work and offered a lot of clarity. I agree with you, Brill.
The World Brain Death Project should be almost mandatory for anyone who's going to treat patients with brain injury, especially if you're going to be in an ICU. The recommendations from this paper basically serve as the basis for the recommendations.
policies that fall out of it and certainly the stuff that we're going to talk about on the episode are from you know that those authors work you know so we should note that the link to the paper can be found in the show notes if you're looking for it right so let's get down to it you know what do you need to know about how to formally declare a patient brain dead now first things first is that the determination of brain death is a clinical diagnosis and to make that clinical diagnosis
Each of these patients that we're going to proceed with brain death testing on have to meet some specific. criteria so i'm going to rattle off a number many of a number of these different criteria many of which you've probably heard already so the first is the patient has to have a diagnosis that is consistent with brain death right they have to have trauma uh terrible stroke whatever it may be
Second, that they should not have any known confounders or possibility of pathologic conditions like Guillain-Barre or locked-in syndrome, something that can mimic brain death. Third is that you need to make sure there's no CNS depression drug effect. present. And certainly a toxicology screen may be indicated as we often get in our trauma patients who arrive in the trauma bay.
And there are some specific guidelines that come from the World Brain Death Project, which are super, super interesting and helpful in your day-to-day practice. And that includes the recommendation that if you use sedating medications, propofol, fentanyl, et cetera. It's recommended that you wait at least five half-lives until the start of clinical testing, perhaps longer if the patient has hepatic or renal insufficiency. They also go on to give you specific levels of drugs. For instance,
barbiturates, the serum level for barbiturates must be less than 10 micrograms per ml. Or if the patient was drinking, alcohol levels must be less than 80 milligrams per deciliter in order to proceed with your clinical testing for brain death.
You also want to make sure the patient's not paralyzed. So using a train of four to check for paralytics is recommended if the patient had received any. This is a little bit broader, but the patient should also have no severe acid-based electrolyte or endocrine.
abnormalities and that's that's again pretty broad you might think of something like uremia or liver failure when it comes to something severe enough to interrupt or interfere with your brain death testing that one's a little variable institutionally too i think To me, it seems like that one, I remember different hospitals kind of, it's a little bit different across the board. Yeah, that's the one I run into on a fairly regular basis of what really counts as severe.
You know, obviously if the sodium is 108, okay, got it. But what if the sodium is just below your reference level and it's been there? for a few days, I have run into other providers that say, well, we can't go forward from this. So some of these guidelines, even though they're more specific than they used to be, there's still room for disagreement, unfortunately.
Yeah, it'll never be totally black and white, but we will go on to talk about things like ancillary testing. So if you do have folks, providers, yourself, et cetera, that disagree or worried about. Do you meet this criteria? Then ancillary testing is recommended, you know, flow studies, et cetera. We're going to dive pretty deep into that in a little bit. Two more things I want to mention. Core temperature greater than 36 degrees.
and specifically if the patient was managed with targeted temperature management for instance out of hospital cardiac arrest they you should not initiate brain death testing until 24 hours after the patient is completely uh rewarm so again more specific guidelines for specific patient populations and last systolic blood pressures has to be greater than 100 millimeters of mercury or map greater than 60 and you can go ahead and you know vasopressors are um permissible
to reach those goals. Yeah, which is another great point where I have run into folks that are very concerned that somebody is not hemodynamically stable because they're on a consistent dose of... you know vays are pressed in the background plus you know a little bit of leave a fed that we're titrating as well you know does that count as instability should we be going forward with the exam but as as you state in the guideline
Baser pressors can be required as long as you've gotten to at least your definition of stability. And I haven't personally seen hospital protocols that are more exacting than that. So again, just more. more room for discussion with some of these that still are going to require perhaps some collegiality with you and your partners. Well, to be clear, Brill, real quick before we go on too, I mean, if the patients, they can be on as much pressure as you want.
the systolic blood pressure is greater than 100 that's all there is to it um you have to meet all these criteria and we'll talk about again also today the importance of documentation uh the world brain death project has all these these different criteria and and details on how to do perform testing etc in the document you can pull out but this also leads to the importance of having robust guidelines at your institution
And then also robust documentation, including things like checklists so you can knock all these things off. You know, there shouldn't be anyone that says, well, we can't test this patient for brain death because they're on a couple of pressers.
absolutely you know not rather right here and uh totally totally agree with that in fact some sometimes because i whenever i have a a case that is nearing um you know this and i think there might be disagreement i often just print out the guidelines either at the local hospital or um if there's a larger protocol or state you know statute that applies sometimes that's nice to show up at the bedside with just to say you know i'm not making this up
Here's what it is in black and white. This is the accepted standard. So in any case, patient meets all the above criteria, then you can go forward with testing. I'm not going to go through all of that right now, but just in general, remember that testing... includes absence of arousal to maximum stimulation, pupillary reflexes, oculosephalic and oculostibular reflexes, corneal reflexes, motor response to pain,
in absence of cough and gag reflexes. What happens when I can't finish this exam for some reason? Which inevitably will happen. No, it certainly happens. Not that intricately. But if you can't do a portion of the exam... you should do all the other things that you can do. So essentially complete it to the fullest extent possible. And we're going to talk about here in a little bit about why an exam might not be able to be completed and when you should perform.
the term is ancillary testing which we'll kind of define and go into and one interesting point um at least everyone listening to the to this podcast Forgoing testing of the oculosephalic reflex when a patient's cervical spine, for example, has not been cleared, doesn't negate the remainder of a complete clinical exam. Again, ask me where I've seen that. So again, the presence.
of a cervical collar doesn't negate the completion of the remainder of that clinical exam yeah i mean especially if you listen to the big trauma series you're probably interested in trauma and that's you'll hear that very very frequently so again you have a complete exam
You go through it all, but you don't do the oculus phallic reflexes against the patient's collar, your spine has not been cleared. That's okay. World Brain Death Project recommends and tells us that if everything else is complete, you're still good to go. So keep that in mind.
especially when you're getting some pushback on that. You don't have to feel uncomfortable about taking the C collar off and performing dial size. Now, in addition to what you talked about, the brain death exam also requires a single apnea test to be performed.
And the goal of the apnea test is to trigger the respiratory system, specifically in the medulla, by allowing serum carbon dioxide levels to rise. And in general, it's recommended that an apnea test be performed after clinical testing is found to be consistent with brain death.
And really, you should probably also temporarily place the patient on a spontaneous ventilator mode and just observe shortly to make sure that they don't have any signs of breathing, that they have an absence of respiratory activity and effort. And it is important to note that apnea testing is contraindicated in patients with high cervical spinal cord or phrenic nerve injury. So this is, again, applicable to some of our trauma patients with high C-spine injuries.
And most institutions have their own protocols for apnea testing. And the World Brain Death Project has their own or makes some general recommendations as well. So again, I'm going to rattle through a few of these specific points. So the first, you pre-oxidate the patient. 100% FiO2.
World Brain Death Project recommends you do it for 10 minutes. You also need to make sure that the patient is normal carving. So you want to adjust the vent and get that PSTO2 between 35 and 45 millimeters of mercury. And you have to prove that with a gas. before you embark on your apnea test. And interestingly, the patient is also going to be oxygenated typically via a tracheal cannula. So you physically disconnect the vent and put a oxygen cannula down into the endotracheal tube.
And essentially to the level of the crina, or at least into the trachea, running oxygen in the patient. Yeah, blow by oxygen. So if you haven't seen this before, it's very, very simple. The nasal cannula just... grows right over whatever airway you have in place and you turn up the flow of oxygen so at least that there's uh there's some blow by to maintain your oxygenation during the test sorry to interrupt Patrick no yeah and there's lots of different ways to set it up but
um again most of the protocols will have whatever the local preference is and what you're shooting for is a pa co2 that's greater than 60. all right that's your trigger that to say you've had a successful apnea test. Now, unless the patient has pre-existing hypercapnia, which in which case you want your PSO2 to be greater than 20 millimeters of mercury above the patient's baseline. And if you get to that mark, PSO2 greater than 60 and the patient doesn't breathe.
that is consistent with brain death. Now, there are reasons that you might need to abort the apnea test, and that's if there's spontaneous respirations, that patient's not brain dead. Or let's say the patient becomes hemodynamically unstable. or their oxygen saturation drops to below specifically 85 percent or they have an unstable cardiac rhythm all these are reasons to abort the apnea test and if the remainder of their exam
again, presuming they're not breathing, is consistent with brain death. That's when you proceed with ancillary testing. Now, when you draw a blood gas when performing an apnea test, typically 10 minutes after you started. Real, one of the other confusing topics... is the number of exams. So are we obligated to perform multiple exams on these patients? Yeah, so yes and no, I guess is the answer to that.
The number of clinical examinations required to pronounce a patient brain dead, unfortunately, varies by country. Okay, that one I'll accept. State, a little more complicated, and even institution. Going back to the World Brain Death Project, they state that a single clinical examination and a single apnea test is the minimum standard for declaring brain death.
Now, in the U.S., some states then go on to stipulate the number of exams that must be performed. Throw out a couple of examples. California, Florida, Iowa, Kentucky, they all require two physicians. On the other side of the spectrum, Alabama, Georgia, Virginia, they just require one, although some local institution guidelines then require two exams, even though the state law only says one.
So just, you know, clear as mud. Yep. Got a side hustle? Like making money from a hobby, selling stuff online, or doing a bit of dog walking outside your day job? You might need to tell HMRC.
so you don't get any tax surprises. To take the hassle out of your side hustle, search HMRC Help for Hustles. So I want to go off on a quick tangent, if I can. So Patrick and Teddy, let's say you're doing... you're doing your apnea test and the patient gets hemodynamically unstable so you you stop or rather you resume your previous vent modes but things keep spiraling and all of a sudden
They go into a cardiac arrest during your apnea test. Not something you wanted, but when has that happened to you and what did you do about it? I've never had it happen to you. Have you, Teddy? I know. I mean, I've never had that. People get unstable. Like they get a little hypoxic. I push a little more presser. And then you say, all right, we're not doing this. We need an ancillary study. I've never, have you had anyone arrest?
Yeah, I guess I'm the unlucky one. I can only remember one. Unfortunately, the patient's family had already determined, you know, DNAR status, although they were okay with continuing intubation. and mechanical ventilator support. We had talked to them about this test we were going to do and just confirmed basically the DNR status before we started it.
Which is really rare. Well, and we're talking about all this stuff very specifically, right? We're talking about the specific guidelines, the criteria, checking boxes, et cetera. And again, as we mentioned at the beginning, this is all about providing clarity for patients' family. And thank goodness that patient had a DNR because someone spoke with them, right? And it clarified their goals for their loved one.
We're trying to share all this information because it is confusing for providers. Imagine what it must feel like for families who are just literally grasping at any last string of hope for their loved ones. And so that's, again, why we're doing this, because you as a provider, you have to be clear on what you're doing, and you have to be clear on what you're talking about and what you're telling that family, because it's confusing and they need clarity.
so that they can have closure too because and to add on to that i think it's not just what you as the provider saying to the family but you as the team right whenever we have a patient like this i think it's important to talk to your residents talk to your nurses because what you don't want is to be pursuing this kind of testing
And there to be like mixed messages from, you know, the team. So everyone has to be on the same page that really we think they're dead and we're going to test to see if we're, if they are, you know.
yeah and it's going back going back to you know this quote unquote real science radio you know everyone there's there's so much misinformation out there in the media or people have had real experiences in which they've been told or misinterpreted the information uh that they've been told and if you go back to it it's understandable when the heart's beating and the chest is rising on the ventilator
It's a very nuanced conversation. And in the end, what it really is about is for everyone listening to this podcast and Brill, myself and Teddy, is time, which is hard because you need to take that time. You need to sit down. like all right here here we go this is this is how all this works this is what we're talking about when we talk about brain death and to say those to say those words it you know this is the same thing if in fact your loved one's brain dead it's the same thing
is if their heart stops beating. It's the same thing for them as a human being. It's also the same legally. Yeah, that's really, really important. Otherwise... nothing changes for the family. You know, they're, they're standing there looking at their loved one who is connected to a bunch of tubes and then nothing changes. And then all of a sudden they're dead. If you don't really have a good discussion with them leading into it.
Right. Yeah. Taking all that complexity and all the variables, but really boiling it down to a simple statement. And, you know, anyone listening to this podcast, too, can become a leader in this space as well, despite kind of understanding these guidelines that we're talking about, to be able to educate.
The whole team, like Teddy said, the whole team's got to be on boards because one little comment, one slip up in terms of using the wrong terminology can, again, be devastating. You have to walk that back, and that's not what you want to be doing at a time like this. You want, again.
clarity for those for those families when it's needed most and and so to that end uh a teddy we again brand out this clinical diagnosis but we can't always get there maybe they're unstable and can't finish that apnea study or uh we're gonna talk about other reasons why too but
this is when ancillary testing comes in so what is what's ancillary testing all about yeah so ancillary testing is something that you're going to pursue when a patient doesn't meet the clinical criteria for establishing brain death, but they have an exam consistent with brain death. So what does that mean? Well, there are co-founders that may interfere with a complete clinical brain death exam. I'm just going to go ahead and list off a few of those. So if you have a patient who has...
and cardiorespiratory instability that does not allow you to complete the apnea tests like we talked about. You need to do an ancillary test. If you have a patient with injuries that... don't allow you to complete a full clinical exam, let's say a spinal cord injury or severe facial trauma, or they have really a severe orbital swelling and you can't see their eyes.
Yeah, that's a really common one, right? A lot of our patients have terrible facial fractures and they have the worst shiners and you can't pry their eyes open. Well, you can't complete that clinical study. Even if it's something as simple as just, you know, some periorbital fractures that led to a lot of swelling. That's totally true. We see that. I feel like it's not uncommon, especially when these patients have terrible head trauma.
A few other ones to mention, hard to correct metabolic abnormalities, like severe uremia or hyperaminemia. You know, those are, you know, that gets into like... questions about dialysis and stuff. Like sometimes it's just a struggle on how long are you going to really work to fix these metabolic abnormalities?
The other things that make it difficult, you know, if you have, sometimes if you have central nervous system depression medications with a really long half-life, you know, we talked about above like Penobarb. Um, you may have some conditions that may mimic brain death, including locked in syndrome and severe neuromuscular disorders like EML or Guillain-Barre. Yeah. Rare, but something you want to be aware of for sure.
And there are other issues that may prompt ancillary testing that kind of go beyond that. This includes patient family preference, for instance. If the patient's family really needs that, either they demand it. or they need it for closure, then that's something you want to consider as their provider about whether that warrants you to order that study or not. And sometimes it may make sense. The other is difficult to interpret spinal cord reflexes.
this can be a doozy because this is a tough one yes no one ever tells you about this this is tough oh my gosh i mean how many times have you come in the room And you have, you know, maybe you're at the bedside and having a tough conversation with the family. You're talking about this very topic.
you know that a loved one will be holding the hand and be like you know honey did you know squeeze my hand or whatever and their hand will move and you're like oh god like twitch and you're like yeah and they're well look at their they're squeezing my wine and you're like yeah you know gosh that's not really what that is but
That's because spinal cord reflexes can occur in the studies range. The lowest one I saw was 13% up to 75% of brain dead patients. I think it's probably on the higher end because you see those movements. They can be simple movements of the extremities, twitches and whatnot here or there, but they can also be complex. And that can include things like head turning or even the Lazarus sign, like the triple flexion where they're rising up out of bed.
And if you look at, again, kind of referencing back to the media, if you go and want to start, you Google brain death or controversy or whatever there is about it, what you'll see are home videos from families showing patients who are having complex.
uh spinal reflexes spontaneous movements and that is without a doubt uh disconcerting right so first of all again heart's still beating on the ventilator chest is rising and then you add that in of course uh and so That's why, again, in addition to those very specific things that Teddy mentioned, like facial fractures can't get to the cornea or pentobarbital levels being too high, we have these kind of more gray areas that you really need to consider.
And so, Brill, what are the options when it comes to ancillary tests? Okay, so two types of ancillary tests. First type are those that evaluate blood flow to the brain. The second type are those that dissect... assess electrophysiologic function. So examples of the latter would be EEG or somatosensory audio or visual book potentials, something in that category.
The World Brain Death Project recommends that studies that evaluate blood flow to the brain, those generally should be used in favor over those that it assess. electrophysiologic function. Again, the EEGs and evoked somatosensory potentials. The most commonly used test of all of this is a nuclear medicine flow study.
And then to a lesser extent in some places, you'll see transcranial Doppler ultrasound. While CTA and MRA have been used to diagnose cerebral circuitry arrest, the brain death, the World Brain Death Project suggests that these modalities not... be used until further research is performed. So actually those are, you know, even though they're like low hanging fruit, we use them for everything else. Not really great.
Well, the initial studies are actually pretty promising, but you have to be very, very sure. So there's going to be more studies. And once those studies are complete, you'll probably, in the not-too-distant future, see the use of something like CTA. I think we use it here. And sometimes when you have a really terrible trauma and you get that as part of their initial workup, you know, and you have that.
in the in the trauma bay you get your scan and that's part of their you know your first scan and you're like okay this is we're not in a good place that's when we kind of play into it right and that's exactly right and that's because the
By using these flow studies, the way you make the diagnosis of brain death is when you see complete absence of blood flow to the brain. So if you're in the trauma pain and you get out of the trauma pain, get to the scanner, and they have complete absence on their CTA neck and head. well sure uh that's a that's a bad thing that's a bad sign um now here's something that's interesting too i want you to kind of just think about this and so it's important to note that loss of flow
defines loss of function, right? You have no blood flow to the brain. There's no function of the brain. However, the presence of flow does not necessarily indicate the presence of function. Okay. So if you have a hint of blood flow unilaterally on your scan, and your clinical exam is entirely consistent with brain death.
Again, this is a clinical diagnosis. So that presence of flow does not necessarily indicate the presence of any brain function. Remember, brain death is death of the entire brain. But it's confusing, right? And so that's why, right? That's why you really want to be careful about ordering closed studies. Yeah. I mean, I think we have to talk about this all the time. I feel like this comes up all the time because.
We are aggressive in saying, oh, they're brain dead. Let's order up a brain flow study. And you're like, well, did we cross the T's and dot the I's? And everyone wants to jump to those ancillary testing. And you really can't do that.
No, I mean, so you can, but what's going to happen is you are going to have a few instances where you have to come back into the room again. I mean, this is all about the patients, the patient's families, their confusion. You have to come back to the room and say, well, you know, they're brain dead on my exam.
they're apneic but there's some blood flow to their brain and then you're stuck in this you got to talk it out walk it out and then you need you know typically what you do in those situations you wait 24 hours and you repeat the study yeah usually by that negative and usually by then you know
the deed has been done there's no blood flow at all but again to the point of what we're talking about here brain death is a clinical diagnosis you don't have to get a confirmatory study you should get it for all the reasons we mentioned um and so to for some folks that i see that have a policy of well for everybody that i pronounce brain death i want to be extra sure that's why i get this study you know that that's probably not the best way to practice uh again can really muddy the water so
we mentioned this a little bit before i think this is important too is teddy what about time of death because this is when it comes to you know the residents at the covering they're actually you in the middle of the night uh they get signed out and say room three is is on their way out there they're uh
that we're doing our brain death testing and it's 2 a.m the nurse calls and says you know we've completed everything mr mr t is is is brain dead um you gotta do some documentation and time of death is important this goes on certificates and all those things
So what are the time of deaths, whether it's clinical or with ancillary studies? Yeah, so if you're going based on the apnea test, so then the time of death should be documented by... looking at the apg whenever the arterial p co2 reaches that target level during the apnea test that's the time of death
and so it's the actual time stamp on the abg when it comes from the laboratory that says you know pa co2 is 80 the patient didn't breathe it's time stamped at this time that is the time of death yep and then Alternatively, if you, you know, like we said, if for some reason you can't do the apnea test and you then go to ancillary testing, that time of death is documented at the time when the ancillary test results are formally interpreted.
and documented by the radiologist and and most of the time that is the attending radiologist um it says this is the time i'm reading the study equals time of death as that time that's right so Let's finish off with a problem that you guys I know have both come across, and I know that a lot of our listeners will have come across, is when despite...
Your best efforts, your compassion, your strong communication, doing all the right things. The family says no. Yes, you tell me they're brain death, but we're not taking that.
patient off the bed layer the interest this is this is art and sometimes it can be a temporary request it can be time limited a lot of times though it's an indefinite request i can remember in my you know career and training and life every time this has happened because it is uh it's one of those things that it leaves an impression on you it's really hard to to navigate this but really you have thoughts
Yeah, well, I'll start, I think, with just going back to the guidelines, and then we'll talk about some of the more, I guess, some of the more physician-oriented issues.
But per the World Brain Death Project, again, just going back to the basis of this episode, after declaration of brain death, somatic support should be discontinued. Nonetheless... three criteria that they mention one organ donation is planned okay sounds sounds appropriate just as a reminder you know opio should be discussing this with the family not you as the
the caring team, just if you haven't heard that advice many, many times before. All right, so second criteria, two, the patient's pregnant and the decision is made to continue support for the sake of the fetus. Thank goodness I did not run into that situation. Personally. Yeah, tough. All right. And then the third criterion, the family request continuation of somatic support after brain death.
due to religious or moral beliefs or other concerns about the use of neurologic criteria to declare death, and the hostage court complies with this request for legal or social reasons. well that's and that's a real thing you know you said so so you said it's a real thing legal or social reasons now we'll talk legal in a minute here but like for social reasons too i mean
You don't want to be the person. No one wants to be the person. The hospital doesn't want to. The doctor doesn't. The nurse. No one involved wants to be the person saying, hey, forget you. You know, your loved one's coming off the ventilator. I don't care what you think. And again, but that is why these guidelines.
Guidelines, guidelines, guidelines, specific guidelines are so, so important. Yeah, well, let's talk about the easier one first, the legal exception. Teddy, what's the legal? Well, it's interesting because there's... really only one state in the country that allows for religious objection. So unless you're in New Jersey, that's the only state that allows that. It doesn't really apply outside of there.
american academy neurology has actually published a position statement on this very issue i think it is on point this is another one that's well worth reading not so much because it's going to necessarily help you with discussions
or get you out of that situation but again i think informing how you think it's a position but also how you think as a position who works in a larger or a provider i should say who works in a larger system again in following these guidelines and so they make some very specific recommendations i'm going to
There's a bunch of them, but I'm going to read three of them that I think hit pretty hard. So the first says that although we respect the autonomy of patients and those acting on their behalf, the AAN recognizes that both legally and ethically, autonomy is not absolute.
and does not include the right to receive desired but unjustified medical treatment. Patients, loved ones do not have absolute autonomy to demand unjustified medical treatment. The second is... that there's some harm or potential for harm to the patient, to the family, or the patient's health care team if you have indefinite accommodation of these requests to keep the patients on the ventilator.
And these potential harms include mistreatment of the newly dead patient, deprivation of dignity of that patient, the provision of false hope with resultant distrust, prolonging the grieving process for the family, and undermining the professional responsibility of the physician to achieve a timely and accurate diagnosis and when that's not done that you know there's potential for societal harm that can arise when we have negotiated standards or inconsistent standards
So again, truth. I mean, this is spot on. And then I think the last thing I want to mention is that the AAN and the World Brain Death Project both recommend that your hospital needs to have in writing. that there's a, there's a timeframe for this, some wiggle room, right? Maybe family's coming in from out of the country. It'll be there within 24 hours. Well, okay.
let's let's give some wiggle room right or in the situation where that family is not gonna budge they will not allow you according to them to ever take that ventilator off Well, hey, it's actually not my decision as a physician caring for your loved one. It's actually hospital policy. And what that hospital policy is, is that the accommodations be made for no longer than 48 hours.
Yeah, and I think that's where I've seen this happen most commonly, especially out here in Hawaii. Sometimes there are family members not just flying from a neighboring island, but from Samoan, you know. flights that are not all that easy to get. And so perhaps that has some differences depending on the location that you're at. But I agree, it's nice to be able to point to something in writing, as we've said a few times.
before print it out you know that should be the conversation starter uh just to create a basis for further discussion about okay what is your end goal here and What can we discuss so that everybody ends up agreeing on something, right? That's really the goal here. Care for the patient, care for their family. Yeah, that's good stuff. That clarity is important. Should we wrap up with some...
Quick hits. There you go. Okay. So number one, when it comes to death, irreversible cessation of heart and lungs, AKA your heart stops, your, you know, respiratory arrest. is the exact same as irreversible cessation of the function of the entire brain. So brain death is equivalent to death. That's a message that we should make sure all the trainees understand as well. Number two.
incorrect brain death diagnosis, and poor communication fuel public distrust. Very, very important, right? We should understand and be experts in this field when we're dealing with these patients because we don't want to make... the wrong diagnosis and and fuel this distrust that's sometimes out there uh and then the third thing i think i want to remind everyone is that
Brain death is a clinical diagnosis, and there's minimal criteria for testing, which must be met before you actually start testing. All right, and then up there. What you got? Four more to wrap it up. Presence of the cervical collar alone does not negate otherwise complete clinical testing. Don't be lazy. Don't be lazy. Flow studies are preferred for ancillary testing.
if you are going to proceed with ancillary testing. Loss of flow to the brain defines loss of function, but presence of flow doesn't necessarily indicate presence of function. which is why you need to think about ordering those ancillary studies before you just go ahead and hit the button. And finally, somatic support should generally be offered for no more than 48 hours after the time of death.
However, it was determined. Fantastic. So thanks everyone very much for listening to behind the knife. Yeah. And for listening to the big T trauma series. Jason, Teddy, it's always a pleasure to have you on. We love talking about trauma. We've got some great episodes planned for the future. These will continue regularly, so I hope you enjoy them. If you are listening to Behind the Knife regularly...
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