We have a patient in the ICU with an unfortunate new onset atrial fibrillation that has caused a basilar artery clot and brain death. She is unresponsive off of sedatives, has no brainstem function, does not clearly initiate breaths, and is not going to recover from this state. She meets brain death criteria, a theoretical and intellectual checklist. But actually dealing with this patient has taught me the nuances of end-of-life care.
The patient's heart still beats. With ventilator support and aggressive management, we can keep her in this comatose state indefinitely. Yet she has practically no chance of recovery or change. She's stopped thinking and feeling, and those qualities that we associate with "being human" are irreversibly damaged. On a technical note, I got to observe cold caloric testing of brainstem function, transcranial doppler, and an apnea challenge.
The ethically correct thing to do is to withdraw support. People may believe that so long the heart beats, the person is "living" but I am inclined to say that which made her the person her family loved is now gone. Reconciliation is difficult, but now is the time for closure. At the family meeting, family members were on their knees begging. Her youngest child is 13. They cannot understand why our abilities are so limited, why anything we do now is futile, how we can say there is no chance for improvement and turn away.
There are so many ways to approach this problem. Would you like to be in a comatose state with no chance of recovery? Would you think about organ donation? If you were the organ recipient, a person with longstanding kidney failure with dialysis beginning to fail, how would you approach this situation? As a taxpayer, it is costing thousands of dollars a day to maintain her in an intensive care setting; is it worth it? Yet what if you were her family member and sanctioning withdrawal of care feels akin to murder?
I have a particular stance on this issue. I believe the intensive care unit is not a place for people with no hope of recovery; ICU is intended to support those patients with a reasonable chance of leaving the unit. I am sympathetic to the costs to society and to the limitations of medical ability. Though I believe in supporting someone until all the family members can reach the bedside, I don't think it is prudent to support someone indefinitely to appease a family, dissuade medico-legal action, or avoid the feeling of guilt and failure. It is time to say goodbye.
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2 comments:
You might want to note that you've skipped some of the possibilities that have to be eliminated in determining the cause of unresponsiveness. ;)
"She...has no brainstem function [...] The patient's heart still beats."
Er... Forgive me as someone lacking formal medical training, but as far as I can recall (or tell from searching online) heartbeat is regulated by areas of the brain stem, so "lack of function" should cause cardiac arrest.
I think that the public would be far more accepting of a "brain death" diagnosis if the medical field didn't have such a tarnished history on the topic. :-/
(Examples that aren't like your patient but had physicians claiming otherwise: here and here.)
Oh, and hello. :-) I've been lurking for a couple of months on Synapse blogs; I grew up in UCSF with VACTERL Association (returning in the next year), and find it fascinating to see the other side.
Excellent points, I appreciate your comments.
The heart is a fascinating organ. It can actually beat and operate without input from the brain or brainstem. The rhythmic action of a heart is determined by pacemaker cells within the heart, a property called automaticity. The cardiac pacemaker or the sinoatrial node fires spontaneously even if a heart is isolated from inputs from the brain. Certainly, autonomic input from the brain regulates the heart allowing us, for example, to increase our blood pressure and heart rate in response to fear; however, these inputs are not necessary for the heart to function.
In contrast, regulation of breathing is controlled by the brainstem such as the ventral respiratory group (VRG) in the medulla. Loss of the brainstem will lead to loss of spontaneous breathing.
You make a very good point in mentioning the difficulties with accepting brain death. There are a few syndromes in which someone can look unresponsive and yet actually be conscious. We have a patient on our service with "locked in syndrome" such that he can only move his eyes to communicate. If observers were not astute enough to realize these were purposeful movements, we may discount them and miss an important fact that changes our management and approach to the patient.
There is controversy about brain death criteria. In the U.S., for example, the criteria are entirely clinical; no lab tests are needed. But there are proponents that say EEG's should be done to measure electrical activity in the brain (which may be done in other countries; I'm not certain).
I think such things reflect a limitation in medical knowledge at this time. We don't know how to define a person such that we can be certain he or she will not recover. A lot of the justification for brain death criteria are based on inductive rather than deductive arguments. Because the stakes are high, I think this is a rich and important field for both physicians and non-physicians to think about, challenge, and understand.
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