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A Case of Brain Death in the Medical Intensive Care Unit FREE TO VIEW

Paul Hutchison, MD; Naomi Kern, FNP; Jessica Altman, MD; Thomas Corbridge, MD
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Northwestern University, Chicago, IL

Chest. 2013;144(4_MeetingAbstracts):280A. doi:10.1378/chest.1698515
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SESSION TITLE: Critical Care Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: While brain death is not uncommon in intensive care units (ICUs) specializing in neurologic illness, it is a rare mechanism of death in medical ICUs.

CASE PRESENTATION: A 23 year-old male patient with acute myelogenous leukemia was admitted to an inpatient oncology unit for a stem cell transplant; his course was complicated by Clostridium difficile colitis and pancytopenia. On morning rounds he was found to be acutely somnolent and minimally interactive, and he required transfer to the medical ICU. He was intubated for airway protection and treated for hypotension with intravenous fluids and vasopressors. Two hours later the resident was called to the room for dilated, nonreactive pupils and lack of response to noxious stimuli. Head CT revealed diffuse intraparenchymal and subarachnoid hemorrhage and subdural hematomas. Examinations by a neurologist and the ICU attending, which included cold caloric testing, the occulocephalic maneuver, elicitation of brain stem reflexes and apnea challenge were consistent with brain death. The attending physician declared the patient brain dead and communicated this to the family; however, the family disagreed with the diagnosis given the presence of a heartbeat. The team decided to continue treatment for a short time to allow the family to process this information, but it felt the immediate tension between continuing mechanical ventilation and nursing treatment in a deceased patient and the desire to respect alternate viewpoints. The following day the family accepted the diagnosis and the patient was disconnected from the ventilator.

DISCUSSION: Despite publication of the “Harvard Criteria” in 1968 and the prevalence of brain death in cases of organ donation, it continues to pose clinical challenges (1). In particular, a declaration of death while a patient demonstrates a heart rhythm and blood pressure on in-room monitors can be confusing for family members. Similarly, healthcare professionals who are not familiar with these scenarios may be very uncomfortable caring for these patients. We believe that treating this patient for a short period of time was useful to the family and was in keeping with previously published recommendations (2).

CONCLUSIONS: It is incumbent on ICU clinicians to ensure context-appropriate care of patients declared brain dead as families cope and prepare for discontinuation of medical therapies. However, continuation of treatments must be balanced with responsible use of ICU resources.

Reference #1: Wijdicks EFM. The diagnosis of brain death. N Engl J Med 2001; 344:1215-1221.

Reference #2: Hardwig J. Treating the brain dead for the benefit of the family. J Clin Ethics 1991;2:53-6.

DISCLOSURE: The following authors have nothing to disclose: Paul Hutchison, Naomi Kern, Jessica Altman, Thomas Corbridge

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