Clinicians may encounter a dilemma when following current guidelines to determine brain death: Apnea testing isn't always possible.
It happened to Margie Ream, MD, PhD, from the Division of Child Neurology, Nationwide Children's Hospital, Columbus, Ohio, and colleagues recently. They describe the case in a paper in Pediatrics published online December 8.
The 4-year-old girl was brought to their hospital after being found unconscious. She met all components for the determination of brain death except for a positive apnea test result.
This element of the guidelines could not be performed because the child was on high-frequency oscillatory ventilation (HFOV) and stopping it would presumably have led to lung collapse, hypoxia, and sudden changes in pulmonary vascular resistance, leading to cardiac compromise, the authors say. Ultimately, the brain death evaluation was forgone because the family elected to allow for the child's natural death.
Inadequacy of Guidelines?
But Dr Ream and colleagues say they were left with "an enhanced awareness of the difficulties that can arise when adhering faithfully to current guidelines for brain death determination in pediatric patients whose tissue oxygenation is maintained through means other than conventional mechanical ventilation."
They say this case highlights an inadequacy in current brain death guidelines.
"Declaring brain death is one of the most emotionally challenging tasks for a physician," Dr Ream told Medscape Medical News. "For most clinical scenarios, guidelines make a physician's job more efficient and lead to less variability in practice. But strict adherence to brain death guidelines can, as was the case with our patient, make the task more, rather than less, complex."
Current guidelines were developed by considering the most common clinical scenarios, she said. "By definition, guidelines cannot include extraordinary circumstances as in our case (a patient with lung injury on HFOV)."
In this case, the use of ancillary tests that aid in the diagnosis of brain death was "impractical," the clinicians say, because the HFOV equipment is not portable, rendering studies in the radiology department impossible.
"We chose not to perform a bedside ancillary test, such as EEG [electroencephalography], due to the likelihood that it would provide inaccurate information that would cause further suffering for the family," Dr Ream said.
"Our desire/obligation to meet formal brain death criteria compromised our ability to care for the patient and her family by placing the burden of the decision to discontinue artificial means of physiological support on the family, as well as potentially limiting organ donation opportunities if the family so desired," she explained.
"This dilemma, while uncommon, is likely not an isolated case," Dr Ream noted. She believes the pediatrics community "needs to reevaluate brain death criteria and to consider changing or replacing the requirement for apnea testing."
Apnea Testing "Essential" Component
Thomas A. Nakagawa, MD, from Wake Forest Baptist Health and Brenner Children's Hospital in Winston-Salem, North Carolina, led the task force that updated the pediatric brain death guidelines in 2011.
"This case highlights difficulties that clinicians may encounter when attempting to determine if a patient has died based on neurologic criteria. To abandon the apnea test would remove an important and essential component of brain death testing," Dr Nakagawa told Medscape Medical News.
"This clinical perspective actually highlights the strength of the guidelines that requires clinicians to identify and complete every possible component of testing rather than ignoring requirements that cannot be accomplished," he said.
"The revised guidelines recommend a rigorous and thorough approach to the determination of brain death for infants and children," Dr Nakagawa explained. "Standardization is important to reduce diagnostic error that can occur when all aspects of the pediatric brain death guidelines have not been completed. The revised pediatric brain death guidelines address the most common circumstances that the vast majority of pediatric intensivists and others involved with pediatric brain death encounter in their routine practice."
He noted that advancing technologies "will continue to challenge our ability to determine death. These issues are important for our medical community and need continued exploration."
In many patients brain death cannot be determined because all clinical criteria are not met, he added. "In situations where we have exhausted all possible medical treatments, withdrawal of life-sustaining medical therapies can occur, as in this case, allowing patients to die comfortably without the need for advanced medical technologies, that in some cases ultimately prolongs the dying process," Dr Nakagawa said.
Also reached for comment on this paper, Leslie M. Whetstine, PhD, associate professor, philosophy, Walsh University, North Canton, Ohio, said this case is "interesting in that it challenges us to examine why the apnea test is required to determine death on neurologic criteria.
"We have an opportunity, and an obligation, to have an open discussion on the philosophical rationale for determining death on neurologic criteria. Avoiding this issue and/or clinging to an unsound concept of death ultimately threatens credibility in the medical establishment," Dr Whetstine said. "This could have dangerous long-term consequences, particularly for the future of organ donation, where trust integral."
The article had no external funding and the authors have disclosed no relevant financial relationships.
Pediatrics. Published online December 8, 2014. Abstract
Medscape Medical News © 2014 WebMD, LLC
Send comments and news tips to news@medscape.net.
Cite this: A Brain Death Dilemma: When Apnea Testing Isn't Possible - Medscape - Dec 09, 2014.
Comments