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Controversies After Brain Death

2016; Elsevier BV; Volume: 149; Issue: 2 Linguagem: Inglês

10.1016/j.chest.2015.09.040

1931-3543

Ariane Lewis, Panayiotis N. Varelas, David M. Greer,

Anesthesia and Neurotoxicity Research

Luce1Luce J.M. The uncommon case of Jahi McMath.Chest. 2015; 147: 1144-1151Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar described the case of Jahi McMath, a teenager whose family requested organ support be continued after she was declared brain dead, citing religious objection to death by neurologic criteria. Only four states (California, Illinois, New Jersey, New York) have laws about how to handle religious objection to brain death. Whereas New Jersey's statute is very clear about how to manage situations like the McMath case, the laws in the other three states are vague (Table 1).2California AB 2565 Assembly Bill. 2008. http://www.leginfo.ca.gov/pub/07-08/bill/asm/ab_2551-2600/ab_2565_bill_20080927_chaptered.html. Accessed November 17, 2015.Google Scholar, 3Illinois Compiled Statutes 210 ILCS 85 Hospital Licensing Act. Section 6.24—Illinois Attorney Resources—Illinois Laws. 2008 [cited 2015 Aug 13]. http://law.onecle.com/illinois/210ilcs85/6.24.html. Accessed November 17, 2015.Google Scholar, 4Halperin JJ, Sori A, Grossman BJ, Rokosz GJ, Strong C. Guidelines for determining death based on neurological criteria: New Jersey. 2014. http://www.njsharingnetwork.org/file/Brain-Death-Guidelines-July-27-2014sq-2.pdf. Accessed November 17, 2015.Google Scholar, 5New York State Department of Health and New York State Task Force on Life and the Law. Guidelines for Determining Brain Death. 2011. http://www.health.ny.gov/professionals/hospital_administrator/letters/2011/brain_death_guidelines.htm. Accessed November 17, 2015.Google Scholar Thus, there is no concrete guidance for physicians in 98% of the country (49 states) about how to behave in situations like the McMath case.Table 1Accommodation Laws by StateStateLawCalifornia2California AB 2565 Assembly Bill. 2008. http://www.leginfo.ca.gov/pub/07-08/bill/asm/ab_2551-2600/ab_2565_bill_20080927_chaptered.html. Accessed November 17, 2015.Google Scholar"If the patient's legally recognized health care decision-maker, family, or next of kin voices any special religious or cultural practices and concerns of the patient or the patient's family surrounding the issue of death by reason of irreversible cessation of all functions of the entire brain of the patient, the hospital shall make reasonable efforts to accommodate those religious and cultural practices and concerns."Illinois3Illinois Compiled Statutes 210 ILCS 85 Hospital Licensing Act. Section 6.24—Illinois Attorney Resources—Illinois Laws. 2008 [cited 2015 Aug 13]. http://law.onecle.com/illinois/210ilcs85/6.24.html. Accessed November 17, 2015.Google Scholar"Every hospital must adopt policies and procedures to allow health care professionals, in documenting a patient's time of death at the hospital, to take into account the patient's religious beliefs concerning the patient's time of death."New Jersey4Halperin JJ, Sori A, Grossman BJ, Rokosz GJ, Strong C. Guidelines for determining death based on neurological criteria: New Jersey. 2014. http://www.njsharingnetwork.org/file/Brain-Death-Guidelines-July-27-2014sq-2.pdf. Accessed November 17, 2015.Google Scholar"Hospitals should establish written procedures for the acknowledgement of the patient's religious beliefs, if the examining physician has reason to believe, on the basis of information in the patient's available medical records, or information provided by a member of the patient's family or any other person knowledgeable about the patient's personal religious beliefs, that such a declaration of death by neurological criteria would violate the personal religious beliefs of the patient. In these cases, death shall be declared, and the time of death fixed, solely upon the basis of cardio-respiratory criteria."New York5New York State Department of Health and New York State Task Force on Life and the Law. Guidelines for Determining Brain Death. 2011. http://www.health.ny.gov/professionals/hospital_administrator/letters/2011/brain_death_guidelines.htm. Accessed November 17, 2015.Google Scholar"Hospitals must establish written procedures for the reasonable accommodation of the individual's religious or moral objections to use of the brain death standard to determine death when such an objection has been expressed by the patient prior to the loss of decision-making capacity, or by the surrogate decision-maker. Policies may include specific accommodations, such as the continuation of artificial respiration under certain circumstances, as well as guidance on limits to the duration of accommodation." Open table in a new tab Should a brain death evaluation be performed in spite of a family's objection to determination of death by neurologic criteria? Once an evaluation has been performed and a patient is determined to be brain dead, is family permission necessary to discontinue organ support? If support is continued, should vasopressors, hormones, or antibiotics be started if clinically indicated? Should a do-not-resuscitate order automatically be issued, or should the family be allowed to determine code status? Should the patient be kept in an intensive care unit or transferred to a regular floor or long-term care facility? Should a time frame for discontinuation of support be mandated, or should support be continued until the patient exhibits a terminal cardiac rhythm? If support is continued until the patient becomes asystolic, should the death certificate reflect the time of death by neurologic criteria or the time of asystole? Who should be fiscally responsible for the patient's care after brain death determination? These controversies are particularly challenging because they produce emotional distress for both the family and the medical team at a time that is already wrought with raw emotion. The ethical responsibilities of physicians facing these circumstances are gray given the competing desires to (1) respect families, (2) maintain a patient's dignity, and (3) optimize intensive care resources and health-care dollars. Furthermore, physicians may fear repercussions of ignoring a family's wishes, such as legal action, negative publicity, or job loss. Because solving these controversies is a formidable task for individuals or institutions, we recommend the creation of guidelines on management of these complex situations. Additionally, families may request continuation of organ support after brain death because of nonacceptance of death or the desire to await arrival of other family members, so physicians also need guidance to manage these scenarios. The Uncommon Case of Jahi McMathCHESTVol. 147Issue 4PreviewA 13-year-old patient named Jahi McMath was determined to be dead by neurologic criteria following cardiopulmonary arrest and resuscitation at a hospital in Oakland, California. Her family did not agree that she was dead and refused to allow her ventilator to be removed. The family's attorney stated in the media that families, rather than physicians, should decide whether patients are dead and argued in the courts that the families' constitutional rights of religion and privacy would be violated otherwise. Full-Text PDF