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Case

John Doe is an unidentified male who was discovered unconscious on the street with obvious head trauma, apparently from a fall. Emergency Medical Services (EMS) responded to the 911 call from a bystander. EMT’s found him in cardiac arrest, initiated CPR, and were able to establish return of spontaneous circulation (ROSC). He was intubated as part of the resuscitation. Following stabilization in the Emergency Department (ED), he was transferred to the neurocritical care unit (NCCU) on vasopressors and mechanical ventilation. Clinically he demonstrated severe neurological injury due to the head trauma and to an unknown downtime after cardiac arrest. He is comatose. Neurologic exam confirms the absence of purposeful movements or responses to stimuli. Multiple imaging studies show extensive brain damage, indicating a grave prognosis for any meaningful recovery and possible progression to brain death. The NCCU team intends to pursue testing to determine death by neurologic criteria once toxicology screening is completed.

In the 48 hours of his NCCU stay, the patient’s identity is determined, and his family is contacted. Anthony D’souza is a 52-year-old immigrant from India. He is a businessman who travels extensively. He is widowed and has two adult children who serve as his surrogate decision makers. The family is Fundamentalist Christian. In consultation with the Family Advocate and a hospital chaplain, the clinical team initiates compassionate end-of-life discussions with Mr. D’souza’s family to explore next steps. The team explains that continued life-sustaining treatments are unlikely to result in any improvement in Mr. D’souza’s neurological status. The children call other family members, including the patient’s brother and sister-in-law from out of state, to come visit the patient, and the children want to wait on making any decisions until they arrive.

When Mr. D’souza’s exam shows loss of all brainstem reflexes, he is normothermic, and his toxicology screen is negative, the clinical team approaches the children with the plan to pursue testing for death by neurologic criteria. His children object, saying their religious and cultural beliefs adhere only to cardiac death. Plus, they feel that as long as he is on supportive measures like mechanical ventilation, there is a chance of a miracle occurring.

Learning Goals and Objectives

1. Explore strategies for engaging with families who exhibit mistrust of the health care system, intense emotions, and/or opposition to the declaration of death by neurological criteria.
2. Discuss the deeply rooted cultural and theological beliefs that focus on death by cardiopulmonary criteria.
3. Examine the moral and legal aspects of confirming death by neurological criteria.
4. Discuss how conversations about organ donation in comatose patients should be conducted.