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Password: Ethics

Case:

An 8-month-old girl was admitted to the pediatric intensive care unit (PICU) after a high-impact motor vehicle collision. She was ejected from the vehicle and was found nearby unresponsive and pulseless. CPR was performed for 30 minutes with return of spontaneous circulation. On arrival at the hospital, imaging showed multiple injuries, including intracranial hemorrhage and early concerns for anoxic brain injury. On the initial exam, she was comatose with a few brainstem reflexes present and occasional extensor posturing, but no purposeful movements. Despite maximal neuroprotective measures, 48 hours after injury, she no longer has brainstem reflexes and demonstrates no response to noxious stimuli except for triple-flexion reflexes. An MRI of her brain shows extensive anoxic brain injury and evidence of brainstem herniation. Her care teams are concerned that her exam is consistent with death by neurologic criteria (brain death).

Her father unfortunately died in the accident. Her mother has been at her bedside since she arrived in the PICU, and both maternal and paternal grandparents have visited frequently. They all become very emotional upon hearing that she has an irreversible brain injury and might meet the criteria for death by neurologic criteria. Her mother says, “That’s not possible. She moves her leg when I touch her. I know she knows I’m here. I can’t lose her, too.” The family does not want the team to do an examination for death by neurologic criteria because they believe she will get better if she has more time.

Questions:

1. What is death by neurologic criteria, and how does the determination process differ from the common conception of death, or death by cardiopulmonary criteria?
2. How is the topic of death by neurologic criteria communicated to families? How do the various care team members work together to help families understand what it means and what will happen during the examination?
3. What is the process if families refuse evaluation for death by neurologic criteria or disagree with the determination of death?
4. What resources are available to families coping with the traumatic loss of their child?

Learning Objectives:

1. Review the definition of death by neurologic criteria and the process of determination outlined in the new health system policy.
2. Explore how the multidisciplinary care team works together to help families understand and cope with death by neurologic criteria.
3. Know what resources are available and the next steps if a family is not in agreement with the evaluation or determination of death by neurologic criteria.
4. Recognize that families are grieving and be able to provide appropriate support.

References:

1. JHM MELP014 Death by Neurologic Criteria Policy
2. Nakagawa TA, Ashwal S, Mathur M, et al; Society of Critical Care Medicine; Section on Critical Care and Section on Neurology of the American Academy of Pediatrics; Child Neurology Society. Guidelines for the determination of brain death in infants and children: an update of the 1987 Task Force recommendations. Crit Care Med. 2011 Sep;39(9):2139-55.
3. Kompanje EJ. Families and brain death. Semin Neurol. 2015 Apr;35(2):169-73. doi: 10.1055/s-0035-1547536. Epub 2015 Apr 3.
4. Greer, David M et al. “Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project.” JAMA vol. 324,11 (2020): 1078-1097.