A better model for brain death needed

Process variations related to brain death have far-reaching implications beyond delaying an official declaration of death, including added stress for the patient's family, missed opportunities for organ donation and increased costs of care, according to an article in the December issue of Critical Care Nurse (CCN).

"Brain Death: Assessment, Controversy, and Confounding Factors" urges clear standards and uniform protocols be developed for declaring a patient brain dead. It concludes that aggressive surveillance, patient advocacy and collaboration during all phases of care following severe brain injury are imperative—and as a primary provider of bedside care, nurses are well positioned as key team members to lead this charge.

The article also calls for timely and optimal clinical assessment, potentially identifying treatment opportunities before a brain injury progresses to a terminal stage. It advocates for consistent standards for determining brain death to facilitate protocol implementation, including uniform intervals for examinations necessary for determination of death due to neurological criteria.

Author Richard B. Arbour, RN, MSN, CCRN, CNRN, CCNS, reviews clinical factors related to brain injury, identifies and illustrates criteria for determining brain death and details confounding factors in brain death. He also discusses the role of bedside nurses and advanced practice nurses in caring for critically ill patients with a life-threatening brain injury.

"Bedside nurses are best positioned to recognize even subtle neurological changes after brain injury," he said. "These subtle changes can identify treatment opportunities to promote the primary goal of patient recovery well before consideration of a brain death protocol.

"Frontline clinicians are also trained to recognize a patient's worsening neurological status and initiate formal, collaborative neurological evaluation for brain death, as clinically appropriate, and remain involved during a brain death protocol," Arbour said.

After a patient is declared brain dead, it is the nurse's role to continue to provide optimal family communications, including addressing potential organ donation.

Arbour has more than 30 years of clinical experience in the care of critically ill patients with a focus on neuroscience critical care, organ donation/transplantation and end-of-life issues. He is widely published and recognized nationally and internationally for his expertise in end-of-life care, neuroscience critical care, organ donation and care of the organ transplant patient in both pre- and post-operative phases. He is currently a liver transplant coordinator at Thomas Jefferson University Hospital in Philadelphia.

As the American Association of Critical-Care Nurses' bimonthly clinical practice journal for high acuity, progressive and critical care nurses, CCN is a trusted source for information related to the bedside care of critically and acutely ill patients.