Brain death in the pediatric patient: historical, sociological, medical, religious, cultural, legal, and ethical considerations

Apnoeic oxygenation in paediatric anaesthesia: a narrative review

Apnoeic oxygenation refers to oxygenation in the absence of any patient or ventilator effort to move the lungs. This phenomenon was first described in humans in the mid-20th century but has seen renewed interest in the last decade following the demonstration of apnoeic oxygenation with low-flow, and subsequently high-flow, nasal oxygen. This narrative review summarises our understanding of apnoeic oxygenation in the paediatric population. We examine the evidence supporting oxygenation via tracheal tube, modified laryngoscopes and nasal cannulae. The evidence for prolongation of safe apnoea time at induction of anaesthesia is also appraised. We explore the capacity for carbon dioxide clearance, flow rate selection with high-flow nasal oxygen and complications associated with the technique. It remains uncertain whether apnoeic oxygenation in paediatric patients results in a meaningful clinical benefit compared with standard care for outcomes such as the number of tracheal intubation attempts or the incidence of hypoxaemia. In particular, the role of apnoeic oxygenation in paediatric difficult airway management is unclear as this has not been the targeted focus of any published research to date.

Cancer biology as revealed by the research autopsy

A research autopsy is a post-mortem medical procedure performed on a deceased individual with the primary goal of collecting tissue to support basic and translational research. This approach has increasingly been used to investigate the pathophysiological mechanisms of cancer evolution, metastasis and treatment resistance. In this Review, we discuss the rationale for the use of research autopsies in cancer research and provide an evidence-based discussion of the quality of post-mortem tissues compared with other types of biospecimens. We also discuss the advantages of using post-mortem tissues over other types of biospecimens, including the large amounts of tissue that can be obtained and the extent of multiregion sampling that is achievable, which is not otherwise possible in living patients. We highlight how the research autopsy has supported the identification of the clonal origins and modes of spread among metastases, the extent that selective pressures imposed by treatments cause bottlenecks leading to parallel and convergent tumour evolution, and the creation of rare tissue banks and patient-derived model systems. Finally, we comment on the future of the research autopsy as an integral component of precision medicine strategies.

"We Can Do Anything but We Can't Do Everything": Exploring the Perceived Impact of International Pediatric Programs on U.S. PICUs

Purpose: Every year, an increasing number of international patients seek medical care in the United States (U.S.), yet little is known about their impact. Based on single institution experiences, we wanted to explore the perceived impact of international pediatric patients on large academic U.S. pediatric intensive care units (PICUs), as they are already taxed systems. Methods: To explore current perceptions, seven geographically diverse institutions who advertise care for international patients on their websites and have ≥24 PICU beds were identified after IRB approval was obtained. We consented and interviewed PICU division chiefs or medical directors from each institution regarding their demographics and international patients. Common themes were identified. Results: Participating institutions were diverse in geographic location, census, and resource allocation strategies. Five of the seven institutions reported the presence of a formal international patient program. Four of those five reported an increase in international patients receiving PICU care over the past 5 years. International patients sought complex surgeries, advanced cancer treatments and metabolic/genetic evaluations. We identified three primary domains that require further exploration and research: (1) cultural and language differences leading to barriers in providing optimal care to international patients (2) institutional financial considerations, and (3) perceived positive and negative impact on the care of local/domestic patient populations. Conclusions: The presence of international programs raises a number of important ethical questions, including whether clinicians have a greater duty to serve residents of the local community as opposed to international patients when resources are limited. Further exploration is warranted.

Controversy in the Determination of Death: Cultural Perspectives

The definitions of death have changed throughout recorded history to include not just cardiac death but death by neurological criteria as well. Given the many cultures present in the world, it comes as no surprise that declaring death takes many forms. In the Western world, brain death has gained common acceptance (though not universal), while other cultures and religions have struggled with this issue, especially as it surrounds the controversy of donated organs. There is legal precedent to support death by neurological criteria, as well as support for hospital systems and physicians to terminate somatic support of the brain-dead patient; however, these laws differ greatly from country to country. When dealing with a controversial topic, differing laws, and grief-laden families, it becomes especially crucial that health care staffs are educated regarding varying cultural beliefs surrounding death. In the majority of cases, with kindness and compassion, common ground between science and social perspectives can be found, leading to resolution of care for this group of patients.

Ethical Assessments of Brain Death and Organ Procurement Policies: A Survey of Transplant Personnel in the United States

The Questionnaire on Prolonging and Shortening Life was developed to assess the views of medical personnel regarding brain death, organ procurement policies, and related issues. The questionnaire was completed by 189 transplant physicians, 197 clinical coordinators, 150 medical students, and 70 nursing students. Ninety-five percent supported the so-called dead donor rule. What this rule means in practice appeared unclear among the population. More than 60% supported procuring organs from anencephalic and “higher brain-dead” patients, although patients in both groups are not dead by current legal standards. Performance on items relating to so-called non–heart-beating organ donation suggested that 75% of the group do not support non–heart-beating organ donation without assurance that the donors are brain-dead before procurement begins. Given that current recommendations to increase organ donation look to non–heart-beating organ donation rather than to anencephalic patients and those in a persistent vegetative state, these findings suggest that further ethical discussion and analysis are urgently needed.

Medical ethics in pediatric critical care

Ethically charged situations are common in pediatric critical care. Most situations can be managed with minimal controversy within the medical team or between the team and patients/families. Familiarity with institutional resources, such as hospital ethics committees, and national guidelines, such as publications from the American Academy of Pediatrics, American Medical Association, or Society of Critical Care Medicine, are an essential part of the toolkit of any intensivist. Open discussion with colleagues and within the multidisciplinary team can also ensure that when difficult situations arise, they are addressed in a proactive, evidence-based, and collegial manner.

Donation after cardiac death: the potential contribution of an infant organ donor population

OBJECTIVE

To determine the percentage of deaths in level III neonatal intensive care unit (NICU) settings that theoretically would have been eligible for donation after cardiac death (DCD), as well as the percentage of these who would have been potential DCD candidates based on warm ischemic time.

STUDY DESIGN

We conducted a retrospective study of all deaths in 3 Harvard Program in Neonatology NICUs between 2005 and 2007. Eligible donors were identified based on criteria developed with our transplantation surgeons and our local organ procurement organization. Potential candidates for DCD were then identified based on an acceptable warm ischemic time.

RESULTS

Of the 192 deaths that occurred during the study period, 161 were excluded, leaving 31 theoretically eligible donors. Of these, 16 patients had a warm ischemic time of <1 hour and were potential candidates for DCD of 14 livers and 18 kidneys, and 14 patients had a warm ischemic time of <30 minutes and were potential candidates for DCD of 10 hearts.

CONCLUSIONS

Eight percent of NICU mortalities were potential candidates for DCD. Based on the size of the potential donor pool, establishing an infant DCD protocol for level III NICUs should be considered.

Brain death: close relatives' use of imagery as a descriptor of experience

AIM

This paper is a report of a study to explore the use of imagery to describe the experience of confronting brain death in a close relative.

BACKGROUND

The brain death of a loved one has been described as an extremely difficult experience for close relatives, evoking feelings of anger, emotional pain, disbelief, guilt and suffering. It can also be difficult for relatives to distinguish brain death from the state of coma and thus difficult to apprehend information about the diagnosis.

METHODS

Narrative theory and a hermeneutic phenomenological method guided the interpretation of 17 narratives from close relatives of brain dead patients. All narratives were scrutinized for experiences of brain death. Data were primarily collected in 1999. The primary analysis related to close relatives' experience of brain death in a loved one. A secondary analysis of the imagery they used to describe their experience was carried out in 2003.

FINDINGS

Six categories of imagery used to describe the experience of confronting a diagnosis of brain death in a loved one emerged: chaotic unreality; inner collapse; sense of forlornness; clinging to the hope of survival; reconciliation with the reality of death; receiving care which gives comfort. Participants also identified two pairs of dimensions to describe their feelings about the relationship between their brain dead relative's body and personhood: presence-absence and divisibility-indivisibility. Being confronted with brain death meant entering into the anteroom of death, facing a loved one who is 'living-dead', and experiencing a chaotic drama of suffering.

CONCLUSION

It is very important for members of the intensive care unit team to recognize, face and respond to these relatives' chaotic experiences, which cause them to need affirmation, comfort and caring. Relatives' use of imagery could be the starting point for a caring conversation about their experiences, either in conversations at the time of the death or when relatives are contacted in a later follow-up.

Dignified death for severely impaired infants: beyond the best-interest standard

The Baby Doe rules, a set of federal regulations on the treatment of extremely ill infants, went into effect in 1985. Some scholars have argued that these rules are inappropriate given that they fail to pay attention to the patient's suffering. Instead, researchers suggest that, when dealing with a severely impaired infant, the best-interest standard be used. Other ethicists have found the best-interest standard also insufficient, deeming it to be supported by weak arguments rooted on the beholder's beliefs. In this article, alternative viewpoints that might be used to complement the best-interest standard and help support the rights of severely impaired infants to a natural and dignified death are reviewed. The use of palliative instead of intensive care for severely impaired newborns is also considered.

Circumstances surrounding end of life in a pediatric intensive care unit

OBJECTIVE

Approximately 60% of deaths in pediatric intensive care units follow limitation or withdrawal of life-sustaining treatment (LST). We aimed to describe the circumstances surrounding decision making and end-of-life care in this setting.

METHODS

We conducted a prospective, descriptive study based on a survey with the intensivist after every consecutive death during an 8-month period in a single multidisciplinary pediatric intensive care unit. Summary statistics are presented as percentage, mean +/- standard deviation, or median and range; data are compared using the Mantel-Haenszel test and shown as survival curves.

RESULTS

Of the 99 observed deaths, 27 involved failed cardiopulmonary resuscitation; of the remaining 72, 39 followed withdrawal/limitation (W/LT) of LST, 20 were do not resuscitate (DNR), and 13 were brain deaths (BDs). Families initiated discussions about forgoing LST in 24% (17 of 72) of cases. Consensus between caregivers and staff about forgoing LST as the best approach was reached after the first meeting with 51% (35 of 68) of families; 46% (31 of 68) required >or=2 meetings (4 not reported). In the DNR group, the median time to death after consensus was 24 hours and for W/LT was 3 hours. LST was later withdrawn in 11 of 20 DNR cases. The family was present in 76% (45 of 59) of cases when LST was forgone. The dying patient was held by the family in 78% (35 of 45) of these occasions.

CONCLUSIONS

More than 1 formal meeting was required to reach consensus with families about forgoing LST in almost half of the patients. Families often held their child at the time of death. The majority of children died quickly after the end-of-life decision was made.

No going back: narratives by close relatives of the braindead patient

The aim of this narrative study was to illuminate the meaning of being a relative of a patient diagnosed as brain dead. This has so far been explored only to a limited extent. By phenomenological-hermeneutic analysis of 14 narratives, a chronological narrative in 4 steps was identified: the disquieting event; the uncertain vigil; the arduous struggle; and the difficult road ahead. From the analysis, the metaphor of an inner journey emerged, starting from a life situation taken for granted and experienced as safe, and moving towards the unknown, the unfamiliar. During the journey, a series of events of decisive importance in the relative's life were found to take place. Major stages along the road were efforts made to comprehend the reality of death, saying farewell and taking leave of the loved one. The importance of the ICU nurse taking part in the relative's inner journey is discussed in relation to Eriksson's theory of suffering and Martinsen's theory of caring. Implications and suggestions for nursing care activities are discussed.

Care of the potential pediatric organ donor

Although all of this information may create the impression that caring for a potential organ donor is an exceedingly complex task, in the authors' experience, this often is not true, and much energy can--and should--be devoted to the care of the bereaved family. Of crucial importance are the early recognition of brain death and the consequent radical switch of the treatment goal from preservation of the patient's brain and life to preservation of organs for the lives of others. Care for the donor is the natural extension of care for a critically ill or injured patient. During the foregoing discussion, the authors had to stress the absence of sound evidence on many points. Because many reports originate from transplant centers dedicated to a specific organ, gaining a comprehensive view on management options in the ICU further is hampered. Thus, this situation leaves another field in which investigations originating from pediatric intensivists could provide evidence urgently needed to make optimal choices. The next decade should see the thyroid hormone controversy solved by at least one controlled prospective study and the differential applicability of inotropic, vasoactive, or fluid-centered strategies. It seems self-evident that only graft survival and related parameters can form adequate endpoints for future studies.

Ethical assessments of brain death and organ procurement policies: a survey of transplant personnel in the United States

The Questionnaire on Prolonging and Shortening Life was developed to assess the views of medical personnel regarding brain death, organ procurement policies, and related issues. The questionnaire was completed by 189 transplant physicians, 197 clinical coordinators, 150 medical students, and 70 nursing students. Ninety-five percent supported the so-called dead donor rule. What this rule means in practice appeared unclear among the population. More than 60% supported procuring organs from anencephalic and "higher brain-dead" patients, although patients in both groups are not dead by current legal standards. Performance on items relating to so-called non-heart-beating organ donation suggested that 75% of the group do not support non-heart-beating organ donation without assurance that the donors are brain-dead before procurement begins. Given that current recommendations to increase organ donation look to non-heart-beating organ donation rather than to anencephalic patients and those in a persistent vegetative state, these findings suggest that further ethical discussion and analysis are urgently needed.

Withdrawal and limitation of life support in paediatric intensive care

OBJECTIVES

To compare the modes of death and factors leading to withdrawal or limitation of life support in a paediatric intensive care unit (PICU) in a developing country.

METHODS

Retrospective analysis of all children (< 12 years) dying in the PICU from January 1995 to December 1995 and January 1997 to June 1998 (n = 148).

RESULTS

The main mode of death was by limitation of treatment in 68 of 148 patients, failure of active treatment including cardiopulmonary resuscitation in 61, brain death in 12, and withdrawal of life support with removal of endotracheal tube in seven. There was no significant variation in the proportion of limitation of treatment, failure of active treatment, and brain death between the two periods; however, there was an increase in withdrawal of life support from 0% in 1995 to 8% in 1997-98. Justification for limitation was based predominantly on expectation of imminent death (71 of 75). Ethnic variability was noted among the 14 of 21 patients who refused withdrawal. Discussions for care restrictions were initiated almost exclusively by paediatricians (70 of 75). Diagnostic uncertainty (36% v 4.6%) and presentation as an acute illness were associated with the use of active treatment.

CONCLUSIONS

Limitation of treatment is the most common mode of death in a developing country's PICU and active withdrawal is still not widely practised. Paediatricians in developing countries are becoming more proactive in managing death and dying but have to consider sociocultural and religious factors when making such decisions.

Brain death and evoked potentials in pediatric patients

OBJECTIVE

To define the evoked potential responses (auditory and somatosensory) obtained from pediatric brain-dead patients.

DESIGN

Prospective study over an 8-yr period (1988-1996).

SETTING

A 14-bed pediatric intensive care unit in a multidisciplinary regional referral center (teaching hospital).

PATIENTS

Fifty-one pediatric patients with clinically established brain death.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Auditory brainstem and somatosensory evoked potentials were performed with a mean evolution time of 24 hrs after clinical brain death. The first brainstem auditory evoked potential recording was compatible with the diagnosis in 45 patients (90%): 27 patients (53%) did not respond, wave I was patent in 16 (7 bilateral, 6 from the left side, and 3 from the right side), and 2 patients evoked waves I and II in one or both ears. Gross anomalies were found in the remaining six patients. Sixteen patients were tested for somatosensory evoked potentials. N13 identifiable wave (62.5% of the patients) or a flat record were the obtained findings. Electric silence was noted initially on the electroencephalogram (EEG) in only 14 of 29 patients. Later flattening was observed in seven patients. Missing brainstem evoked response was noted earlier than cortical electric silence (range, 12-144 hrs). Any central wave could be pointed out in the evoked potentials of patients with an isoelectric EEG.

CONCLUSIONS

Evoked potential is useful in confirming the diagnosis of brain death in infants and in children as well as in adults. The test can be performed at bedside without interfering with patient care, and results are similar to those obtained in adult patients. Flattening of the EEG requires more time than achieving compatible evoked-potential responses.

Brain death in ICUs and associated nursing care challenges concerning patients and families

In order to document the incidence and causes of brain death (BD) and the frequency of organ donation (OD) in a Swedish University Hospital, a retrospective review of deaths in a neurosurgical department and in the general intensive care units (ICUs), was carried out for the period 1988-1994. BD diagnosis was established in 197 (10.6%) of all deaths (n = 1843). The hospital records of all BD patients were examined in detail following a specific study plan. The majority of the BD patients (89%) were acute admissions to hospital, and among them 81 were transferred between hospitals often over a long distance. Among the BD patients the total number of OD was 65 (33%). The most common diagnosis leading to BD was spontaneous intracerebral bleeding and traumatic head injury. The BD diagnosis was established by neurological examination (60%) and by cerebral angiography (40%). Of the BD patients, 50% died within 48 hours in the ICU and the majority of requests for OD (67%) were made to the relatives of these patients. The findings are discussed with focus on the workload and psychological stress of ICU nurses when caring for BD patients and their families; a task which includes taking part in processes concerning BD diagnosis information and OD requests.

Brain death

The development and evolution of the concept of brain death has been necessary due to our technologic advances in medical care and organ transplantation. The current operational definition of brain death is based on coma, absent brain stem reflexes, and apnea, with use of confirmatory testing only as necessary. This definition has demonstrated functional utility and may be further refined over time. Medical providers and the public continue to become increasingly comfortable with the concept of brain death.

Your child is brain dead

One to two per cent of admissions to Paediatric Intensive Care Units eventually fulfil the criteria for brain death, implying the need for very difficult decisions. Brain death is defined as irreversible loss of function of the whole brain. The diagnostic criteria caused a great deal of anxiety but are now the subject of a consensus approach. When the situation can be anticipated it is of immense value for the professional staff to develop a good working relationship with the parents to help and support them through the phase of impending disaster and facing the issue when the time actually comes. However, it is vital to help parents to make their own decision regarding continuation or otherwise of life support and they should be supported in whichever decision they take. They must be absolutely convinced that the child is brain dead and this territory may have to be covered again and again in discussion, questions must be answered factually, and time allowed for reflection. Stage management of the process of 'switching off' is vital and the parents' wishes may vary widely from one family to another. They must be warned what is likely to happen and provided with appropriate privacy and support for expression of their grief. The question of asking for post-mortem permission has to be handled sensitively and long-term support for the parents must be offered. Education of undergraduate and postgraduate doctors in this area is now receiving more attention with skills being increased by video teaching and role play. It should not be overlooked that the professional staff attending such patients sometimes require counselling and support themselves.

Ethical issues in the pediatric intensive care unit

Advanced technology and better scientific understanding of mechanisms of disease now permit intensive care personnel to extend life beyond what some patients and families consider reasonable, leading, in part, to the "patients' rights" movement and the articulation of legal and moral guidelines for foregoing life support. In the case of pediatrics, commentaries on a few of the topics that have arisen most frequently or have provided the greatest challenge in the authors' experience are provided.