Faculty Bibliography

Introduction Brain death is accepted as medically and legally equivalent to cardiopulmonary death throughout much of the world. However, families sometimes make "requests for accommodation" based on refusal to accept an established brain death declaration or desire to avert an examination for determination of brain death. We sought to evaluate the medical literature to identify the demographics and management of these requests. Methods We performed a comprehensive literature review of Cochrane, Embase and Medline for documents published between 1/1/92 and 7/15/17 that addressed requests for accommodation. Results We identified 19 documents for inclusion. In addition to the large number of requests (~1,000) described in two surveys of practitioners in the USA, we found 28 distinct requests for accommodation for persons of all ages (range: infancy to 87-years-old), nine of whom were children. Nearly every (25/28) request was made in the past 15 years. With the exception of one case from the United Kingdom, every request for accommodation was made in the USA. Requests for accommodation were made for a variety of reasons including belief that neurologic recovery could occur, desire to await arrival of additional family members prior to discontinuation of support, lack of conceptual acceptance of death with a beating heart and religious beliefs. Management of requests varied from continuation of support until cardiopulmonary arrest, withdrawal of organ support with a family's authorization, withdrawal of organ support against a family's wishes, transfer to another hospital or country or discharge home for continuation of organ support. In some cases, healthcare teams acted independently, but in others, they relied on recommendations from an ethics team or instructions from a court. Conclusions Requests for accommodation are increasing. This trend is particularly evident in the USA. Although the rationales for requests vary, uniform management guidelines are needed

Introduction Hypothermia can blunt brainstem reflexes and impair the elimination of sedatives and analgesics. As a result, it can be challenging to perform a brain death (BD) evaluation after treatment with therapeutic hypothermia. We sought to review the literature to determine when it is appropriate to do a BD evaluation after therapeutic hypothermia. Methods We reviewed Cochrane, Embase and Medline for documents published between 1/1/92 and 7/15/17 that addressed BD determination after use of therapeutic hypothermia. Results We identified 24 documents, all of which were published between 2008 and 2017. Two case studies on patients treated with therapeutic hypothermia who had findings consistent with BD, but subsequently demonstrated return of some brainstem activity, have garnered much attention in the literature: 1) A 10-month-old boy was cooled to 32-33degreeC and sedated for 24 hours then declared BD 10 hours after being rewarmed and 6 hours after discontinuation of sedation, but subsequently began breathing again; 2) A 55-year-old man was cooled to 33degreeC and sedated for 36 hours, then was declared BD 22 hours after being rewarmed and 28 hours after being taken off sedation, but later was found to breathe spontaneously and have corneal and cough reflexes. While the literature consistently questions when it is appropriate to conduct a BD evaluation after hypothermia, there is no answer based on high level evidence. Because it can be challenging to determine when a condition is irreversible after hypothermia, it has been noted that it can be helpful to augment a clinical evaluation for BD determination with ancillary testing to assess for cerebral blood flow. Conclusions There is a need for clear guidelines and expert consensus on timing of the clinical exam for BD determination and both the role for, and modality of, ancillary testing after therapeutic hypothermia

BACKGROUND: Patients without surrogates are referred to as "unbefriended." Because these patients do not have representatives to assist with medical decision-making, patient autonomy and self-determination, fundamental concepts of American healthcare, are jeopardized. METHODS: We present a case of an unbefriended patient in a vegetative state and discuss the ethical and legal complications associated with management of unbefriended patients. RESULTS: An unbefriended patient was admitted to our hospital with a cardiac arrest in the setting of an intracerebral hemorrhage. Despite aggressive medical and surgical management, he suffered significant brain injury and was in a vegetative state. In our state, unless an unbefriended patient will imminently die despite medical therapy, all measures must be taken to prolong the patient's life, so a tracheostomy and feeding tube were placed and he was transferred to a long-term care facility. The process for making decisions on behalf of unbefriended patients is complicated and varies throughout the country. Some potential ways to avoid these complex situations include: early conversations about treatment wishes while patients have capacity, mandatory advance directives, and increased training and reimbursement for physicians to proactively have end-of-life discussions. CONCLUSION: The unbefriended are one of the most high-risk patient groups. Because our patient had no surrogate with whom we could have a goals-of-care discussion, we were obligated to continue aggressive management despite knowing it would prolong, but not improve, his life. Proactive preventative measures to identify and document end-of-life wishes may make management of these patients less ethically and legally complicated.

Although pediatric brain death guidelines stipulate when ancillary testing should be used during brain death determination, little is known about the way these recommendations are implemented in clinical practice. We conducted a survey of pediatric intensivists and neurologists in the United States on the use of ancillary testing. Although most respondents noted they only performed an ancillary test if the clinical examination and apnea test could not be completed, 20% of 195 respondents performed an ancillary test for other reasons, including (1) to convince a family that objected to the brain death determination that a patient is truly dead (n=21), (2) personal preference (n=14), and (3) institutional requirement (n=5). Our findings suggest that pediatricians use ancillary tests for a variety of reasons during brain death determination. Medical societies and governmental regulatory bodies must reinforce the need for homogeneity in practice.