Faculty Bibliography

We describe two unusual cases of cardiopulmonary death in mechanically ventilated patients in the neurological intensive care unit. After cardiac arrest, both patients were pulseless for a protracted period. Upon extubation, both developed agonal movements (gasping respiration) resembling life. We discuss these cases and the literature on the ethical and medical controversies associated with determining time of cardiopulmonary death. We conclude that there is rarely a single moment when all of a patient's physiological functions stop working at once. This can pose a challenge for determining the exact moment of death.

Although the concept of brain death is accepted by the majority of physicians, lawyers, ethicists and society at large, controversies about determination of death by neurological criteria persist, and often reach the public eye. In this article, we examine four prominent controversial brain death cases from 2013-2016. We review current controversies, including protocol variability, recognition of the American Academy of Neurology (AAN) criteria for brain death as an accepted medical standard, and management of objections to discontinuation of organ support after determination of brain death. Brain death remains conceptually and legally valid, and it is vital that these issues are solved. We argue that medical societies and governmental regulatory bodies must support the AAN criteria in order to decrease protocol variability, and must fully endorse the validity of these criteria as accepted medical standards.

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.

OBJECTIVES: We sought to 1) evaluate how pediatricians approach situations in which families request continuation of organ support after declaration of death by neurologic criteria and 2) explore potential interventions to make these situations less challenging. DESIGN: A survey on management and personal experience with death by neurologic criteria was distributed electronically to pediatric intensivists and neurologists. We compared responses from individuals who practice in states with accommodation exceptions (accommodation states where religious or moral beliefs must be taken into consideration when declaring death: California, Illinois, New Jersey, New York) to those from non-accommodation states. SETTING: United States. SUBJECTS: The survey was opened by 254 recipients, with 186 meeting inclusion criteria and providing data about the region in which they practice; of these, 26% were from accommodation states. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: More than half of physicians (61% from both accommodation states and non-accommodation states) reported they cared for a pediatric patient whose family requested continuation of organ support after declaration of death by neurologic criteria (outside of organ donation; range, 1-17 times). Over half of physicians (53%) reported they would not feel comfortable handling a situation in which a pediatric patient's family requested care be continued after declaration of death by neurologic criteria. Nearly every physician (98%) endorsed that something needs to be done to make situations involving families who object to discontinuation of organ support after declaration of death by neurologic criteria easier to handle. Respondents felt that public education, physician education, and uniform state laws about these situations are warranted. CONCLUSIONS: It is relatively common for pediatricians who care for critically ill patients to encounter families who object to discontinuation of organ support after death by neurologic criteria. Management of these situations is challenging, and guidance for medical professionals and the public is needed.

BACKGROUND: The morbidity, mortality, and monetary cost associated with intracerebral hemorrhage (ICH) is devastatingly high. Several scoring systems have been proposed to prognosticate outcomes following ICH, though the original ICH Score is still the most widely used. However, recent research suggests that systemic physiological factors, such as those included in the APACHE II score, may also influence outcome. Additionally, no scoring systems to date include pre-morbid functional status. Therefore, we propose a scoring system that incorporates these factors to prognosticate 3- and 12-month functional outcomes. METHODS: We used the Random Forest machine learning technique to identify factors from a dataset of over 200 data points per patient that were most strongly affiliated with functional outcome. We then used linear regression to create an initial model based on these factors and modified weightings to improve accuracy. Our scoring system was compared to the ICH Score for prognosticating functional outcomes. RESULTS: Two separate scoring systems (ICHOP3 and ICHOP12) were developed for 3- and 12-month functional outcomes using GCS, NIHSS, APACHE II, pre-morbid modified Rankin scale (mRS), and hematoma volume (3-month only). Patient outcomes were dichotomized into good (mRS 0-3) and poor (mRS 4-6) categories based on functional status. AUCs in the derivation cohort for predicting mRS were 0.89 (3-month) and 0.87 (12-month); both were significantly more discriminatory than the original ICH Score. CONCLUSION: The ICHOP scores may provide more comprehensive evaluation of a patient's long-term functional prognosis by taking into account systemic physiological factors as well as pre-morbid functional status.

BACKGROUND: Three recent lawsuits that address declaration of brain death (BD) garnered significant media attention and threaten to limit physician power to declare BD. METHODS: We discuss these cases and their consequences including: the right to refuse an apnea test, accepted medical standards for declaration of BD, and the irreversibility of BD. RESULTS: These cases warrant discussion because they threaten to: limit physicians' power to determine death; incite families to seek injunctions to continue organ support after BD; and force hospitals to dispense valuable resources to dead patients in lieu of patients with reparable illnesses or injuries. CONCLUSIONS: Physicians, philosophers, religious officials, ethicists, and lawyers must work together to address these issues and educate both the public and medical community about BD.

BACKGROUND AND PURPOSE: The ideal strategy to prevent infections in patients with external ventricular drains (EVDs) is unclear. METHODS: We conducted a cross-sectional survey of members of the Neurocritical Care Society on infection prevention practices for patients with EVDs between April and July 2015. RESULTS: The survey was completed by 52 individuals (5% response rate). Catheter selection, use of prolonged prophylactic systemic antibiotics (PPSAs), cerebrospinal fluid (CSF) collection policies, location of EVD placement, and performance of routine EVD exchanges varied. Antibiotic-impregnated catheters (AICs) and conventional catheters (CCs) were used with similar frequency, but no respondents reported routine use of silver-impregnated catheters (SICs). The majority of respondents were either neutral or disagreed with the need for PPSA with all catheter types (CC: 75%, AIC: 85%, and SIC: 87%). Despite this, 55% of the respondents reported PPSAs were routinely administered to patients with EVDs at their institutions. The majority (80%) of the respondents reported CSF collection only on an as-needed basis. The EVD placement was restricted to the operating room at 27% of the respondents' institutions. Only 2 respondents (4%) reported that routine EVD exchanges were performed at their institution. CONCLUSION: Practice patterns demonstrate that institutions use varying strategies to prevent ventriculostomy-related infections. Identification and further study of optimum care for these patients are essential to decrease the risk of complications and to aid development of practice standards.