Health Care Staff Retain Their Humanity

The term complicated grief is used when yearning for a loved one is persistent and the person grieving withdraws socially and is preoccupied by the loss. Although fewer than 1 in 10 people experiences this type of grief, it can wreck a person’s life if the symptoms aren’t managed. Parents grieving the death of a young adult are at increased risk of physical and mental deterioration including depression that may necessitate hospitalization. It’s crucial that health care staff retain their humanity, treat patients and family members as individuals, and make decisions that respect their values. Some family members reach a default position of skepticism and profound sadness. Sudden, unexpected waves of emotion with yearning, regret and ambivalence are not unusual. Family members may need grief counseling. We discuss that with them in detail early on, and then social workers follow up. Risk factors for prolonged grief include concurrent stressors and lack of social support. Families should know that support doesn’t stop when they leave the hospital and that medical staff is available for a phone call or visit. Unfortunately, there’s nothing more we can do for your son. His blood pressure was very low overnight and he’s not moving.

Tip of My Tongue

We think his brain is no longer functioning, and without support, he wouldn’t breathe or have a blood pressure. We need to do a careful examination to find out where we are, but it’s possible that he has already passed on. You’ve expressed your concerns and warned us this was very possible. Can we donate his organs? His driver’s license indicates that he wanted to donate. That’s something we’ll consider. You can meet with an organ donation representative after we’ve completed our examination. I’m so sorry for your loss, but rest assured, we tried everything. Maybe something good can come out of this tragedy and your son can save lives. That’s what we’d like. Can we be there when you do your examination? First let me explain what we’ll do. Then you can decide if you want to be there. Most individuals who suffer an acute catastrophic injury to the brain need to be placed on a ventilator.

Welcome To The Good Times

We call this brain death, and it represents irrevocable loss of function in a person’s brainstem. Allow me to provide some detail so you can better understand this condition. This illustration shows a mass that is compressing on and displacing the brain. The brainstem gradually loses its function in a vertical direction, as indicated. The cerebellum and brainstem are located below the cerebrum. The brainstem connects the hemispheres with the spinal cord. Decades ago, scientists considered the brainstem nothing more than a bridging structure, but we now know that the brainstem controls all vital functions of the brain and is absolutely the most important structure in it. This understanding came about in the 20th century, and the significance of this radically different insight cannot be overstated. The brainstem awakens us and keeps us awake, and it also regulates everything else that supports life including the ability to recognize yourself and your surroundings. It holds the keys to breathing, maintaining a blood pressure, having muscle function, swallowing, moving your eyes, grimacing and making other facial movements, and registering touch and pain. In short, brain death is massive damage to the brain’s hemispheres followed by terminal brainstem injury. Once the brainstem stops functioning, recovery is impossible, and a person has passed the point of no return.

Lay It All Down

In a vegetative state, the cerebrum is damaged, but the brainstem remains largely intact, allowing breathing and blood pressure to continue independently. A patient in a vegetative state may recover, although it’s exceptionally rare. I can’t emphasize enough that viability of the brainstem is key to our understanding of acute injuries to the brain. It’s far too easy to confuse a vegetative state and brain death, even among health care staff. That’s because on the surface, these conditions appear to be the same. When comatose patients who become brain dead arrive at a hospital, they’re often in very bad shape. Suddenly, all their movements, including primitive reflexes, may stop. Their muscle tension is gone, and they’re floppy and flaccid. They no longer respond to suctioning of secretions, and their blood pressure drops. Keeping such patients at a level sufficient to maintain heart and kidney function requires medication. In brief, without aggressive life support, the body will decline quickly, and the heart will stop. But this can’t continue indefinitely. Saying that the patient died is medically correct, but many people only accept death if there’s no heartbeat, blood circulation or breathing. A person dies when the brain or heart stops functioning. When the brain stops, the heart stops, and when the heart stops, the brain stops. Once the brain, specifically the brainstem, is dead, we cannot revive it. Most of the time, we test all reflexes and try to stimulate the individual’s breathing centers. Some experts believe it’s valuable to have family members witness the examination, particularly if it helps them realize that their loved one has died. Gaining a better understanding of brain death and how it’s diagnosed with simple tests may remove any doubts they have, and it provides transparency. Other experts contend that having family members present causes families too much distress. In any case, I offer families the opportunity and explain the tests I’ll be doing. They include applying hard pressure to the patient’s face, arms and legs, squirting ice water in the ears, complete removal from the ventilator for 8 to 10 minutes, and several blood draws. In my experience, few family members want to watch all of that being done to a loved one. I’m also not sure that those who have watched me have found it helpful. I know for sure, however, that some of them didn’t like what they were seeing, even though they understood that these tests were necessary. A declaration of brain death is made methodically, carefully, slowly, and with great deliberation and consultation. The reasons family members object are many and very varied.