Decision Making In Case Of A Brain Dead Patient On A Ventilator

A 80 year old man is admitted to the hospital with a massive intracranial bleed. He has been placed on a ventilator because of the respiratory failure associated with intracranial herniation, When you try to remove the ventilator there are no respiration.
The patient makes no purposeful movements and there is no pupilary reaction when you shine a light in his eyes. There is no nystagmus on cold caloric question testing. Oculocephalic and corneal reflexes are absent. He left no specific wishes for his care.

Which of the following is the most appropriate action regarding this patent?

A. Remove the ventilator.
B. Make the patient DNR ( Do not resusticate)
C. Place a nasogastric tube to prevent aspiration.
D. Get a court order authorizing you to remove the ventilator.
E. Do an EEG (electroencephalogram) three times separated by six hours each time.

Answer: A. Remove the ventilator.

Discussion: The patient meets the criteria for brain death. These are: negative corneal reflex, no nvstagmus in response to caloric stimulation of the tympanic membranes, negative pupilary and oculocephalic reflexes, and the absence of spontaneous respiration when you try to remove the ventilator.. If there are no brainstem reflexes and the patient will not spontaneously breathe, then the patient is brain dead. There is no hope of recovery in this circumstance. 

An EEG is not necessary because the clinical presentation is clearly consistent with brain death.

Although the heart has continued to beat, it is the same as taking the heart out of the chest and seeing it beat in a specimen pan simply because of the automaticity of the heart's intrinsic conduction pathway. When the patient is brain dead, you do not need to seek court or ethics committee approval prior to stopping all therapy.

Remember although you have legal right to turn off the ventilator immediately on a person who is brain dead,you should talk to talk to the family first.