Picture this: A 45-year-old woman is brought into an emergency room suffering from cardiac arrest. CPR is initiated at the scene, but once she is in the hospital she remains in a comatose state, and after five days she undergoes a neurological exam where she is determined brain-dead. The medical characters of this story want to withdraw care, medication and ventilation, while the patient’s family refuses because her heart is still beating. What are the clinician’s medical, legal and ethical responsibilities in such a situation? How can a doctor be sure that the patient will not regain consciousness? To even begin to look at these questions, we need to tackle an even larger one: What does it mean to be brain-dead?
When a doctor declares a patient brain-dead, it means that a patient has no neurological activity in either their brain or their brainstem. In the United States, a person is considered legally dead when he or she loses all brain activity. However, through ventilators and other technologies, a person can remain breathing far after they are determined brain-dead, although once off these machines they would quickly lose all ability to keep blood and oxygen circulating throughout their body.
The complexities that come along with brain-dead patients began in began in the 1950’s with the creation of the mechanical ventilator, which allowed physicians to keep patients breathing when their respiratory drives were lacking. Instantly, many questions popped up for physicians about the ethics of physiologically maintaining a person when there was no hope for his or her recovery, as well as questions about the worth of using resources that could financially burden patients’ families and their hospitals. There was also the question of the emotional toll that plays on a family when they are in a constant state of limbo. At the same time that the ventilator came out, the field of human organ transplantation began to emerge with transplants in the renal, hepatic and cardiac fields. The ideal state for organ donation is when there is still oxygenated blood flowing through the body prior to long-term ventilation. Thus, another difficult situation that can present itself in these cases is when the patient is a candidate for organ donation. Prolonging the donation of organs of a brain-dead patient could inadvertently kill another patient who would otherwise have a chance at a higher quality life.
With patients, there also come considerations of their social, cultural and religious beliefs and those of their family. Conventionally, when a person passes away the mourning process begins; however when a person is termed brain-dead, it is difficult for the family to grieve as they can still feel, hear and see a heartbeat. It is as though the person is simply sleeping.
From a medical and legal perspective, once someone is declared brain-dead, the law allows a physician to remove ventilation and discontinue life support, and the physician does not have an obligation to meet with the family before taking such steps. In reality, the process is not that simple; physicians usually communicate with ones loved ones in order to best ease them into the next stage, as well as make them aware of the treatment. That being said, there are still the ethical dilemmas that present themselves when it comes to the family associated with the patient and the needs they have and require, especially when they refuse to take their loved one off the ventilator.
Although these questions are many with far fewer answers than desired, an important message that can be gained from this dilemma is that every situation is more complicated than it seems. For centuries, we defined death as the instance where there is no longer any cardiorespiratory function, which today could lead to thousands of lives saved via transplant. However, trying to make the grey lines more black and white can also lead to manipulation of the borders of life and death, with a risk of intruding on an individual’s right to life. There are numerous factors that we need to consider when making such decisions: What would the patient have wanted? Religiously, there may be issues that the patient’s family is dealing with or the family’s own difficulty with saying goodbye to someone who appears to be okay. Are the family members waiting for their loved one to heal, or for their own shock and pain to recover? It seems that the most important aspect to not lose sight of in such a situation is that the individual in the hospital is still a person, a human being, who at some point was living his or her best life. Let’s not lose sight of that detail, and consider: What is truly best for the patient in the new condition to which he or she is confined?