Morte encefálica: condutas médicas adotadas em sete unidades de tratamento intensivo pediátrico brasileiras

Abstract

Objective: To assess the incidence of brain death (BD) and its medical management and adopted protocols after its diagnosis in seven pediatric intensive care units (PICUs) located in three Brazilian regions. Methods:A cross-sectional and multicenter study was conducted, based on the retrospective review of medical records regarding all deaths that occurred between January 2003 and December 2004 in seven Brazilian PICUs of tertiary hospitals located in Porto Alegre (two), São Paulo (two) and Salvador (three). Two pediatric intensive care residents from each hospital were previously trained and filled out a standard protocol for the investigation of demographic data, cause of death, diagnosis of BD, related protocols and subsequent medical management.Results: A total of 525 death patients were identified and 61 (11.6%) were defined as BD. The incidence of BD was different (p = 0.015) across the seven PICUs, but with no difference across the three regions. Intracranial hemorrhage was the most frequent cause of BD (31.1%). In 80% of the cases the diagnosis of BD was confirmed by complementary exams (south = 100%, southeast = 68% and northeast = 72%; p = 0.02). The interval between the diagnosis of BD and the withdrawal of life support was different (p < 0.01) across the three regions, being faster (p = 0.04) in the south (1.8±1.9 h) than in the southeast (28.6±43.2 h) and than in the northeast (15.5±17.1 h). Only six (9.8%) children with BD were organ donors. Conclusion:Although a Brazilian law defining the criteria for the determination of BD has been in place since 1997, we verified that it is not followed as strictly as it should be. Consequently, unnecessary life support is offered to deceased individuals, and there is a discrete involvement of PICUs in organ donation. J Pediatr (Rio J). 2007;83(2):133-140:Brain death, organ donation, pediatric intensive care, medical ethics.

Conflitos éticos vivenciados por enfermeiros no processo de doação de órgãos

“…The beating heart affects the performance of the procedure, and this difficulty increases when there are conflicts between medical team and family members, or when personal values and religion are involved. (13,14) Difficulties reported by multidisciplinary teams during the organ donation process, such as lack of knowledge, negligence, and lack of commitment and professionalism, confirmed the results of earlier studies. (15)(16)(17) In general, research reveals that lack of knowledge about the organ donation process has a negative impact on attitudes toward organ donation, even among health professionals, which can lead to not identifying potential donors and not performing the brain death protocol, identified in practice by actions of professionals involved.…”

“…(11,12) Removing life support might cause discomfort because the individual appears to be alive through artificial maintenance. (13) However, criteria for brain death seem to be accepted; there is little resistance to removal of the organs for transplant but rather to the withdrawing of devices. This contradiction leads to beliefs that brain death is usually considered only for transplantation, when, in fact, it means death, independent of whether or not the organs will be used.…”

Family refusal to donate organs and tissue for transplantation

“…The non-perception of the patient as a deceased person makes the family members believe in the reversibility of the situation, or manifest doubts about the real death condition of their relative, due to the removal of organs (7)(8) . Some cultures and religious groups do not accept death while the vital functions of the subject do not cease, because the individual seems to be alive, even though the body is being kept through artificial support (9) . This situation evidences the need for clarification to the population about the concept of brain death.…”

“…Therefore, there is still a lot to be clarified, discussed and demystified, both in the medical and lay communities (9) . …”

Comunicação de más notícias: dilemas éticos frente à situação de morte encefálica

“…Esse comportamento sugere que esses médicos consideram a morte encefálica diferente da morte. Portanto, há muito que ser esclarecido, discutido e desmistificado, tanto na comunidade médica como na comunidade leiga 20,21 . É perceptível a existência de receio por parte da comunidade médica latino-americana em retirar o suporte ventilatório de pacientes que ainda têm o coração batendo.…”