Ethics Consultation: Persistent Brain Death and Religion: Must a Person Believe in Death to Die?

Abstract

We first heard about this case from nurses in one of our intensive care units (ICUs) while we were conducting an inservice. When the session was over, we discussed it between ourselves, and decided that it must have been misrepresented. The case had been presented as one of a teenager who was brain dead, had been so for six months, yet had been brought into the ICU for treatment. We have run into this before, we thought: medical professionals confusing brain death with persistent vegetative state (PVS). But, of course, we reasoned, no one can be brain dead for six months. To us, as it would to many, the case sounded like a clinical and ethical impossibility.A week later, we were called by an attending physician from another ICU, at the urging of that unit's nursing staff. They had a patient who was brain dead, whose presence was causing distress among the staff. Ronald Chamberlain, a fifteen-year-old boy, had been a patient at a nearby longterm rehabilitation facility that is equipped to care for ventilator-dependent patients.

Organ support after death by neurologic criteria

“…Respondents reported that their behavior in these situations was highly motivated by fear of litigation and media coverage, both of which have been reported to occur when families are dissatisfied. 3,7,8,16 Many respondents requested the creation of guidelines for management of situations in which families object to discontinuation of organ support after DNC. Although delaying discontinuation of organ support can give a family time to come to terms with a patient's death, 6,7,16 it can also promote confusion about the patient's status and increase the risk of complicated grief (a state of profound grief for greater than 6 months that is marked by disbelief, anger, bitterness, intrusive thoughts of the deceased, and difficulty moving on in life).…”

“…3,7,8,16 Many respondents requested the creation of guidelines for management of situations in which families object to discontinuation of organ support after DNC. Although delaying discontinuation of organ support can give a family time to come to terms with a patient's death, 6,7,16 it can also promote confusion about the patient's status and increase the risk of complicated grief (a state of profound grief for greater than 6 months that is marked by disbelief, anger, bitterness, intrusive thoughts of the deceased, and difficulty moving on in life). 3,5,6,8,17 For clinicians and hospital personnel, ongoing treatment after DNC can be seen as a violation of a patient's dignity and bodily integrity, and a misallocation of valuable resources including an intensive care unit bed, medical equipment, medications, and health care professionals' time and energy.…”

“…3,[7][8][9] Although there are case reports 3-9 on management of objection to DNC, there are no universal legal or medical society guidelines to dictate behavior in these challenging cases. As a result, the frequency of objection to DNC and the manner in which individual centers handle From the…”

“…13 The questions of what constitutes reasonable accommodation and how these situations should be handled in states that do not have accommodation exceptions have left physicians, nurses, administrators, and ethics committees flustered. 3,[7][8][9] Although there are case reports 3-9 on management of objection to DNC, there are no universal legal or medical society guidelines to dictate behavior in these challenging cases. As a result, the frequency of objection to DNC and the manner in which individual centers handle these objections is unknown.…”

“…1 The American Academy of Neurology (AAN) advises that organ support be discontinued after declaration of DNC unless donation is planned, 2 but families sometimes request continuation of support. [3][4][5][6][7][8][9] Four states have legal accommodation exceptions. [10][11][12][13] New Jersey's statute states that DNC cannot be declared in violation of a patient's religious beliefs.…”