Medical Aspects of Serious Brain Issues

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Medical Aspects of Serious Brain Issues

• Robert L. Fine, MD, FACP
• Director Office of Clinical Ethics, Baylor Health
  Care System
• Director of Palliative Care, Baylor University
  Medical Center
• Co-Chair, VITAS Corporate Ethics Committee

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Communication about brain injuries

• Miscommunication about brain injuries is very
  common.
• Different members of the same team will describe
  the same patient as brain dead, comatose,
  unconscious, vegetative or locked-in.
• These are mutually exclusive terms!
• Terri Schiavo has been described as vegetative,
  minimally conscious, not brain dead, and
  disabled.

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Coma eyes closed unconsciousness

• Most serious brain injuries present in coma, best
  understood as eyes closed unconsciousness.
• Coma is rarely permanent.
• Some patients become brain dead - a complete
  absence of all brain function.
• Some patients recover and become normal.
• Some patients recover but are left with a
  specific functional deficit such as paralysis,
  weakness, or cognitive impairment.
• Some patients enter the vegetative state.
• Transient, persistent, or permanent!
• Some patients become locked - in.
• Some patients enter the minimally conscious
  state.

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Brain death

• Irreversible loss of the clinical function of the
  whole brain, including cortical (upper brain
  motor and cognitive), mid-brain (integrative),
  and brain stem (vegetative) function.
• Brain death is a product of modern technology
  made possible by the mechanical ventilators and
  CPR.
• First suggested by two French neuropsychologists
  who referred to le coma depasse or a state
  beyond coma.
• Mollaret, P., Goulan, M. Le coma depasse. Rev
  Neurol (Par) 1959 1015-15
• The need for organs to transplant led to the
  Harvard criteria for irreversible coma.
• Report of the Ad Hoc Committee of the Harvard
  Medical School. A definition of irreversible
  coma. JAMA 1968 Aug 5 205(6) 337-40

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Brain death

• The diagnosis is a clinical judgment by the
  physician based upon the total absence of all
  brain functions.
• Cause should be reasonably established and
  reasonably irreversible.
• May occur as a result of a primary brain injury
  such as trauma or brain hemorrhage, or as a
  result of non-neurological illness such as
  cardiac arrest with resultant anoxic brain
  injury.
• Diagnosis may be confounded by drug intoxication,
  metabolic/endocrine disturbance, severe facial
  trauma, pre-existing pupillary abnormalities,
  chronic CO2 retention, hypothermia.

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Brain death testing

• Bedside testing
• Absent grimace or withdrawal response to pain
• Pupils unresponsive to light
• Absent corneal reflex
• Absent gag reflex
• Absent cough reflex to suctioning
• Absent oculocephalic response - the eyes turn
  with the head - no eye movement -dolls eye
• Absent vestibulo-ocular (caloric) response - the
  eyes fail to deviate away from the side you
  irrigate with ice water - no eye movement

• Apnea testing
• Pre-test criteria euvolemia, Temp 36.5º C, SBP
  90, pCO2 40
• Pre-oxygenate with 100 O2, to achieve pO2 gt 200,
  disconnect the ventilator (or set rate at 0),
  deliver 100 O2 at 6 L/min by cannula into the ET
  tube
• ABG at 8 - 10 minutes
• Test is positive if no respiratory movement and
  pCO2 60
• Inconclusive if pCO2 lt 60, SBP lt 90, O2 sat lt
  80, or cardiac arrhythmia

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Additional brain death testingPlum F MD.
Clinical Standards and Technological Confirmatory
Tests in Diagnosing Brain Death, pages 34-66 in
The Definition of Death Contemporary
Controversies. Youngner, Arnold, and Shapiro.
Johns Hopkins Press. 1999
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Brain death

• Not all cultures / persons accept whole brain
  death.
• Brain death is legally dead under state law in
  all 50 states, except
• New York allows for "the reasonable accommodation
  of the individual's religious or moral objection
  to the determination as expressed by the
  individual, or by the next of kin or other person
  closest to the individual."
• New Jerseys law states that when a physician
  has reason to believe that a declaration of
  neurological (or brain) death would violate an
  individual's personal religious beliefs, death
  will be declared solely on the basis of
  cardio-respiratory criteria.

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Brain death

• Brain dead patients may be maintained for
  prolonged periods with ventilatory support,
  pacemakers, and various hormones - we just dont
  normally do that!
• Some who oppose withdrawal of life-sustaining
  treatment in the vegetative state feel the same
  about brain death.
• Jesse Koochin case 2004 -
• 6 year old child with a malignant and incurable
  brain tumor is taken from Florida to Mexico and
  then to Utah for alternative medicine.
• In Utah he is declared brain dead
• His parents reject this diagnosis and and argue
  that his heart is still beating.
• A Utah judge orders that this brain dead child be
  maintained on a ventilator at the insistence of
  the parents.
• With the assistance of a hospice, he is
  maintained for about one month at home on a
  ventilator before cardiac arrest. CPR fails to
  revive him.

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Vegetative state eyes open unconsciousness

• The Vegetative state is a product of modern
  technology first described in 1972.
• Jennett B, Plum F. Persistent vegetative state
  after brain damage. Lancet 1972I734-7.
• Eyes open unconsciousness - a disassociation
  between being awake and being aware
• Lack of evidence that the upper brain receives or
  projects information a lack of integration
  between upper brain and midbrain but the brain
  stem is generally intact.
• The condition of Karen Quinlan, Nancy Cruzan, and
  Teri Schiavo.
• According to multiple judges in Florida who
  listened to multiple witnesses, there was clear
  and convincing evidence that Ms. Schiavo was
  permanently vegetative.

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Vegetative state eyes open unconsciousness

• Diagnosis is a clinical judgment based upon
• Sleep-wake cycles exist without awareness of self
  or others when awake.
• No comprehension or expression of language.
• No sustained and reproducible voluntary or
  purposeful response to external stimuli.
• Spastic limbs may move non-purposively.
• Noxious stimuli may cause reflex withdrawal.
• Some emotive events may occur such as smiles or
  grimaces but not in reproducible response to
  stimuli.
• Multi-Society Task Force on PVS. Statement on
  medical aspects of the persistent vegetative
  state. NEJM 19943301499-1508, 1572-1579.

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Vegetative state recovery

• Prognosis for recovery is determined by the cause
  of the injury, co-morbid conditions, and length
  of time one has been been vegetative.
• Duration greater than 1 month is said to be
  persistent.
• Duration greater than 3 months when the cause is
  non-traumatic, such as anoxic brain injury after
  CPR is permanent.
• Duration greater than 12 months after traumatic
  brain injury is permanent.

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Vegetative state recovery

• A variety of treatments have been attempted over
  the years to improve the condition but none have
  been successful enough to become routine practice
  in most cases.
• Such treatments were tried on Ms. Schiavo in
  1990-1991 including thalamic stimulator implant.
• Hyperbaric oxygen and vasodilator therapy have
  been suggested by 2 doctors in favor of treating
  Ms. Schiavo. Neither could produce a single
  patient or study from the peer reviewed
  literature.
• Will stem cell treatments change this? Many who
  oppose withdrawal of artificial nutrition and
  hydration in the Schiavo case also oppose the
  most promising types of stem cell research.
• When recovery occurs, it is usually only to a
  state of severe ongoing brain injury.
• The longer one is vegetative - the worse the
  prognosis for meaningful neurological recovery.

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Vegetative state survival

• Younger patients in particular may survive for
  decades if provided with Artificial (assisted)
  Nutrition and Hydration (ANH).
• Although patients may be cared for at home, most
  often they are placed in a nursing home setting.
• Medicaid becomes the payer and they dont pay
  well, thus poor quality treatment ensues in many
  cases.
• Diffuse contractures and skin breakdown are
  common.
• If ANH is not withdrawn, patients often
  eventually die from infections.

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1 year outcome in post-traumatic vegetative state
Note bene consciousness ? normal
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1 year outcome in non-traumatic vegetative state
Note bene consciousness ? normal
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Minimally Conscious State

• Minimally Conscious State (MCS)
• Sleep-wake cycles exist.
• Arousal level ranges from obtunded to normal.
• Reproducible but inconsistent evidence of
  perception, communication ability, or purposeful
  motor activity
• Visual tracking often intact.
• Communication ranges from none to unreliable with
  inconsistent yes/no responses, verbalization, and
  gesture.
• Giacino JT, Zasler ND, Katz DI et al. Development
  of practice guidelines for assessment and
  management of the vegetative and minimally
  conscious states. J Head Trauma Rehab, 1997 12
  79-89.

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Locked - in state

• Locked - in State
• Consciousness is preserved but the patient is
  paralyzed except for eye movement and blinking.
• The Diving Bell and the Butterfly A Memoir of
  Life in Death, by Jean-Dominique Bauby
• born 1952
• locked - in 12/8/95
• died 3/9/97

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Anatomic injury, functional status, and suffering

• Anatomic injury
  Functional status families see at the
  bedside

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We still carry the historical baggage of a
Platonic heritage that seeks sharp essences and
definite boundaries. Thus we hope to find an
unambiguous "beginning of life" or "definition of
death," although nature often comes to us as
irreducible continua.

• Steven Jay Gould