• Often these battles occur after some event has already broken the trust between the family and the medical staff. The unexpected death after a tonsillectomy could trigger this. It may take an outside resource, such as a mediator, or the ethics committee, to help bridge the distrust. Early involvement of these resources will usually prevent the adversarial relationship generated by going to court.
• Perform the neuro exam with the family present. They can see for themselves the large number of tests and reflexes, such as a blink reflex, none of which are present. This helps counteract what their eyes are telling them about a beating heart and warm skin.
• Imaging studies are not required to declare brain death but can help the family visualize what has happened. The black void of a cerebral blood flow study is quite stark, as is a massive stroke imaged by CT or MRI. The flat line of a patient’s EEG alongside a normal EEG conveys what a thousand words cannot.
• It is important to be respectful of dissenting opinions without implying agreement or acceptance of them. Too much deference to a family’s denial or delusions, which can easily occur if there is the overhanging threat of malpractice litigation, can be interpreted by the family as confirmation that there really was an unspoken ambiguity in the declaration of death by neurological criteria. The goal is to guide the family to acceptance of a tragic reality. It is neither wise nor compassionate to end up in a 3-week legal battle.
Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at Saint Louis University. He is also listserv moderator for the AAP Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities. E-mail him at pdnews@frontlinemedcom.com.