ICU nurses doubt whether clinical neurological examination can establish brain death

More than half of Sweden's intensive care nurses doubt that a clinical neurological examination can establish that a patient is brain dead. Intensive care nurses also perceive that this uncertainty can affect relatives when the question of organ donation is raised, is reveiled in a thesis from the Sahlgrenska Academy, University of Gothenburg, Sweden.

End-of-life care in an intensive care unit (ICU) also includes caring for patients who are brain dead and who by their death become potential organ donors. The thesis investigated attitudes and actions of ICU nurses in the context of organ donation. Information was gathered through both interviews and a questionnaires that went out to 1,100 ICU nurses in Sweden - around half of the total workforce.

The survey showed that less than half - 48 per cent - of ICU nurses perceive that solely clinical neurological examinations can be relied upon for determining that a patient is brain dead. Swedish regulations stipulate that physicians should perform certain clinical tests to establish that the person is deceased. Supplementary contrast x-ray of the brain is only performed in some circumstances, for example when the patient has been affected by medication.

The author of the thesis, Anne Flodén, a registered nurse and researcher at the Institute of Health and Care Sciences, is of the opinion that it is problematic if the nurses' caring for these patients experience doubts about the reliability of the methods used to establish death. She believes that one explanation for their doubts could be that the concept of brain death challenges most of our preconceptions about death and dying. The deceased patient still has a heartbeat and the body is warm, but is, according to Swedish legislation, deceased.

"If you don't perceive the patient as deceased it's not surprising that you don't see the possibility for organ donation."

Respecting the wishes of the deceased patient was viewed as vital to the ICU nurses, irrespective of whether organs were to be donated or not. Supporting the family through the process and ensuring that the decision about donation reached by them was genuinely considered and taken of their own free will were also considered important.

"Nothing must go wrong" was an expression that came up time and time again, both in terms of the relation to the family and caring for a potential donor," says Flodén.

The nurses' own thoughts on the diagnosis of brain death and organ donation were considered to be important, since nurses will act on the basis of their perceptions, consciously or subconsciously, and their perceptions could also affect the family's attitude to organ donation.

"If a nurse is having doubts, this will be obvious to the family and could also trigger uncertainty in them," says Flodén.

"The questionnaire also showed that 39 per cent of ICU nurses had been in situations where the question of organ donation had not been raised with close relatives as the situation was considered so emotionally delicate that it was felt to be inappropriate," says Flodén.

She is adamant that the responsibility does not lie with individual ICU nurses, but instead points to a need for a clear and supportive organisation and for guidelines for the entire donation process, particularly the early stages.

"This problem was raised by many of the ICU nurses in several of the studies," says Flodén. "They were disappointed in the lack of structure and guidelines and are therefore calling for more support from management on these issues."