The process of declaring brain death and then donating organs is one that is very interesting to many nurses (including myself). How exactly is brain death declared? How does the process of donating organs work? I interviewed Tony Hume, a nurse from New Mexico, who has a great deal of experience with these situations to help answer these questions.
Tell me a little about your background and experience as a nurse.
It may not be what you asked, but I have worked in some setting of a hospital most of my life. I was a volunteer for anything that anyone would take me for. I volunteered for the American Spinal Injury Association, did medical transcription, was a valet at a hospital, was an interpreter, followed a group and wrote down notes on a computer, did photography. I first got paid as an EMT-B in a firehouse, worked in outpatient psych, then worked as a CNA. Finally, after getting my RN I worked in Progressive Care, then ICU full time (a hospital that didn't have split up ICUs). I took every chance I could to float: ER, Cath Lab, Nephrology, Med Surg, cardiology, Outpatient, interventional radiology, anything and everything. When I was moving to Albuquerque I wanted to work in the ICU again, and I prayed to get a phone call from anyone besides Neuroscience. Of course, they called first and I didn't want to turn down a job. Also of note: I did some consulting work for Bard and I am president of the New Mexico chapter of the Association for Vascular Access. I did an interview of a nurse in Colorado a long time ago and became very interested in vascular access. I even did research and submitted for publication to JAVA.
What made you interested in the critical care setting?
Literally wasn't interested at all in nursing school. It kind of just happened. I got a job in critical care and fell in love. When I went to school I wanted to work in psych. I think ICU just fits my personality. I can delve into the whole picture of the patient, really think about disease processes and participate in care that can dramatically change patient outcomes.
When dealing with organ donation, what has usually happened leading up to declaring brain death?
I would say a majority of organ donation is the result of traumatic brain injuries (TBIs). It is hard to say. I know some are people who have had strokes. I would say a majority of these are aneurysms that have ruptured.
How is brain death declared?
The University of New Mexico Hospital (UNMH) has a very detailed policy. Patients must meet certain criteria before we can even do any testing. Body temperature, labs, CO2 many things have to be within normal limits. Certain medications like paralytics, sedation, and pain medications cannot have been given within the last 24 hours. Many things have to be just right before we ever do the test to make sure we don't have any confounding information. The brain death testing itself involves two separate physicians clinical testing. These happen at two different times, and at UNMH only certain physicians may do this. Usually it is limited to only certain attending physicians. They do a battery of clinical tests to check for any brainstem reflex. This involves testing all the cranial nerves. I would probably do a more thorough job of describing this list if I had the policy in front of me. I know they look for pupil dilation, they rub a cotton swab across the eyes to check for a blink, they do dolls eyes testing, and they do a cold caloric test, they test for a cough and gag. Like I said this is to test if any of the cranial nerves are working in the brain. Sometime in this process we do an apnea test. This is when we disconnect the patient from the ventilator. We place a tube with 6 LPM of oxygen into their endotracheal tube. This is a great way to see the difference between oxygenation and ventilation. Often even without any breathing the patient will remain with their SPO2 in a good range. During this time we check a blood gas every couple of minutes to watch their CO2. If their CO2 raises by a certain number of points or percentage in this time and we have seen no evidence of muscle movement we consider this test complete. If the patient is apneic and two separate physicians have decided that they have no brain activity with their clinical test then the patient is declared legally dead, and the physician calls time of death.
What happens between brain death and the actual organ donation?
After brain death the family is given time to grieve and we still are treating the patient. Donor Services will be notified, and they will get in contact with the family. If the family decides they do not wish to donate then we eventually withdraw care of the patient when the family is ready, allow them to grieve some more, and eventually send the patient off to the morgue or the funeral home the family has decided on.
If the family decided to donate, then Donor Services take over and a lot of work is to be done. The nurse then takes all the orders from the Donor Services team. This usually includes hanging several medications like vasopressin and levothyroxine because the brain is dead and no longer producing them. Sometimes these patients are very unstable, and we work to correct any issues to make the lungs, heart, kidneys, or whatever else healthier. Often there are several tests, like an Echocardiogram (trans-esophageal most of the time), CT of the lungs, ultrasounds of the kidneys, and fixing any other injuries they had when they came in. There are a huge number of labs to make sure organs are working properly or help improve organ function and to help with placing organs and avoiding rejection. Often times this period takes a minimum of 24 hours more like 2-4 days until we take the patient to the OR for organ harvest.
How is it decided who the organs recipient will be?
I honestly have no idea. I know that they have to be matched on many levels to avoid rejection, but I am not involved in the placement of organs.
What kind of nursing care do these patients need while waiting to donate their organs?
We take care of them in many of the same ways as any other patient, but we are just not doing neuro checks. We still turn them, bath them, clean their teeth, everything else is the same just with some extra medications, labs, and tests.
Are you the person to bring up organ donation to the family or is there a team of people that start that conversation?
The nurse should leave the initial discussion to the Donor Service team to avoid any conflict of interest. After their initial conversation I answer questions and help them just as I would help any other grieving family.
How do you help the donor families while going through this stressful time?
We help them the same as any other grieving family. I always recommend that the nurse get the family some drinks and snacks and encourage the family to continue taking care of themselves. Many times, families do not understand that brain death is the same as death. The patient is dead even if they still have a pulse. Sometimes this takes time for them to understand.
During this time, we often continue to treat the patient to keep their heart working, even if we know they do not want to donate. We do this as a courtesy although some people abuse this and ask us to keep their heart beating for a long time. Generally, we will do this for a couple of hours to let the family come in and say goodbye or whatever else they want to do before we take out the breathing tube.
Many times, we have to reiterate that the patient is dead. I recommend using the word, say that they are dead. Sometimes people don't understand, and you have to read the situation. With people who are religious I will say that they have died, their soul has moved on from the body. Whatever we can do to assist in their understanding of the situation. Often the more education and the more involved the family can be the less scared, anxious, and frustrated they will be. This all boils down to keeping the family informed and doing the best we can with educating in the situation.
Random notes: Sometimes the patient is not going to meet brain death criteria, but their death is inevitable, and the family wants us to allow the patient to die. Organ donation is still an option with donation after cardiac death (DCD). The DCD process involves bringing the patient to the OR, withdrawing care, allowing the patient to die, pronouncing them dead, resuscitating them, and then moving into organ harvest. Also, there are many other ways someone can donate and positively impact another person's life.
Any advice for nurses wanting to be involved in critical care?
I would say to take every opportunity you can. If you are brand new to patient care I would recommend working on a med/surg floor to get experience. Try and float to different units and get experience. Do extra education, get your certifications for ACLS, TNCC, ENPC, whatever else you can. Get a critical care book and become familiar with things you haven't heard of before. Ask to shadow someone in the ICU. Get in touch with the educator or unit director of the unit you are interested in and ask what you can do to prepare for a career in ICU. They will likely have a lot of resources and want you to be successful and work on their floor.