What was happening in 1968? 1 10/13/2015 Apollo 8 orbits the Moon - - PDF document
10/13/2015 Pediatric Brain Death and other end of life issues C.C. DeLine, MD Pediatric Neurologist What was happening in 1968? 1 10/13/2015 Apollo 8 orbits the Moon 747 Jumbo Jet introduced Martin Luther King, Jr. and Robert F .
C.C. DeLine, MD Pediatric Neurologist
A Definition of Irreversible Coma Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death
JAMA, Aug 5, 1968. Vol 205 No 6
Improvements in resuscitative and supportive measures have led to increased efforts to save those who are desperately injured. Sometimes these efforts have only partial success so that the result is an individual whose heart continues to beat but whose brain is irreversibly damaged. The burden is great on patients who suffer permanent loss of intellect,
those in need of hospital beds already occupied by comatose patients.
Obsolete criteria for the definition of death can lead to controversy in obtaining
All tests were repeated in 24 hours.
UPDATES
Guidelines for the Determination of Brain Death in Infants and Children: An Update of the 1987 Task Force Recommendations Thomas A Nakagawa, Stephen Ashwal, Mudit Mathur, Mohan Mysore and the Society of Critical Care Medicine, Section on Critical Care and Section
and the Child Neurology Society Pediatrics 2011: 128, e720 Can be found online at http://pediatrics.aappublications.org
(no root or suck in neonates)
(over ventilator)
APNEA TEST
No spontaneous respiratory efforts with PaCO2 ≥ 60 mm Hg and ≥ 20 mm Hg increase above baseline
ANCILLARY TESTING
Only required when apnea test cannot be completed or if there is uncertainty about the results of the neurological examination.
ANCILLARY TESTS
Thomas A. Nakagawa, et. al., Pediatrics 2011; 128: e720-e740
APPENDIX 8
Algorithm to Diagnose Brain Death in Infants and Children
20%
18%
7%
7%
5%
(23,440 in 2013)
Age Group Cause 1-4 5-9 10-14 15-24 Accidents 32% 31% 27% 41% Birth Defects 12% 7% 6% 1% Cancer 8% 18% 15% 5% Suicide 0% 0% 13% 17% Homicide 8% 5% 5% 15% Heart Disease 4% 3% 3% 3% Respiratory Disease 1% 3% 3% 3% Stroke 1% 1% 1% 1% 2013 Statistics 4,068 2,427 2,913 28,486
Many of these deaths are sudden and unpredictable, but
after long, complicated courses, including multiple hospitalizations and frequent contact with health care providers, and their technology.
1991 – Guidelines for the appropriate use of Do-Not-Resuscitate Orders published by AMA Council on Ethical and Judicial Affairs
Natural Death Act Allows a patient (or surrogate) to execute a directive for the withholding or withdrawal of life- sustaining procedures in the event of a terminal illness. The purpose of CPR is to prevent sudden and unexpected death.
The DNAR order is vastly underutilized in our pediatric patient population. CASE 1
James is a 14 y/o diagnosed with leukemia and presents with his 3rd relapse which has not responded to chemotherapy. His condition has been steadily deteriorating and his chances of recovery are extremely poor. The family has indicated to his nurse they want a DNRO.
CASE 1
labs or x-rays, no blood transfusions, no IVs, no antibiotics, etc.?
CASE 1
James becomes air hungry, his HR and BP are
transferred to the PICU.
CASE 2
Angelica is a 5 y/o with severe CP , intellectual disability, epilepsy, severe scoliosis, restrictive lung disease,
sleep apnea and progressive heart failure. She has a feeding G- tube and is on BiPap at home. She is admitted with aspiration pneumonia and respiratory distress.
CASE 2
DNAR? If yes, why?
CASE 2
The family thinks she is suffocating and wants medicine given to comfort her. She is already
to give her more because he is afraid she will stop breathing and be the case of her death.