Brain Death in ICU Nursing Care 1998

8/13/2019 Brain Death in ICU Nursing Care 1998

1/9

ra in d e a t h in I C U snd ssoc i tednurs ing c rechal lengesc o n c e r n i n g p t i e n t s

an d fam iliesIngvar Fr id Ingeg erd Bergbo m -Engberg and H eng o Ha l jam ie

I n g v a r F r idRNA, RN T, PhD-student,G6teborg Univers i ty Col legeof He al th Sciences,Billerudsgatan I, S=416 75G6teborgI n g e g e r d B e r g b o m -E n g b e r gRNT , P hD, BoreasUniversityCol lege of H eal th Sciences,Box 55 140, S-504 04 Bor-asH e n g o H a l ja m i i eMD, PhD , Department ofAnaesthesiology and IntensiveCare, SahlgrenskaUniversityHospita l , S-41345 G6teborg,S w e d e nRequests or of fpr ints to IF)Manus cr ipt accepted17 February 1998

I n o r d e r t o d o c u m e n t t h e i n c i d e n ce a n dc au s es o f b ra i n d e a t h ( B D ) a n d t h ef r e q u e n c y o f o r g a n d o n a t i o n ( O D ) i n aS w e d i s h U n i v e r s i t y H o s p i t a l, ar e t r o s p e c t i v e r e v i e w o f d e a t h s i n an e u r o s u rg i c al d e p a r t m e n t a n d i n th eg e n e r a l i n t e n s i v e c a r e u n i t s ( I C U s ) , w a sc a r r ie d o u t f o r t h e p e r i o d 1 9 8 8 - 1 9 9 4 . B Dd i agnos is w as es tab l i shed i n 197 ( I 0 . 6 )o f a l l d e a t h s ( n = 1 8 4 3 ) . T h e h o s p i t a lr e c o rd s o f a ll B D p a t i e n ts w e r e e x a m i n e di n de ta i l fo l l ow i ng a spec if ic s tudy p l an .T h e m a j o ri ty o f t h e B D p a t i e n ts ( 8 9 )w e r e a c u t e a d m is s io n s t o h o s p i t a l, a n da m o n g t h e m 8 1 w e r e t r a n s f e rr e db e t w e e n h o s p i ta l s o f t e n o v e r a lo n gd i s ta n c e . A m o n g t h e B D p a t i e n t s t h et o t a l n u m b e r o f O D w a s 6 5 ( 3 3 ) . T h em o s t c o m m o n d i a gn o s is l e a d i n g t o B Dw a s s p o n t a n e o u s in t r a c e r e b r a l b l e e d in ga n d t r a u m a t i c h e a d i n ju r y . h e B Ddi agnos is w as e s tab l i shed by n euro l og i ca le x a m i n a t i o n ( 6 0 ) a n d b y c e r e b r a la n g i o g r a p h y ( 4 0 ) . O f t h e B D p a t i e n ts ,5 0 d i e d w i t h i n 4 8 h o ur s i n t h e I C U a n dt h e m a j o r i t y o f r e q u e s t s f o r O D ( 6 7 )w e r e m a d e t o t h e r e la t iv e s o f t h e s ep a t i e n t s .

T h e f in d i n g s a r e d is c us s ed w i t h f o c u son the w ork l oa d an d psycho log ica l s t resso f I C U n u r se s w h e n c a r i n g f o r B Dp a t i e n t s a n d t h e i r f a m i li e s ; a t a s k w h i c hi nc l udes tak i ng p ar t i n p rocesses

c o n c e r n i n g B D d i a gn o s is i n f o r m a t i o n a n dO D r e q u e s t s .

I N T R O D U C T I O NC a r i n g o r p a ti e nt s w i t h i m m i n e n t o r c o n f i r m e dB D i n a n I C U i s o n e o f th e h e a v i e s t d u ti e s o f a nI C U n u r s e. A l t h o u g h t h e c r i te r ia f o r B D , s i n c et h e fi rs t d o c u m e n t a t i o n i n 1 9 6 8 b y a n A d H o cC o m m i t t e e a t H a r v a r d M e d i c a l S c h o o l , h a v eb e e n a c c e p t e d i n m o s t d e v e l o p e d c o u n t r i e s(Far re ll Lev in 1993) , IC U nurses s ti ll exper i -e n c e t h e s p e c i f i c n u r s i n g c a r e r e q u i r e m e n t si n c l u d e d i n t h e t r e a t m e n t o f B D p a t ie n t s a s am a j o r c h a l l e n g e ( G i b s o n 1 9 9 6 ) . T h e n u r s i n gc a r e is n o t o n l y c o n f i n e d t o t h e p a t i e n t b u t a l soi n c l u d es e x p o s u r e t o t h e s p e c if i c n e e d s o f f a m i -l ies in cr is is (Evans 1995) caused by the usuallyra the r s t r ess fu l , complex acu te c l in ica l s i tua t ion( M i ll a r 1 9 9 4 ) . T h e f a m i l y m e m b e r s o f t h e I C Up a t i e n t r e q u i r e i n f o r m a t i o n a n d r e a s s u r a n c ea b o u t t h e p a t i e n t ' s c a r e ( Q u i n n e t a l 1 9 9 6 ) t ofee l conf iden t (Zazpe e t a l 1997) and ge te n o u g h s u p p o r t t o a l l e vi a te t h e a n x i e t y i n h e r e n tin the i r s i tua t ion (Da ley 1984 , F re iche l s 1991) .

F u r t h e r m o r e , t h e f a m i l y o f a B D p a t i e n t isexposed to various diff icul t , s t ressful processess u c h a s u n d e r s t a n d i n g B D a n d t h e e t h ic a l d e c i -s i o n i n c l u d e d i n g r a n t i n g o r r e f u si n g p e r m i s s io nf o r o r g a n d o n a t i o n ( O D ) ( P e ll e ti e r 1 9 9 2 ,Douglass Da ly 1995 , Evans 1995) . I t i s obv i -o u s t h a t o f t e n t h e I C U n u r s e i n t h e s e s i tu a t io n sm u s t n o t o n l y g i v e i n f o r m a t i o n c o n c e r n i n g t h epa t ien ts , bu t a l so suppor t the fami ly mem bersa n d p r e p a r e t h e m f o r t h e p o s s ib i li ty o f B D a n dp o s si b le O D (D a v i s L e m k e 1 9 8 7 , J o h n s o n1992 , Pe l le t i e r 1993) . A l l the pa r t i cu la r needs o ft h e f a m i l y, i n c o m b i n a t i o n w i t h t h e n e c e s si t y t om a i n t a i n a c a r in g a t ti t u d e t h r o u g h o u t t h e c o u r s eo f the i l lness, can giv e r ise to s tress react io ns inI C U n u r s e s ( H i b b e r t 1 9 9 5 ) , w h o a r e e x p o s e dno t on ly to spec i f i c nurs ing ca re p rob lems asso-c ia ted wi th BD bu t a l so to ex i s ten t ia l ques t ionsevoked by the t r agedy tha t has h i t the fami ly .

I n o r d e r t o h e l p I C U n u r s e s t o a c h i e v e am o r e h o l i s t ic a p p r o a c h i n c a r i n g f o r B Dp a t i e n t s a n d t h e i r f a m i l y m e m b e r s , m o r er e s e a r c h i s n e e d e d c o n c e r n i n g n u r s i n g c a r ep r o b l em s i n v o l v e d in t he B D a n d O D p r o -c e s s e s ( G i b s o n 1 9 9 6 ) . T h e m o r e k n o w l e d g et h a t c an b e g a t h e r e d c o n c e r n i n g t h e B Dp a t i e n t, t h e e a s i e r i t w i l l b e f o r th e I C U n u r s et o m a i n t a i n a p r o f e s s i o n a l a p p r o a c h t o t h e f a m -i ly o f t h e B D p a t ie n t ( S m i t h 1 9 9 2 , M c C o yB e l l 1 9 9 4 , W a t k i n s o n 1 9 9 5 , G i b s o n 1 9 9 6 ) .R e p o r t s o n t h e i n c i d e n c e o f B D , i .e . h o wc o m m o n l y I C U n u rs es h a v e to d e al w i th B D -assoc ia ted p rob lems , a re ava i lab le f rom severa lc o u n t r i e s ( G o r e e t a l 1 9 9 2 , R y a n e t a l 1 9 9 3 ,

Intensiveand Crit ical Care Nursing 1998) 14,21-29 1998HarcourtBrace Co. -td

8/13/2019 Brain Death in ICU Nursing Care 1998

2/9

2 2 n t e n s i v e n d r i t ica l a re Nu rs i n g

V e r n o n e t a l 1 9 9 3 , S t a w o r n e t a l 1 9 9 4 ,C h a p m a n e t a l 1 9 9 5 , M e i j a & P o l la c k 1 9 9 5 ,M o t i e t a l 1 9 9 5 , N a v a r r o 1 9 9 6 ) , b u t t h e r e a r en o r e c e n t S w e d i s h s t u d ie s o f i ll n es s o r i n j u r yl e a d i n g t o B D a n d O D .

A I M O F T H E S T U D YT h e a i m o f t h e p r e se n t s tu d y w a s to d o c u m e n tt h e i n c i d e n c e a n d c a u s e s o f B D i n t h eG / S t e b o r g r e g i o n , t h e s p e c i f i c n u r s i n g c a r ew o r k l o a d a s s o c i a t e d w i t h B D p a t i e n t s i n t h eI C U , a n d t h e f re q u e n c y o f O D .

P A T I E N T S A N D M E T H O D SA r e t r o s p e c t i v e r e v i e w w a s m a d e o f all d e a th sd u r i n g t h e p e r i o d 1 J a n u a r y 1 9 8 8 - 3 1 D e c e m b e r1 9 9 4 , i n t h e I C U s o f th e t h r e e m a j o r h o s p i ta l s( A , B a n d C ) i n th e G 6 t e b o r g r e g i o n . T h e

A ge and sex P r im ar y diagnosis N u m b e r o f :

- m ed ic o - t ec hn i c a l tr ea t m e n t s- p o t e n t d r u g infusions E x am ina t i on a n d t r e a t m e n t s :- outside I C U- ins ide ICU- t ransferra l between hospi ta ls

T i m e :- f rom i l lness o ICU ar r iva l- in ICU- f r om c on f i r m ed B D t o w i t hd r a wa l o f r es p i r a t o r y

t r e a t m e n t D iagnos ti c m e t hods f o r B D c on f i r m a t i on N u m b e r o f :

- requests f o r o r g a n d o n a t i o n- o r gan dono r s

D e a th s B D O D % O D( n ) ( n ) ( %) ( n ) ( %) o f B DG ener a l I C U :Hos pi ta l A 864 37 (4.3)Hos pi ta l B 211 23 (10.9)Hos pi ta l C 495 32 (6.5)S um m ar y gene r a l I CUs 1570 92 ( 5 .9 )Neur os u r g i c a l unit:Hos pi ta l A 283 105 (37. I ) *Tota l , a l l un i t s 1853 197 (10.6)

I I (1 .3) 29.77 (3.3) 30.48 (1.6) 25.026 (1.7 ) 28.3

39 (I 3.8)* 37.165 (3.5) 33.0

TChi-square: p < 0.001 vs gene ra l ICU.

r e g i o n h a s , a c c o r d i n g t o S w e d i s h o f f ic i a l a n n u a ls t at is t ic s f o r 1 9 9 7 , a p o p u l a t i o n o f a b o u t 7 6 5 0 0 0i n h a b i t a n t s . E a c h o f t h e h o s p i t a l s r e c e i v e s e m e r -g e n c i e s 2 4 h o u r s o f t h e d a y a n d h a s i ts o w n g e n -e r al I C U ( G - I C U ) . H o s p i t a l A h a s , i n a d d it i o n ,a n e u r o s u r g i c a l d e p a r t m e n t ( N D ) w h i c h i s ar e f er r a l u n i t f o r a ll o f W e s t e r n S w e d e n , i n c l u d -i n g 1 2 h o s p i t a l s w i t h e m e r g e n c y d e p a r t m e n t s .P a t i e n t s t r e a t e d i n s p e c i a l i z e d I C U s ( i n f e c t i o u sd i s e a s e , t h o r a c i c s u r g e r y , c a r d i o l o g y , p a e d i -a t t i c s ) w e r e n o t i n c l u d e d s i n c e t h e s e p a t i e n t sw e r e u s u a l ly n o t B D p a t ie n t s .

F r o m t h e o f f i c ia l r e c o r d s o f t h e t h r e e h o s p i -t al s a t o t a l n u m b e r o f 1 8 5 3 I C U d e a t h s h a do c c u r r e d d u r i n g t h e s t u d y p e r i o d . D e t a i l e d c a s er e p o r t s w e r e a v a i la b l e f o r 1 8 4 2 ( 9 9 .4 ) a n d o np e r u s a l o f t h e r e p o r t s 1 9 7 e s t a b l i s h e d d i a g n o s e so f B D w e r e i d e n t i fi e d . R e p o r t s o f a ll t h e s e 1 9 7B D c as es w e r e f u r t h e r e x a m i n e d a c c o r d i n g t ot h e d e t a i l e d p l a n p r e s e n t e d i n T a b l e 1 .

T h e s t u d y w a s a p p r o v e d b y t h e E t h i c a lC o m m i t t e e o f th e U n i v e r s it y o f G t t e b o r g .

T h e m a t e r i a l i s p r e s e n t e d u s i n g d e s c r i p t iv es t at i st i cs . I n a d d i t i o n , a n a l y si s o f v a r i a n c e( A N O V A ) , W i l c o x o n s i g n e d - r a n k t e s t , a n d t h eC h i - s q u a r e t e st w e r e u s e d f o r c o m p a r i s o n sb e t w e e n t h e d i f f e r e n t g r o u p s . A p - v a l u e o f l es st h a n 0 . 0 5 w a s c o n s i d e r e d s i g n i f i c a n t .

R E S U L T S

D u r i n g t h e t i m e p e r i o d s tu d i ed , 1 J a n u a r y1 9 8 8 - 3 1 D e c e m b e r 1 9 94 , 18 5 3 d e at hso c c u r r e d i n th e G - I C U s a n d t h e N D ( T a b le 2 ).T h e r e v i e w o f t h e m e d i c a l r e c o rd s o f t h ep a t i e n ts r e v e a l e d 1 9 7 c a s es w i t h t h e d i a g n o s i s o fB D , i. e. 1 0 .6 i n c i d en c e o f B D . T h e m e a n a g eo f t h e B D p a t i e n t s w a s 5 0 . 3 _+ 1 7 . 9 ( S D ) y e a r s( r a n g e 2 - 8 5 y e ar s ; 9 5 c o n f i d e n c e i n t e r v a l( C I ) 4 7 . 8 - 5 2 . 8 y e a r s ) . G e n d e r d i s t r i b u t i o n w a s1 0 0 f e m a l e s , m e a n a g e 5 0 . 5 _+ 1 7 . 2 ( S D ) y e a r s( 9 5 C I 4 7 . 0 - 5 3 . 9 y e a r s ), a n d 9 7 m a l e s , m e a na g e 5 0 . 2 + 1 8 . 6 ( S D ) y e a r s ( 9 5 C I 4 6 . 4 - 5 3 . 9y e a rs ) . I n T a b l e 2 t h e n u m b e r o f d e a t h s in t h eI C U o f e a c h s e p a ra t e h o s p it a l i s s h o w n t o g e t h e rw i t h t h e i n c i d e n c e o f B D a n d O D . I n t h e N Da s c o m p a r e d t o t h e G - I C U s a s i g n i f i c a n t l yh i g h e r p r o p o r t i o n o f B D ( 3 7 .1 v s 5 . 9 , p 6 0 y e ar s w a s a ss o c i at e d w i t h f e w e r ( p