Discussing brain death, organ/tissue donation
Program to assist doctors, boost organ donor rates
Doctors recognize the importance of delivering news of brain death as well as possible — thoroughly, taking as much time as necessary, conveying the information of irreversible loss of brain function clearly and at a level family members can absorb.
But because the delivery of bad news is not a subject that has been given great attention by medical schools, physicians perform this difficult task by feeling their way through the encounters, usually with mixed success.
"Brain death can be a difficult concept for families to grasp," says June Hinkle, RN, MSN, director of bereavement services at The Ohio State University Medical Center in Columbus. "The circumstances are often sudden and traumatic, and while they hear the words 'brain-dead,' they see a body that is pink, warm, and still [mechanically] breathing. It's a very difficult concept. It doesn't happen frequently, and residents don't get much experience [in delivering news of brain death]."
Compounding the damage inflicted when news of brain death is delivered incompletely or insensitively is the potential loss of donor tissue. Patients who suffer brain death are a major source of potential organ donors, even though only a small percentage of all patient deaths are classified as "brain deaths." Before families can consider — much less consent to — organ and tissue donation, they first must have a clear understanding of brain death. The longer that process takes, the less viable the donor tissue becomes.
"Time is essential if you are going to pursue donation, because once the brain has died, the body follows suit," Hinkle points out. "There is a lot we can do to keep a body going" — measures medical staff would not take if the family is not going to agree to donate.
"It requires a lot of medication to keep the heart going, so it's sort of essential that we know how aggressive to be in maintaining a heartbeat, because you want to keep the body stable until it reaches the operating room."
If discussions between the physician and family regarding the patient's condition are incomplete or otherwise handled clumsily, they might not understand that their loved one is dead, and so any discussion about donating organs or tissues might strike the family as premature — making the potential for donation even bleaker.
Simulation program developed
Hinkle says the need for some sort of model that would give residents the opportunity to practice delivering news of brain death and experience simulated family responses led her to search the literature for models of testing that use simulations.
"Medical students are now required, as part of their boards, to go to a setting where they have to evaluate a simulated patient, and they in turn are evaluated by their instructors," she explains. "It allows them to see patients before they — the residents — get to clinical settings. They learn to use tools and take histories in a controlled environment. So they are used to that style of testing."
With a grant from the Ohio Department of Health Second Chance Trust Fund, which supports organ and tissue donation efforts, and development assistance from LifeLine of Ohio, a federally appointed organ procurement organization, Hinkle created a monitored, simulated laboratory to give residents realistic rehearsals for delivering news of brain death.
The simulation takes place in a laboratory that recreates, as closely as possible, a hospital setting, complete with multiple exam rooms, albeit ones equipped with camera and one-way-window monitoring. Actors portray next of kin, who react as real families might when told that a relative or friend is dead.
Realism is crucial, says Hinkle, from the circumstances that render the "patients" brain-dead to the reactions of the actor-families to the news and how it is delivered.
"Unfortunately, [brain death] is usually a situation where the person was fine in the morning, and then you get called to the hospital and there's been a motor vehicle accident or a bleed in the brain or a gunshot," she explains. "It's a sudden, traumatic change for the family, and it then becomes how well they understand the concept and how easily they can understand that the person is gone."
The aim is not merely to present information to families in a way that pushes them to donate organs and tissue, Hinkle stresses.
"There are great benefits to the family. They can grasp the news faster, and that gives them time to say goodbye, to realize that this really is the end, without a period of confusion and not really knowing what's going on," she says.
Targets those most likely to need it
The Ohio State program is in its first year, and is tailored to the physician populations that are most likely to deliver news of brain death — surgical residents, pulmonary fellows, and emergency medicine residents. The training directors for each program added the simulation to their programs' continuing education program.
A resident going through the simulation is provided with a patient history — gunshot wound, motor vehicle accident, or brain bleed — as well as diagnostic results (X-rays, etc.) and the patient's current status. The physician also is shown how to do a proper coma exam, Hinkle says, so that the diagnosis of brain death can be confirmed.
The actors playing family members are trained to act like next of kin would in such a situation and learn the appropriate questions to ask.
"Then, we videotape the residents' delivery; first, they deliver the news of injury and that the situation looks bad, and then they deliver the news of brain death," explains Hinkle. "They get to see the videotape themselves, and they get feedback. We critique what we like and what we don't like, behaviors that we like and behaviors we think they should think about."
The "family" is involved in the feedback phase, submitting an evaluation of how well the doctor fared in terms of his or her composure, mannerisms, and communication of the necessary information about brain death. Their comments are used as coaching tools, Hinkle says, to help doctors recognize what they can improve on and what clues to look for in family members' responses and behaviors that indicate they are not getting the message.
Residents have been very positive in their feedback about the program, Hinkle says, and Ohio State already has gotten inquiries from other hospitals about gaining access to the training.
"Our goal is to continue with new residents each year, and I think it will come down to cost- and time-effectiveness as to whether we bring in older residents," she says. "It would be interesting to re-evaluate older residents [who went through the training early in their residencies] to see if they improve over time."
- June Hinkle, RN, MSN, director of bereavement services, The Ohio State University Medical Center, Columbus, OH. Phone: (614) 293-8505. E-mail: email@example.com.