Papers

Presence of relatives during testing for brain stem death: questionnaire study

Janet Pugh, nursing sister ^a, Linda Clarke, nursing sister ^a, Janine Gray, senior lecturer in medical statistics ^b, Jolien Haveman, clinical psychologist ^b, Paul Lawler, consultant ^a, Stephen Bonner, consultant ^a. 

^a Intensive Care Unit, South Cleveland Hospital, Middlesbrough TS4 3BW, ^b Centre for Health and Medical Research, University of Teesside, Middlesbrough TS1 3BA

Correspondence to: S Bonner

In brain stem death, where the body remains warm and pink and has a pulse and a chest that rises and falls, relatives may have difficulty accepting that the patient has died. It has been suggested that if relatives witness tests for brain stem death being performed then this may improve their understanding that death has occurred.¹ But, however careful the explanation, any potential benefit to relatives of observing testing for brain stem death may be offset by doubts caused by the movement of limbs during testing (due to spinal reflexes), which often occur when testing for cranial nerve activity (shown as facial movement) by using painful stimuli.

Despite these concerns, we occasionally allow relatives to observe testing for brain stem death because it may help some families to understand that the patient has died. As there is no evidence to support or refute this practice, we undertook a survey to establish current practice in intensive care units in the United Kingdom.

	Subjects, methods, and results

Top Subjects, methods, and results Comment References

After obtaining ethical approval, we telephoned 28 neurotrauma intensive care units to identify which senior staff would usually be involved in testing for brain stem death. We sent a questionnaire to the 147 consultants and 167 senior nurses identified; the response rate was 79% (116/147) for consultants and 77% (129/167) for senior nurses.

Overall, 32% (37/116) of consultants and 42% (54/129) of nurses had experience of relatives' presence during testing, and 69% (63/91) of these felt that this was helpful for relatives (table). Nurses were more likely than doctors (84% v 53%) to believe that witnessing the tests would help relatives to accept that the patient had died, and 48% thought that relatives may gain comfort from being present.

The major potential problems were cited as spinal reflexes (85%) and dealing with the relatives' distress (70%). Forty five per cent of respondents said they would be more willing to allow the presence of relatives if adequate support was available, particularly careful explanation and a dedicated person able to support the family.

	Comment

Top Subjects, methods, and results Comment References

Two thirds of consultants and nurses who had previous experience of relatives being present during testing felt that the relatives had benefited from this. The diagnosis of brain stem death is extremely stressful for relatives. Relatives have refused to allow ventilation to be discontinued, leading in one case to a delay of 48 hours.² Public confusion remains between brain stem death and the "persistent" (not "permanent") vegetative state, when patients rarely regain consciousness.³

Relatives who observed cardiopulmonary resuscitation showed improved psychological outcome after three months.⁴ By contrast, testing for brain stem death is more controlled, with time to prepare relatives for what they will observe. It is possible that allowing relatives to be present may help them to understand the diagnosis and may assist the grieving process. Witnessing the first disconnection test might help relatives "understand the difference between breathing and being breathed" and may help them "accept that a declaration of death is imminent."⁵ Coolican said that relatives should be offered a choice about witnessing testing for brain stem death and that by "participating . . . in dying or death" relatives might benefit in the control thus exercised.¹

However, testing for brain stem death was described by some respondents as "macabre" and "harrowing" and will often seem that way to relatives' families. Relatives observing testing must be capable of understanding the importance of the apnoea test and that movements that seem purposeful and involve the neck as well as the hands and the limbs are in fact only spinal reflexes. Continual explanation is essential.

At present, a minority of doctors and nurses invite relatives to observe testing for brain stem death. More may consider doing so in the future. Whether this is beneficial to these families remains to be seen. The problems associated with the presence of relatives at testing for brain stem death should not be underestimated.

	Acknowledgments

We thank Andrea Cook for organising the questionnaire survey.

Contributors: LC and SB had the original idea. All contributors participated in the study design, interpretation of findings, and writing of the paper. JG performed the statistical analysis and JH the qualitative analysis. SB will act as guarantor.

	Footnotes

Funding: None.

Conflict of interest: None declared.

The questionnaires completed by the consultants and senior nurses appear on the BMJ's website

	References

Top Subjects, methods, and results Comment References

1.	Coolican MB. Families facing the sudden death of a loved one. Crit Care Nurs Clin North Am 1994; 6: 607-612[Medline].
2.	Swinburn JMA, Ali SM, Banerjee DJ, Khan ZP. Ethical dilemma: discontinuation of ventilation after brain stem death. To whom is our duty of care? BMJ 1999; 318: 1753-1754[Free Full Text].
3.	Black D, Bates D, Grubb A. Permanent vegetative state. J R Coll Physicians Lond 1997; 31: 260.
4.	Robinson SM, MacKenzie-Ross S, Campbell Hewson GL, Egleston CV, Prevost AT. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet 1998; 352: 614-617[CrossRef][Medline].
5.	Pallis C, Harley DH. ABC of brainstem death. London: BMJ Publishing Group, 1996.

(Accepted 5 July 2000)