Education And Debate Ethical debate

Brain stem death: managing care when accepted medical guidelines and religious beliefs are in conflictConsideration and compromise are possibleCommentary: Delay in stopping treatment can become unreasonable and unfair

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7244.1266 (Published 06 May 2000) Cite this as: BMJ 2000;320:1266

What should doctors do when a patient in intensive care is declared brain stem dead, but according to their family's religious beliefs is still alive and must continue to be given treatment? Two UK paediatric intensive care specialists describe how they resolved such a difficulty by allowing their patient, an orthodox Jew, to remain on mechanical ventilation until she died from “natural” causes, while a former chief rabbi explains the Jewish position in more detail. However, two Australian intensive care specialists believe that unreasonable delay in stopping treatment serves neither the interests of the patient nor those of society and can be difficult for staff.

Consideration and compromise are possible

  1. David Inwald, Wellcome fellow (D.Inwald@ich.ucl.ac.uk)a,
  2. Immanuel Jakobovits, former chief rabbib,
  3. Andy Petros, consultantc
  1. a Portex Department of Anaesthesia, Intensive Care and Respiratory Medicine, Institute of Child Health, London WC1N lEH
  2. b 44a Albert Road, London NW4 2W
  3. c Paediatric Intensive Care Unit, Great Ormond Street Hospital, London WC1N 3JH
  4. Intensive Therapy Unit, Royal North Shore Hospital, St Leonards NSW 2065, Australia
  1. Correspondence to: D Inwald

    A young orthodox Jewish girl in our paediatric intensive care unit was declared brain stem dead. However, neither her parents nor their religious advisers accepted that she was dead and refused to countenance withdrawal of care. We describe the ethical dilemmas surrounding her management and suggest strategies for dealing with similar cases in future.

    Summary points

    Brain stem death is not recognised by orthodox Jews as death of the individual

    Families should not be pressurised into consenting to withdrawal of care

    Rabbinical authorities should be consulted for moral guidance if an orthodox Jew is declared brain stem dead while being ventilated mechanically

    Compromises that are acceptable to medical and nursing staff are usually possible

    Asystole usually occurs within a few days of brain stem death even if limited supportive care is continued

    Case report

    A 3 year old Jewish girl was being investigated by a paediatric neurologist at another hospital because of unsteadiness, intermittent tremors, and facial weakness. Magnetic resonance imaging, performed under general anaesthesia, showed a large, right sided, temporal mass extending into the midbrain. The scan was performed as a day case and the child returned home to await urgent neurosurgical referral. The procedure had been undertaken …

    Correspondence to: M Fisher

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