VOL: 97, ISSUE: 48, PAGE NO: 35
Jennifer Stuckey is a third-year nursing student at Staffordshire UniversityI was on a clinical placement in the intensive care unit at a Staffordshire hospital when Henry (not his real name) was admitted. He was only 46, had been involved a road traffic accident on Saturday morning and came to ICU via A&E. He had a Glasgow Coma Score of 3 and was unresponsive.
I was on a clinical placement in the intensive care unit at a Staffordshire hospital when Henry (not his real name) was admitted. He was only 46, had been involved a road traffic accident on Saturday morning and came to ICU via A&E. He had a Glasgow Coma Score of 3 and was unresponsive.
When I reported for duty the following Monday afternoon, Henry had been certified brain-stem dead. Although the unit was very busy, everybody was sombre. Only when I got home did I realised how much we had been affected by the incident.
Tests must be carried out before a patient can be certified brain-stem dead. These must be done either by two consultants or by one consultant and a senior registrar, neither of whom is involved in organ transplantation. The tests, which attempt to stimulate the various reflexes that signal life in the brain stem (Viney, 1996), include:
- Shining a light into each of the patient's eyes in turn to see if the pupils react;
- Applying a swab to the cornea of each eye to see if it causes blinking;
- Irrigating each ear in turn with a small volume of ice-cold water to see if the eyes move;
- Passing a suction catheter down the windpipe to find out if the patient gags or coughs;
- Exerting pressure on the bony margin above the eye to see if the patient grimaces in pain.
If any of these functions is present, the brain stem is still working and testing is stopped immediately. If none of the reflexes can be activated, the two doctors apply the 'apnoea' test, in which the ventilator is disconnected for a few minutes to see if the patient begins to breathe spontaneously. If movements of the chest wall are seen, testing is discontinued.
At the same time, a flow of oxygen is delivered to the lungs via a flowmeter connected to a catheter to ensure a high concentration of oxygen in the body and prevent hypoxia. If no respiratory reflexes are seen, the ventilator is reconnected until a second identical set of tests can be carried out, usually within a few hours. This provides an additional safeguard for the patient.
Henry's relatives were approached that afternoon about the possibility of organ donation. I was given the chance to help care for him but declined as I felt I did not know enough about the situation. I did, however, observe what was happening to him and found myself struggling to come to terms with it.
Later in the afternoon I was asked to do one set of the hourly observations on Henry. I did this quite happily - he seemed to me to be alive. Ventilators were powering rhythmic movements of the chest wall, giving the illusion of life.
It was not until I got home that the reality hit me: I had been carrying out observations on a patient who was dead. I was extremely upset.
Two days later I had an appointment with my course tutor. When she asked how I was getting on, I broke down in tears and told her about Henry. She explained what brain-stem death was and how the nursing care of such patients is directed at preserving the organs so that if they are donated they are in optimum condition for the recipient.
She also explained that there should be a subtle shift in the focus of care from the patient to his or her relatives, so that the whole family becomes the pivot of the nurse's therapeutic intervention.
This can only be achieved if the nurse is aware of the ethical, legal, moral, cultural, spiritual and mythical issues surrounding organ donation, and has developed values and beliefs in relation to the essence of caring for both patients and their loved ones (Adam and Osborne, 1999).
Having spoken at length with my tutor and later with my clinical liaison officer, I reached a much better understanding of brain-stem death and felt I could deal with it rationally.
Henry's family gave permission for his organs to be used for transplants, and a team came to remove them that night. The transplant coordinator explained that his organs would probably be used for a number of patients and promised to let me know what happened. The letter I received put my mind at rest as it helped me to see that Henry's death had improved or saved the life of 13 people - some of whom were his relatives.
When a second patient in ICU was declared brain-stem dead, I didn't get so upset or dwell on the circumstances and felt more able to help the relatives cope with their pain.