A 65-year-old man was admitted to the intensive care unit after going into cardiac arrest when alone at home. Cardiopulmonary resuscitation and advanced cardiac life support were performed extensively in the field, and return of spontaneous circulation was eventually achieved. Two days later, he remains intubated and is on full ventilator support. The patient is unresponsive to verbal and tactile stimuli. His temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, and pulse is 70/min. The treating physician discusses with the patient's family the possibility of brain death. The patient is diagnosed with brain death. The physician explains this finding to the patient's family and discusses withdrawing of mechanical ventilator support. Everyone in the family appears to understand and agrees to proceed with withdrawing ventilatory support. A relative then walks into the patient's room and notices some movements in the patient's legs and toes. The relative believes the patient is not dead and gets angry with the treating physician. Which of the following is the most appropriate response to the relative's reaction?

Question

A 65-year-old man was admitted to the intensive care unit after going into cardiac arrest when alone at home.  Cardiopulmonary resuscitation and advanced cardiac life support were performed extensively in the field, and return of spontaneous circulation was eventually achieved.  Two days later, he remains intubated and is on full ventilator support.  The patient is unresponsive to verbal and tactile stimuli.  His temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, and pulse is 70/min.  The treating physician discusses with the patient's family the possibility of brain death. The patient is diagnosed with brain death.  The physician explains this finding to the patient's family and discusses withdrawing of mechanical ventilator support.  Everyone in the family appears to understand and agrees to proceed with withdrawing ventilatory support.  A relative then walks into the patient's room and notices some movements in the patient's legs and toes.  The relative believes the patient is not dead and gets angry with the treating physician.  Which of the following is the most appropriate response to the relative's reaction?

Quizplus · Accepted Answer

Explanation: Brain death is the irreversible absence of cerebral and brainstem reflexes including pupillary, oculocephalic, oculovestibular (caloric), corneal, gag, sucking, swallowing, and extensor posturing. Patients with brain death can have spontaneous movements, but these originate from peripheral nerves or the spinal cord. Possible reflexes include finger flexion, truncal movements (eg, superficial and deep abdominal muscles), triple flexion response (flexion at the hip, knee, and ankle with foot stimulation), plantar reflexes (Babinski sign), limb movements to painful stimuli, and alternating flexion-extension of the toes. Explaining this in a calm manner is the appropriate response to help dissipate any anger and anxiety among family members. (Choices A, C, D, and E) This patient does not require any further testing or consultations based on limb movements alone as the criteria for brain death have already been fulfilled. Educational objective: Patients with brain death can have spontaneous movements originating from peripheral nerves or the spinal cord. References: Fasciculations in brain death. (http://www.ncbi.nlm.nih.gov/pubmed/20890193) Undulating toe movements in brain death. (http://www.ncbi.nlm.nih.gov/pubmed/15525292)

A 65-Year-Old Man Was Admitted to the Intensive Care Unit