Case Presentation: 20-year-old, nine weeks pregnant female attempted suicide by hanging. Following CPR for fifteen minutes she had a spontaneous return of the circulation. Myoclonic jerks and generalized seizures secondary to anoxic brain injury were noted. Two days later, her brainstem reflexes were absent. Transcranial Doppler revealed no blood flow and she was declared brain dead. The family wanted the pregnancy to continue. Recurrent urinary tract infections, hospital-acquired pneumonias, panhypopituitarism causing hypothyroidism, adrenal insufficiency and severe hypernatremia secondary to diabetes insipidus complicated the clinical course. At 25 weeks oligohydramnios along with poor fetal weight gain was registered. A decision was made to proceed with cesarean section. The baby boy at the age of ten months, is breathing on room air, has bilateral retinopathy of prematurity and failed hearing screen. His growth is otherwise appropriate for the age.
Discussion: Hospitalists may find themselves as primary attending physicians managing a complex patient that requires coordination with multiple specialties. As far as we are aware this is the first patient who was declared brain dead, her body been used an incubator, pregnancy continued for 111 days, and the baby was born against all the odds survived. This case highlights multiple medical and ethical issues.
Brain death (means legally dead) in the USA is defined as an irreversible cessation of whole brain function. The first step in the diagnosis of brain death is to rule out reversible causes like drug intoxication, shock, hypothermia, electrolyte, acid-base and endocrine abnormalities. The next step is to demonstrate absent cortical activity (i.e. no response to painful stimuli and absence of decorticate or decerebrate posturing.) and absent brainstem reflexes (i.e. absent pupillary light and corneal reflex, No cough with tracheal suctioning. No gag reflex, no spontaneous respiration). Standard evaluation is to conduct the apnea test in all patients meeting the brain death criteria. However, we did not want to cause more hypoxic brain damage to the baby. So, we proceeded with transcranial Doppler, confirmed brain blood flow is absent and declared the patient brain dead.
The medical literature to date says that if any pregnant patient had been in cardiac arrest for more than six minutes the outcome to the baby is poor. The risks of fetal demise, hypoxic injury to the fetus, fetal anomalies are explained to the family and they wanted to continue the pregnancy.
The cardiopulmonary resuscitation (DNR) forms do not apply to brain dead patients. The family is aware that any time her heartbeat stops, or other organs fail or if the baby is born or dies in the womb, we would withdraw the support. Psychological counseling is offered to staff members who could not bear the burden of providing care to a dead patient.
The patient was a registered organ donor, and she decided when she is of sound mind (In legal jargon “Respect for patient autonomy”). So, the agency coordinating the organ donation felt that the family does not have a right to revoke the patient’s wish.
Conclusions: Hospitalists, as primary attending physicians should be familiar not only with the clinical diagnosis of brain death but also of the available ancillary tests in confirming brain death. Early involvement of multidisciplinary teams including legal and medical ethics is advisable.