End of Life

Question 1

What is the criteria for withdrawing treatment?

Answer 1

Futility of Tx

Best interest decision

Question 2

What medications are given during the withdrawal of treatment process?

Answer 2

Analgesia
Anxiolytics
Antisialogues

Question 3

What is the definition of death?

Answer 3

Irreversible loss of the capacity for consciousness combined with irreversible loss of capacity to breathe
(reside within the brainstem)

Question 4

What are the types of death?

Answer 4

• Brainstem damage: Most often, secondary to ischaemia from cardiac arrest (Cardiac source)
• Brainstem death in the presence of a beating heart (primary brain damage)

Question 5

How is brainstem function tested?

Answer 5

Pupils
Corneal reflex
Supraorbital pressure

Question 6

What are the preconditions for diagnosing cardiovascular death?

Answer 6

1) Suffered simultaneous apnoea & unconsciousness in the absence of circulation
2) ONE of the following:
- DNACPR
- CPR attempts have failed
- Life sustaining treatment has been withdrawn

Question 7

What tests are carried out to diagnose death?

Answer 7

Absence of central pulse, heart & breath sounds on auscultation = MIN 5 MINS
3 of the following absent:
Pupillary light reflex
Corneal reflex
Motor response to supraorbital pressure

Question 8

How is brainstem death diagnosed?

Answer 8

2 clinicians (at least 1 consultant)
Patient is tested twice

Question 9

What are the preconditions for diagnosing brainstem death?

Answer 9

1) No doubt condition is due to irreversible brain damage of known aetiology
2) Any potentially reversible cause of coma excluded:
Depressant drugs, OD, sedation on ICU, hypothermia, metabolic, endocrine

Question 10

What tests are carried out to confirm brainstem death?

What cranial nerves do these tests correspond to?

Answer 10

Absence of brainstem reflexes:
-Pupils fixed & Unresponsive to light (CN II, III)
-Corneal reflex (CN V, VII)
-Oculovestibular reflexes (V, VIII)
-No motor response within cranial nerves (VII)
No motor response to supraortibtal pressure (CN V, VII)
No cough/gag (CN IX, X)
Apnoea test- last test performed

Question 11

Describe the apnoea test?

Answer 11

Ensure normal O2 sats (pre-oxygenation before test)
Document absence of respiratory function with appropriate stimulus (high arterial CO2)
Reduce ventilatory minute vol to allow CO2 to slowly rise
Once CO2 >6 pt disconnected from ventilator (apnoeic)
oxygenation maintained by mass flow (ET tube attached to anaesthetic circuit)
Observe for any respiratory activity
No activity >5mins blood gas performed ensure arterial CO2 increased by 0.5 (‘Passed test’)
Reconnect to ventilator