title: Family members' requests to extend physiologic support after declaration of brain death: a case series analysis and proposed guidelines for clinical management.
abstract: We describe and analyze 13 cases handled by our ethics consultation service (ECS) in which families requested continuation of physiological support for loved ones after death by neurological criteria (DNC) had been declared. These ethics consultations took place between 2005 and 2013. Patients' ages ranged from 14 to 85. Continued mechanical ventilation was the focal intervention sought by all families. The ECS's advice and recommendations generally promoted "reasonable accommodation" of the requests, balancing compassion for grieving families with other ethical and moral concerns such as stewardship of resources, professional integrity, and moral distress. In cases we characterized as finite-goal accommodation, a "reasonable accommodation" strategy proved effective in balancing stakeholders' interests and goals, enabling steady progress toward resolution. When a family objected outright to a declaration of DNC and asked for an indefinite accommodation, the "reasonable accommodation" approach offered clinicians little practical direction, and resolution required definitive action by either the family or the clinical team. Based on our analysis and reflections on these 13 cases, we propose ethically justified and practical guidelines to assist healthcare professionals, administrators, and ECSs faced with similar cases.
authors.affiliation: Cleveland Clinic, JJ607, 9500 Euclid Avenue, Cleveland, Ohio 44195 USA. flamma@ccf.org.
authors.forename: Anne Lederman
authors.initials: AL
authors.lastname: Flamm
authors.affiliation: Cleveland Clinic, JJ607, 9500 Euclid Avenue, Cleveland, Ohio 44195 USA.
authors.forename: Martin L
authors.initials: ML
authors.lastname: Smith
authors.affiliation: Cleveland Clinic, JJ607, 9500 Euclid Avenue, Cleveland, Ohio 44195 USA.
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Mayer
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001926:Brain Death / Q000175:diagnosis*; D002755:Choice Behavior / Q000941:ethics; D003657:Decision Making / Q000941:ethics*; D033061:Ethics Consultation; D005190:Family; D005260:Female; D006117:Grief; D006323:Heart Arrest; D006801:Humans; D008297:Male; D008875:Middle Aged; D028681:Moral Obligations; D010360:Patient Transfer; D017410:Practice Guidelines as Topic; D012121:Respiration, Artificial / Q000941:ethics; D013997:Time Factors; D028761:Withholding Treatment / Q000941:ethics*; D055815:Young Adult