title: The Least Bad Option: Unilateral Extubation after Declaration of Death by Neurological Criteria.
abstract: Typically, the determination of death by neurological criteria follows a very specific protocol. An apnea test is performed with further confirmation as necessary, and then mechanical ventilation is withdrawn with the consent of the family after they have had an opportunity to "say goodbye," and at such a time to permit organ retrieval (with authorization of the patient or consent of the next of kin). Such a process maximizes transparency and ensures generalizability. In exceptional circumstances, however, it may be necessary to deviate from this protocol in order to spare family members unnecessary suffering and to reduce moral distress felt by clinical staff. It may also be appropriate, we argue, to refrain from even inquiring about organ donation when the next-of-kin is not only certain to refuse, but lacks the decision-making capacity to potentially consent. The case described in this article calls into question generally reliable assumptions about determination of death by neurological criteria, where the best the clinical team could do for the patient and his family was "the least bad option."
authors.affiliation: University of Vermont College of Medicine, Burlington, Vermont USA. Sally.Bliss@uvmhealth.org.
authors.forename: Sally E
authors.initials: SE
authors.lastname: Bliss
authors.affiliation: University of Vermont College of Medicine, Department of Pediatrics, 111 Colchester Avenue, Smith 266, Burlington, Vermont 05401 USA. Robert.Macauley@uvmhealth.org.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Macauley
mesh_terms: D032721:Adult Children / Q000523:psychology; D000368:Aged; D060666:Airway Extubation / Q000941:ethics*; D001049:Apnea / Q000175:diagnosis; D044466:Asian People; D001926:Brain Death / Q000175:diagnosis*; D003643:Death; D003657:Decision Making / Q000941:ethics*; D003717:Denial, Psychological; D003937:Diagnosis, Differential; D034462:Dissent and Disputes; D033061:Ethics Consultation; D006117:Grief; D006282:Health Personnel / Q000523:psychology; D006801:Humans; D008297:Male; D012121:Respiration, Artificial; D013315:Stress, Psychological / Q000209:etiology*; D020521:Stroke / Q000628:therapy*; D020458:Third-Party Consent / Q000941:ethics*; D020858:Tissue and Organ Harvesting / Q000941:ethics*; D009927:Tissue and Organ Procurement; D014481:United States; D014850:Waiting Lists; D028761:Withholding Treatment / Q000941:ethics*