Ethics OSCE Station Blueprint

Station Name: Brain Death

Issue:

Decisions to Forgo Treatment

Presenting Situation:

Mrs. Pike wants information about her husband Matthew's condition. Matthew suffered a cerebral aneurysm while jogging 4 days ago. He has been declared "brain dead".

Activities:

Patient encounter.

Time Required:

10 minutes

This station was developed by Dr. Peter A. Singer (Centre for Bioethics and Department of Medicine, University of Toronto), and Anja Robb (Department of Family and Community Medicine, University of Toronto. It is part of the Ethics OSCE Project which is funded by Educating Future Physicians for Ontario (EFPO). There is an accompanying videotape. This material can be used for teaching or evaluation. It is not copyrighted and may be freely reproduced for educational purposes.

Instructions to Candidate:

Mr. Matthew Pike, a previously healthy 35 year old male, was brought to the Emergency Room 4 days ago after suffering a ruptured cerebral aneurysm. You are his doctor in the Intensive Care Unit. Unfortunately he has deteriorated neurologically and is on a ventilator. He has been declared "brain dead" by a neurologist and a neurosurgeon who examined him on two occasions 24 hours apart. Their examination included an apnea test. When the patient was temporarily taken off the ventilator, he became hypercarbic, acidemic and did not breathe spontaneously. The patient's wife is waiting to talk to you about his condition.

Please tell the wife of her husband's status and what you propose to do.

CHECKLIST ITEMS:
^^^^^^^^^^^^^^^^
YES     NO     The Candidate:
        
               1.      explains meaning of brain death (e.g. no
                       neurological function, diffuse brain
                       damage, brain tissue destroyed).
----|-----------------------------------------------------------
               2.      assures wife of certainty of diagnosis.
                       (i.e. two neurologists/neurosurgeons
                       agree)
----|-----------------------------------------------------------
               3.      assures wife of certainty of prognosis. 
                       (i.e. brain damage is irreversible, no
                       chance of recovery)
----|-----------------------------------------------------------
               4.      states clearly that husband is dead now.
----|-----------------------------------------------------------
               5.      states that brain death is legal
                       definition of death.
----|-----------------------------------------------------------
               6.      states that life support should be
                       stopped.
----|-----------------------------------------------------------
               7.      mentions that husband is candidate for
                       organ donation.
----|-----------------------------------------------------------
               8.      asks about organ donation card or
                       previous discussions about organ
                       donation.
----|-----------------------------------------------------------
               9.      asks wife for her views regarding
                       donation of husband's organs.
----|-----------------------------------------------------------
               10.     states that organ donation will not
                       affect burial. (i.e. can use an open
                       casket)
----|------------------------------------------------------------ 
=================================================================

                              
RATE FROM 1-5:
 +------------------------------------------------------------+
 |        |          |          |    VERY    |                |
 | POOR   |   FAIR   |   GOOD   |    GOOD    |    EXCELLENT   |
 |  1     |    2     |    3     |     4      |       5        |
 +------------------------------------------------------------+

1.      How would you rate the candidate's communication skills?                                 
        1      2       3      4      5

2.      How would you rate the candidate's ability to address the
        ethical issue in this case?                 
        1      2       3      4      5

Instructions to Standardized Patients:

Your name is Nancy Pike. You are the wife of 35 year old Matthew Pike. You have been happily married for 10 years. You have no children. Four days ago your husband went jogging with a friend and collapsed. He had suffered a ruptured cerebral aneurism. He was taken to the hospital and placed in the Intensive Care Unit (ICU). He has not regained consciousness. He is hooked up to a respirator and it looks as if he's in a coma. It all looks pretty scary. Your friends have been very supportive. Each day you have come to see if there is any improvement, but none has been seen. Doctors have told you that they are concerned because tests are not going well. On some level you are afraid Matthew won't make it. It's hard for you to take in all the information because you're still in a state of shock. You're hoping and praying that he'll "wake up".

You are now at the hospital to get the latest word about his condition. You are waiting to see one of the doctors from the ICU.

If asked, you have never discussed the issue of organ donation with your husband. You're not exactly sure what he would want. Neither of you expected anything like this to happen while you're both so young.

If asked whether Matthew had signed an organ donor card, you can say "I don't know. But I do have some of his ID here. I could check." (Don't volunteer the card until asked if Matthew has signed anything.) You should have in your possession some of his ID information you got from the nurse a couple of days ago. Your husband had it with him the day he collapsed. Among those items, you will find an organ donor card (back of the driver's licence) which is signed by M. Pike. (SPs should try to find an assortment of old cards and perhaps the organ donor part of an out-of-date driver's licence.)

Prompts are used to standardize the scenario and give all candidates an opportunity to address relevant issues.

PROMPT 1 (immediately):
What's going on with him?
If "brain death" is mentioned, say:
"What does that mean?"
If candidate is not clear when explaining brain death, follow up with questions like:
"Is he still breathing? Is his heart still beating?"
[if there is still some confusion about husband's status, then go to next prompt.]

PROMPT 2 (by 1-2 minutes):
Is he dead or alive?
[You're trying to get a clear understanding of your husband's status.]

PROMPT 3 (by 2-3 minutes):
Is there any chance at all that he'll wake up?
[You are trying to establish certainty of diagnosis. If candidate clearly states that condition is irreversible and that your husband is dead, then you can say things like: "Why do you have him hooked up if he's dead?"]

PROMPT 4 (by 3-4 minutes):
What are you going to do now? What happens in cases like this?

PROMPT 5 (by 4-5 minutes):
It seems like such a waste. He was so fit. He was jogging at the time. It all seems so senseless.
[If candidate does not mention organ donation, do not use further prompts.]
[If candidate does mention organ donation, and asks for your views, then go to next prompt.]

PROMPT 6 (by 5-6 minutes):
I just don't know what to do or say. I don't know what he would have wanted.
[If candidate has discussed organ donation, and you have agreed, then you can proceed to ask questions about the process of organ donation.]

PROMPT 7 (by 7-8 minutes):
What do we do now? How long will this take? Will we ever find out what happened to the organs? Will this affect his burial? Can he still have an open casket?

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