He left no specific wishes for his care. Which of the following is the most appropriate action regarding this patent?

An 80-year-old man is admitted to the hospital with a massive intracranial bleed. He has been placed on a ventilator because of the respiratory failure associated with intracranial herniation. When you try to remove the ventilator, there are no respirations. The patient makes no purposeful movements. There is no pupilary reaction when you shine a light in his eyes. There is no nystagmus on cold caloric question testing. Oculocephalic and corneal reflexes are absent. He left no specific wishes for his care. Which of the following is the most appropriate action regarding this patent?

a. Remove the ventilator.
b. Make the patient DNR.
c. Place a nasogastric tube to prevent aspiration.
d. Get a court order authorizing you to remove the ventilator.
e. Do an EEG (electroencephalogram) three times separated by six hours each time.


A - Remove the ventilator.
The patient meets the criteria for brain death. These are: negative corneal reflex, no
nystagmus in response to caloric stimulation of the tympanic membranes, negative pupilary
and oculocephalic reflexes, and the absence of spontaneous respiration when the ventilator is
held. If there are no brainstem reflexes and the patient will not spontaneously breathe, then
the patient is brain dead. There is no hope of recovery in this circumstance. An EEG is not
necessary because the clinical presentation is clearly consistent with brain death. Brain death
is the legal definition of death in the United States. Although the heart has continued to beat,
it is the same as taking the heart out of the chest and seeing it beat in a specimen pan simply
because of the automaticity of the heart’s intrinsic conduction pathway. When a patient is
brain dead, you do not need to seek court or ethics committee approval prior to stopping all
therapy. When a patient is brain dead, do NOT place a nasogastric tube for feeding or hydrate
the patient. The brain-dead patient is dead. This would be as illogical as placing a nasogastric
feeding tube in a cadaver on the autopsy table.
Remember, although you have legal right to turn off the ventilator immediately on a
person who is brain dead, you should talk to the family first. If there is an answer that says
“discuss” “conference,” or any other words indicating that you want to always achieve
consensus first, then that is the answer. The boards would greatly prefer you discuss the
matter with the patient’s family first, prior to removing the endotracheal tube.