Nursing care to patients in brain death and potential organ donors

Layana de Paula Cavalcante Islane Costa Ramos Michell Ângelo Marques Araújo Maria Dalva dos Santos Alves Violante Augusta Batista Braga About the authors

Abstracts

Objetivo

Analisar a opinião dos enfermeiros sobre os cuidados de enfermagem ao paciente em morte encefálica e potencial doador de órgãos.

Métodos

Pesquisa descritiva, exploratória, de abordagem qualitativa, desenvolvida em um hospital geral. O material produzido foi analisado, onde emergiu a categoria Dimensões do cuidado, com duas subcategorias: dimensão técnica e dimensão bioética.

Resultados

As dimensões do cuidado dos Enfermeiros ao potencial doador de órgãos e tecidos dão indicativos de uma prática voltada para a manutenção hemodinâmica, estando presente, também, o conflito entre assistir ao paciente em morte encefálica ou a outros com possibilidades de sobrevida.

Conclusão

O cuidado de enfermagem ao potencial doador de órgãos configura-se como um processo complexo e que requer melhor qualificação e maturidade emocional, nem sempre presente.

Cuidados de enfermagem; Morte encefálica; Doadores de tecidos; Unidades de terapia intensiva


Objective

Analyzing the opinion of nurses about nursing care to patients with brain death and potential organ donors.

Methods

A descriptive, exploratory study, of qualitative approach, carried out in a general hospital. The produced material was analyzed, from where emerged the category called Dimensions of care, with two subcategories, namely: technical dimension and bioethical dimension.

Results

The dimensions of the nursing care to potential donors of organs and tissues give indications of a practice focused on maintaining hemodynamic, also with the presence of the conflict between assisting patients with brain death or others with possibilities of survival.

Conclusion

The nursing care to potential organ donors is a complex process and requires better skills and emotional maturity, which are not always present.

Nursing care; Brain death; Tissue donors; Intensive care units


Introduction

The care for patients with brain death is characterized as a complex activity, implemented by multidisciplinary teams working in intensive care units. In such activity, the role of nurses stands out, since they are responsible for providing direct care for the potential organ donors and their families. Their work is of fundamental importance in the management of the pathophysiological repercussions characteristic of brain death, in the hemodynamic monitoring and in the provision of individualized care. The success of transplantation is closely related to the ideal maintenance of the potential donor.

The role of nurses in the embracement of patients’ families is of crucial importance in this moment, since they offer support and sufficient and appropriate information for families in order that they can collaborate with the process of donation and transplant, if this is their will.(1Santos MJ, Massarollo MC, Moraes EL. [Family interview in the process of donating organs and tissues for transplantation]. Acta Paul Enferm. 2012; 25(5): 788-94. Portuguese.)

The regulation of brain death diagnosis by the Federal Council of Medicine (CFM - Conselho Federal de Medicina) occurred in 1991, and it was defined as the irreversible condition of all respiratory and circulatory functions or cessation of all brain functions, including the brain stem.(2Moraes EL, Silva LB, Moraes TC, Paixão NC, Izumi NM, Guarino AJ. [The profile of potential organ and tissue donors]. Rev Latinoam Enferm. 2009; 17(5):716-20. Portuguese.)

The maintenance of the potential donor of organs and tissues should be carried out as soon as the suspected brain death occurs. The awareness of the irreversibility of the condition of death should alert professionals about the chance of using the organs for transplantation. However, the actions of these professionals are essential for maintaining the body waiting in appropriate hemodynamic conditions, while the family decides about the donation of usable organs.(3Guido LA, Linch GF, Andolhe R, Conegatto CC, Tonini CC. [Stressors in the nursing care delivered to potential organ donors]. Rev Latinoam Enferm. 2009; 17(6):1023-9. Portuguese.)

The family is usually fragile and needs care and attention from the health care team, as they are facing a moment of pain with the diagnosis of brain death and the loss of a loved one. In most of the times, the death occurs tragically and unexpectedly. At this moment, the doubts of family members should be eliminated at all stages of the process, and it is essential that the professionals are adequately prepared to operate in this process. Thus, it is possible to establish a link between the team and the family, which may influence, positively or not, at the time of decision about the organ donation.(4Dalbem GC, Caregnato RC. [Organ and tissue donation for transplant: family refusal]. Texto & Contexto Enferm. 2010; 19(4):728-35. Portuguese.,5Pessoa JL, Schirmer J, Roza BA. [Evaluation of the causes for family refusal to donate organs and tissue]. Acta Paul Enferm. 2013;26(4):323-30. Portuguese.)

Given this context, it is important to identify elements in the work process of nurses with the patients who are potential organ and tissue donors and their families that may interfere in the donation/transplantation process.

The nurses of intensive care units have different conceptions of values, as well as social, religious, philosophical and cultural beliefs that may impact on their everyday actions, in the relations with the family of patients with brain death and in the whole process of donation and transplantation. Hence, the objective of this study is to analyze the opinion of nurses about the nursing care to patients with brain death and potential organ donors.

Methods

This is a descriptive, exploratory study of qualitative approach, carried out in an intensive care unit of a general hospital in the city of Fortaleza, state of Ceará, northeast region of Brazil, in the period between August and December 2013. The research subjects were 30 nurses who had been working in the institution for at least six months. This is because after this period, allegedly, the professional is adapted to the environment and the experience of assisting the patients who are potential organ and tissue donors.

Data were generated by two sources. One were the interviews using a structured questionnaire, containing a part of the characterization of the research subjects, with information on gender, age, length of service and training in the field of transplantation. The other was composed of five guiding questions: How do you conceive the donation of organs and tissues? How is your daily life in the care of patients who are potential donors of organs and tissues? How do you perceive your professional practice with patients who are potential organs and tissues donors? Do you consider there are differences in the care provided to patients with brain death and other hospitalized patients? If yes, what are these differences? What are the implications of your practice to patients with brain death for completing the donation-transplantation process?

The interviews were recorded and transcribed to carry out the content analysis.

In the construction of results, excerpts from speeches were used to illustrate the findings that were classified into two subcategories – Technical dimension of nursing care to the potential organ donor; Bioethical dimension of nursing care to the potential organ donor. These subcategories originated a single category called Dimensions of nursing care to the potential donor patient.(6Fontanella BJ, Campos CJ, Turato ER. [Data collection in clinical-qualitative research: use of non-directed interviews with open-ended questions by health profissionals]. Rev Latinoam Enferm. 2006;14(5):812-20. Portuguese.)

The development of the study met national and international standards of ethics in research involving human beings.

Results

The studied group was composed of 30 nurses with the following characteristics: 28 female and two male individuals; aged between 20 and 60 years; 17 had training time lower than five years; 12 were specialists in intensive care; and only three had training in transplantation.

Category: Dimensions of nursing care to the potential donor patient

This category grouped aspects related with care to patients with brain death and potential organ donors, and their families. Two subcategories emerged from this: Technical dimension of nursing care to the potential organ donor; and Bioethical dimension of nurs care to the potential organ donor.

The technical dimension of care comprises the professional skills, the fulfillment of protocols and specific technologies for this care, focused on care aimed at maintaining, monitoring and making viable the organs for transplant. The bioethics dimension consists in care in the context of interpersonal relationships with patients and their families.

Subcategory 1: Technical dimension of nursing care to the potential organ donor

Nurses reported that care to potential organ donor patients is permeated by many complementary and interdependent activities, configuring a complex, multidimensional and multidisciplinary process.

Based on the reports of the study subjects, this subcategory seeks to demonstrate the need for a differentiated care to patients with brain death and potential organ donors, with all the technological support and scientific knowledge, aiming to make the donation organs viable.

It is a potential organ. Some people may benefit from these organs. So I try to keep the blood pressure, keep the patient in temperature, heat this patient, if the pressure starts to get lower and go down, I ask the doctor to start vasoactive drugs, to make more fluids.

I will hydrate, protect the corneas, keep the pressure hemodynamically stable, do everything possible to maintain a stable condition and enable the donation.

The nurse also reported being responsible for other tasks regarded as indirect care, in the process of monitoring the potential organ donor patient, as it appears in the speech:

[...] Making the act itself faster. From providing the declaration and informing the team, trying that the second assessment is made as soon as possible, until assisting the doctor who’s doing the initial evaluation, in order that it occurs satisfactorily.

The nurse has an important place in the team of organ transplant, and should be trained to start the donation process, which includes, among other procedures, the identification and notification of the donor to the hospital coordination donation team, the monitoring and maintenance of these patients, as well as the embracement and care for their families.

Subcategory 2: Bioethical dimension of nursing care to the potential organ donor

This subcategory combines aspects of posture and action that nurses deem as necessary with the families, and for maintaining the body of patients in brain death. At this point, the personal and ethical values interfere in the professional practice with not always positive effects, and repercussions on the donation/transplantation process.

The difficulties of dealing with patients in brain death and potential donors of organs and tissues result on the neglect of care and professional distance from patients.

In general, a change in the behavior of professionals is noticeable in relation to the provision of care from the moment when the diagnosis of brain death is defined.

When dealing with patients in brain death and potential donors, the nurses mentioned the importance of maintaining the care, considering that the lifeless body still represents a person and as such, deserves care and respect, as expressed in the speeches:

First, I think the issue of respect must be very well preserved. Despite being a person in brain death, it is still a living person there, a body that still has a beating heart.

[...] The assistance has to be maintained with dignity and respect.

In this subcategory, the ethical issues, of rights and duties of professionals stand out, in relation to organ donors and their families, as in the discourse excerpt below:

We start by giving a differentiated attention to the family, not as with a living patient, when we give hope to the family that the patient will be fine and get better. And we try to talk to the family, for the family understand and accept the mourning and also for preparing to the donation.

The nurse recognizes that organ donation is an act of solidarity of the family who experiences the pain of loss, and that despite the suffering, is able to detach from the body (material) of the loved one and opt for the donation.

The empathic behavior of nurses with the family can be an important support to these people, although it emotionally drains the professionals, reflecting in their professional practice, leading them to withdraw from those moments as a form of protection.

In the speeches of nurses, it was possible to identify that they feel responsible, directly and indirectly, by the care of patients in brain death, considering the aspects of technical and bioethical dimensions of care to patients who are potential donors of organs and tissues and their families.

Discussion

The speeches refer the technical and bioethical dimensions that constitute the nursing care to patients who are potential donors of organs and tissues and their families. The concern of these professionals is noticeable in relation to technical procedures for the hemodynamic maintenance of patients in brain death, and for acceleration of the process.

The assistance of nurses to patients with brain death aims to preserve the condition of the potential donor. The transplantation of organs and tissues is a safe and effective alternative treatment of various diseases that determines improvements in the quality and perspective of life. Given the growing shortage of organs, it is essential to optimize the use of organs obtained from donors with brain death, which are the main source of organs for transplants currently.(7Rech TH, Rodrigues Filho EM. [Care of the potential organ donor]. Rev Bras Ter Intensiva. 2012;19(2):197-204. Portuguese.)

The demands for care of the patient with brain death is differentiated from others in its specificities, because the aim of the care is different and no longer a curative treatment. The assistance of nurses will be focused on the stabilization of multiple deleterious effects that brain death has on the body in a short period of time, causing hemodynamic instability, which requires extreme agility in bureaucratic processes.

Some nurses state not to prioritize patients who are potential donors of organs and tissues due to considering that other hospitalized patients with life prognosis are more important. The fact that patients in brain death are in an irreversible situation leads professionals to distance themselves from them.

The nurses recognize that the withdrawal from care to patients with brain death is caused by not accepting the condition of patients, associated with the ‘lack of professional, personal and emotional maturity’. It stands out that (not) caring for patients is not due to negligence, but by ignorance and psychological and emotional unpreparedness in dealing with the situation. However, it is emphasized that this kind of attitude directly reflects on the process of organ donation.

Some studies have found similar results with regard to nursing care for these patients. The person with brain death is the one receiving less attention and care by the nursing staff.(1Santos MJ, Massarollo MC, Moraes EL. [Family interview in the process of donating organs and tissues for transplantation]. Acta Paul Enferm. 2012; 25(5): 788-94. Portuguese.

Moraes EL, Silva LB, Moraes TC, Paixão NC, Izumi NM, Guarino AJ. [The profile of potential organ and tissue donors]. Rev Latinoam Enferm. 2009; 17(5):716-20. Portuguese.
-3Guido LA, Linch GF, Andolhe R, Conegatto CC, Tonini CC. [Stressors in the nursing care delivered to potential organ donors]. Rev Latinoam Enferm. 2009; 17(6):1023-9. Portuguese.)

This distance from patients with brain death is reflected in the care provided, because the nurses return to their service with care focused on the technical performance, and concern with control of equipment and technologies present in the intensive care unit. This change in conception can impair the assistance to potential donors and their families, having as consequences the familiar negative and loss of organs that could be donated.(3Guido LA, Linch GF, Andolhe R, Conegatto CC, Tonini CC. [Stressors in the nursing care delivered to potential organ donors]. Rev Latinoam Enferm. 2009; 17(6):1023-9. Portuguese.)

Bioethics is considered a transprofessional, transdisciplinary and transcultural space in health and in life, because it reflects the moral status of our complex societies, emphasizing the quality of life based on tolerance and solidarity. It leads to a reflection about the conflicts that emerge from human evolution and the scientific revolution, but also concerns the existing problems, the emerging problems and the persistent problems.(8Lunardi VL, Barlem EL, Bulhosa MS, Santos SS, Lunardi Filho WD, da Silveira RS, BaoI AC, DalmolinI Gde L. [Moral distress and the ethical dimension in nursing work]. Rev Bras Enferm. 2009;62(4):599-603. Portuguese.,9Mascarenhas NB, Rosa DO. [Bioethics and nursing formal education: a necessary interface]. Texto & Contexto Enferm. 2010;19(2):366-71. Portuguese.)

However, it is worth emphasizing that the focus of bioethics is the quality of human practices on the phenomena of life.(9Mascarenhas NB, Rosa DO. [Bioethics and nursing formal education: a necessary interface]. Texto & Contexto Enferm. 2010;19(2):366-71. Portuguese.) In the care for patients with brain death and potential donors of organs and tissues, the nurses find themselves in a dilemma when caring for a dead person that at the same time, makes life possible.

The process of donating organs is permeated by issues involving human morality. The care of patients with brain death stands out, since they are considered clinically dead, but have the characteristics of a living person. Thus, the professional relationship with the donor leads to a reflection on the meaning of the human being.(1010 Cinque VM, Bianchi ER. [Stressor experienced by family members in the process of organ and tissue donation for transplant]. Rev Esc Enferm USP. 2010;44(4):996-1002. Portuguese.)

When thinking about death and dying, professionals give the meaning of finitude associated with the transience of the material being, which is related to feelings of loss, sadness, grief and longing. Death means transition, transformation and rebirth, relating this perspective to religious beliefs, and finally, gives contradictory meanings.(1Santos MJ, Massarollo MC, Moraes EL. [Family interview in the process of donating organs and tissues for transplantation]. Acta Paul Enferm. 2012; 25(5): 788-94. Portuguese.,8Lunardi VL, Barlem EL, Bulhosa MS, Santos SS, Lunardi Filho WD, da Silveira RS, BaoI AC, DalmolinI Gde L. [Moral distress and the ethical dimension in nursing work]. Rev Bras Enferm. 2009;62(4):599-603. Portuguese.,9Mascarenhas NB, Rosa DO. [Bioethics and nursing formal education: a necessary interface]. Texto & Contexto Enferm. 2010;19(2):366-71. Portuguese.,1111 Lima AA. [Donation of organs for transplant: ethical conflicts in the perception of professionals]. Mundo da Saúde. 2012;36(1):27-33. Portuguese.)

The organ donors are seen as a means and not an end in themselves. The professional gives them importance because they congregate organs and tissues that will be viable to be used by others, hence, they are a source of hope to someone who is waiting for a transplant. However, the donor in brain death is clinically dead, but maintains the characteristics of an alive person.(9Mascarenhas NB, Rosa DO. [Bioethics and nursing formal education: a necessary interface]. Texto & Contexto Enferm. 2010;19(2):366-71. Portuguese.)

Conceptually, the donors are not ‘people’ for their condition of death, however, at no times the nurses refer to them as dead or corpse. The nurses care for ‘people’ with physiological functions preserved alive, and the family gives the status of alive for a dead person, making it difficult to understand the potential donor as a corpse.(7Rech TH, Rodrigues Filho EM. [Care of the potential organ donor]. Rev Bras Ter Intensiva. 2012;19(2):197-204. Portuguese.)

In the opinion of nurses, being with the family of the donor is a complex experience, but they recognize the delicacy and respect needed in this moment of great pain for the family. The nurses suffer due to understanding that even in this situation they need to perform their professional role.(4Dalbem GC, Caregnato RC. [Organ and tissue donation for transplant: family refusal]. Texto & Contexto Enferm. 2010; 19(4):728-35. Portuguese.,5Pessoa JL, Schirmer J, Roza BA. [Evaluation of the causes for family refusal to donate organs and tissue]. Acta Paul Enferm. 2013;26(4):323-30. Portuguese.,1010 Cinque VM, Bianchi ER. [Stressor experienced by family members in the process of organ and tissue donation for transplant]. Rev Esc Enferm USP. 2010;44(4):996-1002. Portuguese.)

More than informing the status of potential donor patients, or about the process of organ donation, it is essential that nurses, for being closer to family, are available and open to perceive the needs of the relatives. Not only informing them about the real condition of the patient with brain death, but also helping them to understand reality as it is presented.(1010 Cinque VM, Bianchi ER. [Stressor experienced by family members in the process of organ and tissue donation for transplant]. Rev Esc Enferm USP. 2010;44(4):996-1002. Portuguese.,1111 Lima AA. [Donation of organs for transplant: ethical conflicts in the perception of professionals]. Mundo da Saúde. 2012;36(1):27-33. Portuguese.)

The nurses who position themselves away from the contact with family members act this way in an attempt of self-preservation, to avoid exposing their human vulnerability due to the inability of organizing the feelings of sadness and helplessness in that moment.(1111 Lima AA. [Donation of organs for transplant: ethical conflicts in the perception of professionals]. Mundo da Saúde. 2012;36(1):27-33. Portuguese.)

In situations that cause discomfort, the health professionals fractionate and isolate themselves. Dealing with distressing situations hinders the care for others, which may explain the difficulty of the staff in dealing with patients in brain death, since the universe of these patients is surrounded by situations of suffering and helplessness.(1Santos MJ, Massarollo MC, Moraes EL. [Family interview in the process of donating organs and tissues for transplantation]. Acta Paul Enferm. 2012; 25(5): 788-94. Portuguese.,8Lunardi VL, Barlem EL, Bulhosa MS, Santos SS, Lunardi Filho WD, da Silveira RS, BaoI AC, DalmolinI Gde L. [Moral distress and the ethical dimension in nursing work]. Rev Bras Enferm. 2009;62(4):599-603. Portuguese.,9Mascarenhas NB, Rosa DO. [Bioethics and nursing formal education: a necessary interface]. Texto & Contexto Enferm. 2010;19(2):366-71. Portuguese.,1111 Lima AA. [Donation of organs for transplant: ethical conflicts in the perception of professionals]. Mundo da Saúde. 2012;36(1):27-33. Portuguese.)

It is important to emphasize that the care provided to patients with brain death requires not only technical skills from nurses, but also skills of multiple aspects (physical, biological, psychological, social, spiritual, economic, political, sociological and historical) closely intertwined. The fact that professionals cannot deal with some of these aspects may lead them to not care properly, keeping away of patients and their families, or even neglecting the patients in this condition.(8Lunardi VL, Barlem EL, Bulhosa MS, Santos SS, Lunardi Filho WD, da Silveira RS, BaoI AC, DalmolinI Gde L. [Moral distress and the ethical dimension in nursing work]. Rev Bras Enferm. 2009;62(4):599-603. Portuguese.,9Mascarenhas NB, Rosa DO. [Bioethics and nursing formal education: a necessary interface]. Texto & Contexto Enferm. 2010;19(2):366-71. Portuguese.,1111 Lima AA. [Donation of organs for transplant: ethical conflicts in the perception of professionals]. Mundo da Saúde. 2012;36(1):27-33. Portuguese.)

Providing nursing care to the families of potential donors who are part of the organ donation process is of utmost importance. Joining patient care with the care for the family is a positive aspect in the direction of reaching the consent in the donation of organs of brain-dead patients.(1Santos MJ, Massarollo MC, Moraes EL. [Family interview in the process of donating organs and tissues for transplantation]. Acta Paul Enferm. 2012; 25(5): 788-94. Portuguese.,4Dalbem GC, Caregnato RC. [Organ and tissue donation for transplant: family refusal]. Texto & Contexto Enferm. 2010; 19(4):728-35. Portuguese.,5Pessoa JL, Schirmer J, Roza BA. [Evaluation of the causes for family refusal to donate organs and tissue]. Acta Paul Enferm. 2013;26(4):323-30. Portuguese.,1010 Cinque VM, Bianchi ER. [Stressor experienced by family members in the process of organ and tissue donation for transplant]. Rev Esc Enferm USP. 2010;44(4):996-1002. Portuguese.)

Conclusion

The nurses seek to address the technical and bioethical dimensions of care to patients who are potential donors of organs and their families, while recognizing the complexity of the process and the need for better qualification and emotional maturity.

References

  • 1
    Santos MJ, Massarollo MC, Moraes EL. [Family interview in the process of donating organs and tissues for transplantation]. Acta Paul Enferm. 2012; 25(5): 788-94. Portuguese.
  • 2
    Moraes EL, Silva LB, Moraes TC, Paixão NC, Izumi NM, Guarino AJ. [The profile of potential organ and tissue donors]. Rev Latinoam Enferm. 2009; 17(5):716-20. Portuguese.
  • 3
    Guido LA, Linch GF, Andolhe R, Conegatto CC, Tonini CC. [Stressors in the nursing care delivered to potential organ donors]. Rev Latinoam Enferm. 2009; 17(6):1023-9. Portuguese.
  • 4
    Dalbem GC, Caregnato RC. [Organ and tissue donation for transplant: family refusal]. Texto & Contexto Enferm. 2010; 19(4):728-35. Portuguese.
  • 5
    Pessoa JL, Schirmer J, Roza BA. [Evaluation of the causes for family refusal to donate organs and tissue]. Acta Paul Enferm. 2013;26(4):323-30. Portuguese.
  • 6
    Fontanella BJ, Campos CJ, Turato ER. [Data collection in clinical-qualitative research: use of non-directed interviews with open-ended questions by health profissionals]. Rev Latinoam Enferm. 2006;14(5):812-20. Portuguese.
  • 7
    Rech TH, Rodrigues Filho EM. [Care of the potential organ donor]. Rev Bras Ter Intensiva. 2012;19(2):197-204. Portuguese.
  • 8
    Lunardi VL, Barlem EL, Bulhosa MS, Santos SS, Lunardi Filho WD, da Silveira RS, BaoI AC, DalmolinI Gde L. [Moral distress and the ethical dimension in nursing work]. Rev Bras Enferm. 2009;62(4):599-603. Portuguese.
  • 9
    Mascarenhas NB, Rosa DO. [Bioethics and nursing formal education: a necessary interface]. Texto & Contexto Enferm. 2010;19(2):366-71. Portuguese.
  • 10
    Cinque VM, Bianchi ER. [Stressor experienced by family members in the process of organ and tissue donation for transplant]. Rev Esc Enferm USP. 2010;44(4):996-1002. Portuguese.
  • 11
    Lima AA. [Donation of organs for transplant: ethical conflicts in the perception of professionals]. Mundo da Saúde. 2012;36(1):27-33. Portuguese.

Publication Dates

  • Publication in this collection
    Nov-Dec 2014

History

  • Received
    20 Aug 2014
  • Accepted
    26 Aug 2014
Escola Paulista de Enfermagem, Universidade Federal de São Paulo R. Napoleão de Barros, 754, 04024-002 São Paulo - SP/Brasil, Tel./Fax: (55 11) 5576 4430 - São Paulo - SP - Brazil
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