Brain death: ethical challenges to palliative care concepts of family care

Brain death is a controversial issue that is often difficult for families to understand or accept. Palliative care interventions can help families to accept the death. However, delaying pronouncement of brain death may be detrimental to the family and lead to financial, ethical, and legal complications, including the potential for insurance fraud. We describe a case of brain death in which the passage of time along with continuation of life support without concomitant testing for brain death led to decreased acceptance of the patient's death by the family. Clinicians should weigh the risks and benefits of harm to the family when deciding how long to keep a brain dead patient on a ventilator. Pronouncement of death, which is good basic medical care regardless of the cause or mechanism of death, should not be delayed for family considerations. Risk management should be involved early in the decision process, if life support is withdrawn without the family's assent.