Abstract Requests for continued treatment judged non-beneficial, now termed potentially inappropriate, pose significant ethical challenges in critical care. The 2015 five-society statement provides a structured resolution pathway, while the 2023 AAN brain-death guideline reaffirms brain death (BD/DNC) as the legal definition of death. When surrogates reject withdrawal of treatment after BD/DNC criteria are met, clinicians face conflicts between professional integrity, legal constraints, and family beliefs. We present a case that illustrates these tensions, culminating in the patient’s home discharge on full life support. A 26-year-old woman with lupus nephritis and related end-stage renal disease on home hemodialysis, prior type A aortic dissection repair, chronic tracheostomy, dysphagia with PEG dependence, and recurrent multidrug-resistant Pseudomonas infections was admitted to the ICU after a 30-minute pulseless electrical activity arrest at home. She received CPR and five doses of epinephrine before return of spontaneous circulation. Imaging revealed diffuse anoxic brain injury, and EEG demonstrated non-reactive suppression. The neurological exam showed absent brainstem reflexes and a GCS of 3. All prerequisites for BD/DNC testing were met, but the patient’s mother refused apnea testing or ancillary imaging, repeatedly requesting “more time.” Over 23 ICU days, the patient remained ventilator-dependent, receiving thrice-weekly dialysis and ceftolozane-tazobactam. Multiple family meetings emphasized the absence of neurologic recovery potential, yet the mother equated the heartbeat with life and demanded ongoing treatment. The hospital ethics committee, unable to authorize unilateral withdrawal, arranged discharge with a portable ventilator, home dialysis, and limited hospice support. This case exemplifies how physiologically effective treatments may be clinically and ethically inappropriate. Ventilation and dialysis maintained circulation but offered no path to recovery once BD/DNC criteria were satisfied. The 2023 AAN guideline permits ancillary testing when apnea testing is refused; however, inconsistent institutional policies and legal uncertainties prolong conflict. Allowing concurrent dialysis and hospice care blurs goals, increases caregiver burden, and lacks reimbursement mechanisms. Early, structured communication, time-limited treatment trials, and expedited ethics consultations may help prevent such impasses. Nationally harmonized laws and clearer institutional protocols on management after confirmed BD/DNC are essential to protect clinicians, reduce moral distress, and conserve ICU resources. This case underscores the need for public education on brain death and transparent ethical frameworks guiding end-of-life decision-making. This abstract is funded by: None
Afram et al. (Fri,) studied this question.