Prioritization of Ethical Themes When Surrogates Object to Technology Removal After Brain Death Determination.

As hospitals revise their policies for brain death/death by neurologic criteria (BD/DNC), they should provide transparent and clear plans for how to handle surrogate requests to continue technology after declaration of death. National guidelines provide little guidance in this matter, and individual institutions should make decisions grounded in an understanding of their local constraints and the ethical values at stake. Ethical arguments exist in favor of and opposed to allowing continuation of technologic support for families who object to BD/DNC. Prioritization of these ethical values influences how institutions handle objections to removal of technologic support after BD/DNC determination. A narrative review of the literature identified six ethical values relevant to institutional responses to surrogate objections: inappropriate treatment, distributive justice, BD/DNC as philosophical or legal death not biological death, dignity and respect, surrogate authority, and medical mistrust. We articulate three potential paths forward an institution can take and the relative prioritization of ethical values in each case. When developing or revising hospital policies on BD/DNC, hospitals must understand the ethical values in tension with any particular approach taken. Hospitals vary in the populations they care for and the resources at their disposal, which may impact prioritization of ethical principles at stake in these decisions. Although some ethical values may not be prioritized, institutions should design systems to honor them to the extent possible given the plurality of beliefs and experiences of the patients for whom we care.