Free COMLEX Level 2 Practice Questions
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Here’s Your First Free COMLEX Level 2 Practice Question
A 74-year-old male is transferred to the intensive care unit following a motor vehicle accident the day prior; he has persistent loss of consciousness. The patient has no advanced directive or power of attorney, and he has lived alone in a nursing home for several years. Vital signs reveal:
- Temperature: 36.5° C (97.7° F)
- Blood pressure: 104/73 mmHg
- Heart rate: 114/min
- Oxygen saturation: 98% on mechanical ventilation
Physical examination reveals the patient is ventilator-dependent and has no pupillary response to light. He is unresponsive to commands, and cold caloric testing fails to elicit a nystagmus. Oculocephalic and corneal reflexes are absent. A CT image of his brain is obtained as shown in the exhibit. An EEG is obtained and reveals no electrical activity. These physical examination findings have been corroborated by a neurologist and a critical care physician.
The most appropriate course of action at this time is to
- A) change the patient’s code status to do not resuscitate
- B) contact the hospital ethics committee
- C) observe the patient for 2 weeks
- D) place a consult for a second neurologist
- E) remove the patient from the ventilator
The Answer and Explanation
Did you get it right? The correct answer is ‘E’.
The patient in the above scenario meets the criteria for brain death, which is defined as the permanent and irreversible absence of cerebral and brainstem function. Once brain death has been diagnosed according to the clinical criteria outlined below, physicians and families must realize that brain death is synonymous with the death of the patient, and removing the patient from the ventilator is appropriate.
Image findings: The CT image displays a left subdural hematoma with a midline-shift to the right.
Trauma and subarachnoid hemorrhage are the most common events leading to brain death, a diagnosis that is made clinically based on loss of brainstem reflexes. The diagnostic criteria also require certain prerequisites to be made in order to exclude mimickers of brain death and to ensure subsequent neurologic examination will not be falsely positive. These prerequisites include the following:
- Underlying cause: The cause of brain death should be known and can be established by history, examination, neuroimaging, or laboratory testing.
- Confounding condition: Exclusion of complicating medical conditions such as severe electrolyte abnormalities, acid-base disturbances, severe endocrine disorders, or recent neuromuscular blockade is required.
- Intoxication: Poisoning, overdose, or intoxication must be reasonably excluded. Drug testing may be necessary.
- Temperature: Normothermia is required prior to making the diagnosis of brain death. Core temperature must be >36°C (97°F).
- Blood pressure: Normal systolic blood pressure >100 mmHg must be achieved, which may require pressors.
Once the prerequisites are made, neurologic examination (table below) is performed. If all reflexes are negative, an apnea test is performed. In its simplest form, this test requires removal of the ventilator and confirmation that the patient is not attempting to breathe while carbon dioxide accumulates in the blood.
The diagnosis of brain death can usually be made clinically, at the bedside. However, if there are discrepancies among exam findings, or the above prerequisites cannot be made, ancillary testing with EEG or blood flow imaging via nuclear medicine or angiography is indicated.
Neurologic Examination Findings Consistent with Brain Death
| Reflex | Description/Notes |
|---|---|
| Pupillary reflex | Fixed and dilated pupils (4-9 mm); constricted pupils indicate drug intoxication |
| Oculocephalic reflex | Lack of evidence of eye movement (doll’s eyes) when head is briskly moved side to side; performed horizontally and vertically |
| Oculovestibular reflex | Absence of eye movement when 50 mL of ice-cold water is irrigated in ear canal |
| Corneal reflex | Absence of eyelid movement when cornea is touched with tissue paper, water, or cotton |
| Noxious stimuli | Absence of facial grimace with deep pressure applied to TMJ condyles and supraorbital ridge |
| Pharyngeal reflex | Absence of gag reflex with deep suctioning of the posterior pharynx and trachea |
TMJ: temporomandibular joint.
Answer A: This patient is not able to make the decision regarding do-not-resuscitate status and does not have a power of attorney to do so. In some states, physicians can invoke “do not resuscitate by exception” in scenarios where the physician feels resuscitation efforts would be futile given the patient’s terminal condition. Regardless, this patient meets criteria for brain death and, therefore, all artificial life-prolonging efforts should be ceased.
Answer B: Brain death is synonymous with death and, therefore, the patient is considered legally dead. Ethically, it would be most appropriate to attempt to contact family members before removing the ventilator, but legally there is no requirement to do so once brain death has been confirmed. An ethics committee would be appropriate if the patient did not meet criteria for brain death and would have no meaningful quality of life going forward. In this scenario however, there is no reason to include the ethics committee in decision-making, so this is not the correct answer.
Answer C: Observation of the patient for 2 weeks prior to making a decision regarding his end-of-life status would not improve the outcome, as clinical criteria have been met for brain death. Some states require 48 hours of observation in infants and up to 6 hours for adults; however, 2 weeks would be inappropriate. This patient has already been observed and now is diagnosed with a permanent and irreversible absence of cerebral and brainstem function. There have been no documented cases of improvement after meeting this criteria.
Answer D: This patient has been examined by both an intensivist and a neurologist, and this meets examiner criteria for even the strictest states. Examiner credential requirements vary by state, but none require more than 2 physician examinations, and most do not even require the diagnosing physician to be a neurologist. Regardless, placing another neurology consult would not provide any additional information and is not necessary in this case.
Bottom Line: Brain death is defined as the permanent and irreversible absence of cerebral and brainstem function. Clinical criteria for brain death include the absence of spontaneous ventilations coupled with the loss of brainstem activity. Meeting criteria warrants removal of life-sustaining interventions such as mechanical ventilation if no documentation exists suggesting the patient (or family) wished otherwise.
COMBANK Insight: Contacting the ethics committee will most likely never be an answer choice on boards.
For more information, see: Diagnosis of Brain Death on UpToDate
Exhibit Image Source: Persson ME, Thelin EP, Bellander BM. Case Report: Extreme Levels of Serum S-100B in a Patient with Chronic Subdural Hematoma. Front Neurol. 2012;3:170. Published 2012 Dec 5th.
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