Medical Expert: Brain-stem death vs. continued life support; an opinion

I found this opinion piece to be worth noting. In my country, the United States; we have more than occasionally bumped up against this tragedy. Someone is declared by medical authorities as brain-dead; others object to the notion of discontinuing life support.

What makes this a social issue is the inevitable collision between medical science as applied by the business of health care; and the faith of the person or persons confronting them.

By faith, I do not mean the religion or beliefs of any particular individual or group. I mean literally what people desire and hope for.

In this article Dr. Richard Huxtable (no relation to the fictional Cosby character) explores, from his perspective, what he believes is at stake with this issue. The Dr. makes several compelling statements...

In many countries, the loss of function in the brain stem – the part of the brain that controls automatic functions such as breathing – means the loss of life: the person is clinically and legally considered dead.

While this apparently seems to be the happy case in "other countries" he focuses on the US cases which brings his opinion to you, the reader. These are the cases of teenager Jahi McMath, and 33-year-old Marlise Muñoz. Both of them have been diagnosed as brainstem dead.

On the one hand- we have the idea that once brain dead, you are in fact, dead, despite your biologic continuance with life-support technology assistance. On the other, we have the presumably heart-felt belief that not being able to breath on one's own, and having no decernable conscious presence in your body does not mean you are dead.

The two cases are far from equal though, in McMaths' case we are confronted by family members who refuse to let go, we are told, and defy logic by hoping for a recovery that doctors say cannot happen. In the Muñoz case, the woman is pregnant and is being kept alive - despite her husband's objections, to carry the child to term.

Ultimately, what the argument made by Dr. Huxtable entails is in keeping with his professions position (with a side promotion of organ donation - a pet peeve of mine.) He gingerly dances around the emotions of "tragic choices" by adopting a "of course these people are dead" framework. I'm not sure I can easily agree.

My take is that we cannot even begin to state "this or that will never happen" because we know less medically than we do about science generally. Everyday the impossible becomes a more mercurial proposition, and things do seem to happen that western medicine either has no comment on, or they enjoin their media darlings to proclaim how silly a belief contrary to theirs would be.

The good Dr. says at one point:

...The evidence suggests this is reasonable. In 2010, a group of US researchers trawled medical literature seeking any example of a person recovering after a brain-death diagnosis. They did not find a single one....

Which, needless to say, is a prime example of why we cannot allow ourselves the luxury of unquestioningly heeding expert opinions...

His assertion is based upon a published US medical research which as I read it states that;

1) In adults, there are no published reports of recovery of neurologic function after a diagnosis of brain death using the criteria reviewed in the 1995 American Academy of Neurology practice parameter.

2) Complex-spontaneous motor movements and false-positive triggering of the ventilator may occur in patients who are brain dead.

3) There is insufficient evidence to determine the minimally acceptable observation period to ensure that neurologic functions have ceased irreversibly.

4) There is insufficient evidence to determine if newer ancillary tests accurately confirm the cessation of function of the entire brain.

(from: www.neurology.org...)

Now I have issue with how this research has been presented by Dr. Huxtable as supportive of his case. I will discard that the research specifically states "There is insufficient evidence to determine if newer ancillary tests accurately confirm the cessation of function of the entire brain" - but instead focus on number 1). Please note the underlined statements:

In adults, there are no published reports of recovery of neurologic function after a diagnosis of brain death using the criteria reviewed in the 1995 American Academy of Neurology practice parameter.

- Adults and adolescents were excluded from this research meaning they cannot properly assert their findings for half the population.

- Why would any guild-member doctor or insurance-owned hospital "publish" anything which would point to an unexplained recovery? In fact, you might note that nothing gets "published" without a meticulously applied "panel of experts" reviewing it.

- Did the researchers actually expect ANY doctors to state for the record that they declared a patient brain dead and then they recovered? Not gonna happen.

- These parameters of which they speak are the result of yet another "panel" of experts deciding what gets called what... and while it all may be clinically benign in its intent, I assure you - the bias of "we are medical science, therefore we cannot be questioned" is firmly entrenched in their paradigm.



Anyway, I thought I might start a conversation with you all on this matter.... but remember, when you go into specifics you might lose the ethical problem... if each case is uniquely distinct, there can be no compromise without surrender; if some can be said to be exactly the same... someone in the family of these experts may one day face an ironically inhuman choice imposed on their behalf, by a committee of experts.

Thanks for reading!

Max, in Jahi's case she has already sloughed off her intestine before even leaving the hospital.. as in what the dead do. This was known during the testimony and was reviewed by the judge. The McMaths own Dr declared her dead.. they just disregarded their own Drs findings. I believe the report concerning the intestinal sloughing was done by a Dr Fiori.

I do believe she is dead and will continue to decompose. I feel allowing the family to drag around a corpse after the coroner has issued a death certificate is setting a bad bad bad precedent. If there were any forensic evidence of the hospital doing wrong... it will NEVER stand in court now.



ETA.. here is the report. PDF.
media.nbcbayarea.com...

reply to post by Advantage


Thank you for your post.

Clearly, the specifics of the case demand that we slow down on generalizations (where the ethical matter is free from contention.)

Were we to simply accept that if a doctor said this patient is dead, he or she is; is it the same as accepting that if a doctor says it is so, a patient will not recover? Whereas the unfortunate McMath family clearly does not accept that, is it the medical community's prerogative to override them? If so why?

Many flat assertions for which medical science is well known are frequently not among those which endure. Medicine was once an art; now it is a commercial enterprise. When the rationale for discontinuing life support gravitates towards "good business practices ," I am among those who wince. The logic is sound; but lacking in solidity.

If someday I am in such a state, I would hope for choices other than assured death.

If you choose to simply unplug the machinery which supports my life sustaining functions; knowing with scientific certainty that I will pass, why not just kill me outright? It would be quicker, (certainly less grief for the stricken,) more efficient (thus using less resources and more profitable) - and coldly speaking, easier to orchestrate than the options offered, no?

But that would mean doctors would be deciding who lives and dies, wouldn't it?

The McMath case is simply another example of a decision to apply resources to the 'brain-stem dead,' but only in the most expedient way. Her brain-stem death debilitated her body's ability to maintain natural bowel musculature function; thus the sloughing of the intestines which you appropriately liken to 'decomposition.' The standard life-support measures she was provided with did nothing except to keep oxygen moving through her body. In a real sense, she lingers only on what life support we can deliver, not "full life support" - as the profession wants to call it.

I wonder when will we develop technologies to fully sustain a body without a brain? I think perhaps then we will know better what brain-death may mean to each individual human.

Maxmars
reply to post by Advantage

 

Thank you for your post.

Clearly, the specifics of the case demand that we slow down on generalizations (where the ethical matter is free from contention.)

Were we to simply accept that if a doctor said this patient is dead, he or she is; is it the same as accepting that if a doctor says it is so, a patient will not recover? Whereas the unfortunate McMath family clearly does not accept that, is it the medical community's prerogative to override them? If so why?

Many flat assertions for which medical science is well known are frequently not among those which endure. Medicine was once an art; now it is a commercial enterprise. When the rationale for discontinuing life support gravitates towards "good business practices ," I am among those who wince. The logic is sound; but lacking in solidity.

If someday I am in such a state, I would hope for choices other than assured death.

If you choose to simply unplug the machinery which supports my life sustaining functions; knowing with scientific certainty that I will pass, why not just kill me outright? It would be quicker, (certainly less grief for the stricken,) more efficient (thus using less resources and more profitable) - and coldly speaking, easier to orchestrate than the options offered, no?

But that would mean doctors would be deciding who lives and dies, wouldn't it?

The McMath case is simply another example of a decision to apply resources to the 'brain-stem dead,' but only in the most expedient way. Her brain-stem death debilitated her body's ability to maintain natural bowel musculature function; thus the sloughing of the intestines which you appropriately liken to 'decomposition.' The standard life-support measures she was provided with did nothing except to keep oxygen moving through her body. In a real sense, she lingers only on what life support we can deliver, not "full life support" - as the profession wants to call it.

I wonder when will we develop technologies to fully sustain a body without a brain? I think perhaps then we will know better what brain-death may mean to each individual human.

I know.. its a mess.

For the hospital in the McMath case, I believe that once declared dead.. by 6 drs and the coroner.. insurance does not pay for venting a corpse in ICU. That was the decision of the family and they were allowed that decision to move her to another facility. I understand the issues with Drs deciding who lives and dies, but when you have a total brain death patient ( brain and stem.. no electrical activity and NO BLOOD FLOW in every test that all of the 6 individual Drs performed over the course of several weeks) That it is unethical and ghoulish to operate ( insert more permanent breathing tube and feeding tube) on a dead body and try to nourish a body that can not utilize nourishment. WIth the McMath case, her brain with no blood flow is rotting as we speak and if the "dr" doesnt plug her nose, the family is in for a rude awakening. SHe can not maintain body temp and there have been NO gut sounds since the day after she "died" in the hospital. The intestines sloughed after that. There is ample evidence that she is only having her decomposition slowed.. it will NOT stop. I have NO idea what Dr they got to perform these things on a dead body, but it is certainly going to be reviwed when all is said and done. Terri Schiavos people are pushing this with the McMaths and attorney. It all quite awful if you really read all of the testimony and etc out there.. and the uncles motivations.. and the actions of the parents when she was in ICU on teh 3rd day directly effecting the clotting and healing process. The mother and grandmother likely caused the catastrophic bleeding and emergency that caused the heart attack and death in the first place. THIS particular case is a red herring in the argument you make.. which I believe is a very important argument.

The Pregnant woman on Life support... I am not aware of any confirmed documentation of her actively decomposing and if she were not able to utlize nourishment, the baby will not live anyway. I dont know this, but I suspect she is not fully brain dead. SHe is also under 20 weeks pregnant.. well under the threashold of being abke to tell if the fetus will be viable or test for damage since the mother was without o2 for an extended period. Its true that when the body experiences this sort of catastrophic trauma, the o2 will go to the fetus more than the mother.. so there may be a chance. There are 6 cases of "brain dead" women who were pregnant. 5 of them gave birth to completely healthy babies. This would indicate to me that in this case, they have some precedents that are set that allow them to make the best medical decision. This decision may change as the body changes.. for good or bad. They ONLY know the baby has a normal heartbeat at this point. Not a whole lot to base the viability of the fetus on at this point. I have not looked but if it is a Catholic hospital.. they WILL keep her on this if at all possible unless ordered to by a court. I believe that the family, mainly the husband, fears the baby being damaged ( with good reason) and wants to respect his wifes decision. I believe that it shouldnt be rejected outright.

The thing with brain death is that the body WILL eventually crash. It is a very labor intensive thing to keep the brain dead body functioning.. all of the systems have to be addressed and medically stimulated. It is a tortuous thing for all involved, really. There is a time with EVERY person declared brain dead that they WILL crash all on their own regardless of medical intervention. You just cant predict it. I think the longest a brain dead body was kept functioning at the level that it mimicked life was several months. Its not indefinite.
This is where you get into ethics, religion, compassion, versus insurance companies, liabilities and death panels.

Advantage


I do believe she is dead and will continue to decompose. I feel allowing the family to drag around a corpse after the coroner has issued a death certificate is setting a bad bad bad precedent. If there were any forensic evidence of the hospital doing wrong... it will NEVER stand in court now.

I do agree with you regarding the state of this girl. She is dead. However, I really feel like the hospital completely bungled this in a way that was callous and defensive. Personally, I think if they had not been so combative and condescending with the process of covering their hiney's for the inevitable law-suit, the family would have been able to come to terms with what had happened and it wouldn't have gotten nearly so messy. As it was, this hospital gave them a nemesis to focus that grief upon in a way that was really negative and arrested the process. They didn't give them a chance to grieve and cope, they just gave them a brawl.

To the OP, I am glad that someone started a conversation about this, and thank you for that.

redhorse

Advantage


I do believe she is dead and will continue to decompose. I feel allowing the family to drag around a corpse after the coroner has issued a death certificate is setting a bad bad bad precedent. If there were any forensic evidence of the hospital doing wrong... it will NEVER stand in court now.

I do agree with you regarding the state of this girl. She is dead. However, I really feel like the hospital completely bungled this in a way that was callous and defensive. Personally, I think if they had not been so combative and condescending with the process of covering their hiney's for the inevitable law-suit, the family would have been able to come to terms with what had happened and it wouldn't have gotten nearly so messy. As it was, this hospital gave them a nemesis to focus that grief upon in a way that was really negative and arrested the process. They didn't give them a chance to grieve and cope, they just gave them a brawl.

To the OP, I am glad that someone started a conversation about this, and thank you for that.

I have a dog in this fight is why I keep up with the minutiae of it all! LOL!

I felt that exact way in the begining. Then I realized the time line.. they allowed the child to stay in ICU under medical care WAAAAY longer than anyone else. They made numerous concessions for this family and this case. Then I saw the video clip of the grandmother pretending she was an RN and is in reality a nurse's aid. The grandmother outted the real issue and admitted to actually suctioning Jahi.. which they should not have done.. they were TOLD not to.. and fed her bits of a big mac. Seriously.. pieces of a big mac. The clots dislodged and she started bleeding. This wasnt a routine tonsillectomy. It involved removing much tissue from the soft pallet, much sinus tissue, and tonsils. SHe had major surgery.. and then they go suction the clot and feed her a hamburger. The nurses and Drs instructed them several times NOT to get her laughing, leave the equipment alone, dont feed her, etc. The bleeding started and the mother went to get a family member and not a Dr or Nurse. Then the nurses were informed. Other parents and children in the ICU have come forward.. it was a circus with these people and the hospital was more than accomidating. The hospital has also not been able to release their own side YET. It is hinging on the McMaths lawsuit.. because HIPPA prevents them from commenting.

More kickers to this story?? The uncle wants to get paid. He said 250K ( which is the cap in that state) is "chump change" and he wanted 30 mil. No joke! Then add to that they are obscuring the reason she actually bled out and denying an autopsy. The body being in a healing or decomposing state obscures the real reason of her death. They will get paid ZERO.. unless the hospital just throws them a bone.

Maxmars.. I was trying to find this. WIthin this whole argument.. cases like both that you have mentioned are used for money and politics... science and ethics be damned. This is another heinous aspect to the whole thing.

www.sfgate.com...

The case of Jahi McMath, the 13-year-old girl who was declared brain-dead after a tonsillectomy at Children's Hospital Oakland, is now the centerpiece of a political fundraising effort aimed at lifting California's $250,000 cap for pain and suffering awards in medical malpractice cases.

Consumer Watchdog, a Southern California nonprofit that has teamed up with the state's trial lawyers on a proposed November ballot initiative to lift the limit, just sent out a mailer to supporters saying, "Hospitals like Children's actually have an incentive to let children like Jahi die.

Advantage
.. and fed her bits of a big mac. Seriously.. pieces of a big mac.

Youngest brother Billy says this happens a lot. Immediate post-surgery, and the family smuggles in food after the pt's been told not to eat over and over. Then they discover the wondrous joy of aspiration. Well, now she's got puke and Big Mac down in her lungs, good going, troops.

Either that, or while they're waiting for surgery, the family decides it's a GREAT time to smuggle in some sammitches and feed them just before the operation, with the nurse constantly telling them the patient can't have anything at all. "We showed you!" (smirk) well, yep, you did, and now your kid will have a ruptured appendix. No, we can't do the surgery now. Sit and watch their belly swell like a beachball, while you ponder the notion that YOU did that to him.

But on topic, I also can't see why families don't 'get it'. If it were my loved one, yeah, as long as there was actual hope, I'd be pitching. But when you have no blood flow at all to the brain on a perfusion scan, man, let it go, because that brain's dead. All you're waiting on now is for the body to catch up.

Advantage

redhorse

Advantage


I do believe she is dead and will continue to decompose. I feel allowing the family to drag around a corpse after the coroner has issued a death certificate is setting a bad bad bad precedent. If there were any forensic evidence of the hospital doing wrong... it will NEVER stand in court now.

I do agree with you regarding the state of this girl. She is dead. However, I really feel like the hospital completely bungled this in a way that was callous and defensive. Personally, I think if they had not been so combative and condescending with the process of covering their hiney's for the inevitable law-suit, the family would have been able to come to terms with what had happened and it wouldn't have gotten nearly so messy. As it was, this hospital gave them a nemesis to focus that grief upon in a way that was really negative and arrested the process. They didn't give them a chance to grieve and cope, they just gave them a brawl.

To the OP, I am glad that someone started a conversation about this, and thank you for that.

I have a dog in this fight is why I keep up with the minutiae of it all! LOL!

I felt that exact way in the begining. Then I realized the time line.. they allowed the child to stay in ICU under medical care WAAAAY longer than anyone else. They made numerous concessions for this family and this case. Then I saw the video clip of the grandmother pretending she was an RN and is in reality a nurse's aid. The grandmother outted the real issue and admitted to actually suctioning Jahi.. which they should not have done.. they were TOLD not to.. and fed her bits of a big mac. Seriously.. pieces of a big mac. The clots dislodged and she started bleeding. This wasnt a routine tonsillectomy. It involved removing much tissue from the soft pallet, much sinus tissue, and tonsils. SHe had major surgery.. and then they go suction the clot and feed her a hamburger. The nurses and Drs instructed them several times NOT to get her laughing, leave the equipment alone, dont feed her, etc. The bleeding started and the mother went to get a family member and not a Dr or Nurse. Then the nurses were informed. Other parents and children in the ICU have come forward.. it was a circus with these people and the hospital was more than accomidating. The hospital has also not been able to release their own side YET. It is hinging on the McMaths lawsuit.. because HIPPA prevents them from commenting.

More kickers to this story?? The uncle wants to get paid. He said 250K ( which is the cap in that state) is "chump change" and he wanted 30 mil. No joke! Then add to that they are obscuring the reason she actually bled out and denying an autopsy. The body being in a healing or decomposing state obscures the real reason of her death. They will get paid ZERO.. unless the hospital just throws them a bone.

Interesting. I did not know that there were actions that the family had taken themselves that may have contributed to this sad state of affairs. I will have to look into that, and thanks for the info. It just goes to show that there are two (or three, or four) sides to every story, and I shouldn't be so quick to make a decision. Sad, though just sad for this poor little girl.