Another side of brain death

A few days ago, I wrote a post about the ordeal and complexities faced by the family of Jahi McMath, and the issues of brain death in a pediatric patient. While this scenario is playing out in California, there is another drama playing out in a hospital in Texas, where a dead pregnant woman is being supported over the objections of her husband and the father of the unborn child who at this point is a 19-week old fetus; too young to be able to survive outside the mother's womb.

According to the Associated Press story,

Munoz found his wife unconscious in the early morning hours of Nov. 26. The family says it doesn't know the exact cause, though a pulmonary embolism is a possibility. Marlise Munoz was 14 weeks pregnant at the time.

He and his wife had both agreed that they did not want aggressive measures performed if they were ever terminally ill, but a Texas law prohibits those advanced directives from being followed in the case of a pregnant woman. So the hospital is continuing to support the body of this dead woman in order to "obey the law."

However,

the law does not address the issue of continuing mechanical ventilation in someone who is brain dead. And since it appears that the woman has been declared dead following the tragedy that occured, is it reasonable for the hospital to continue to artificially maintain this woman for the sake of the fetus?

And what of the fetus?

It will be months until the baby is mature enough to be delivered without a high risk of having to be cared for in a high-level neonatal intensive care unit. And, oh by the way, since no one knows how long the mother was depleted of oxygen when she collapsed, there is no way to tell right now how severely the infant might be affected. And, since there is good evidence to show that maternal breast milk is advantageous for premature newborns, would someone want to continue to support this woman's body so her breasts can be induced to produce milk? How far will we go to prevent a death from progressing in a natural and dignified manner?

I will admit, I have raised a pretty far-fetched issue, but I am convinced that our society is allowing definitions to be clouded, and we are acting out of fear of the law overpowering compassion, empathy, respect and beneficence. This poor woman is neither terminally nor irreversibly ill: she is dead. Her husband understands she is dead, and knows furthermore that his wife would NOT have wanted to be maintained in such a manner if she were alive. Is the hospital acting out of fear of being sued? Out of fear of criminal charges due to the law that governs the terminally ill? Could they be facing a "wrongful birth" suit by the father if the child is born with severe brain damage or other complications from the initial event?

Looking at both the Jahi McMath situation, and this one at the same time makes it pretty clear we need to be having much more open discussions about end of life issues, and we need to be teaching these definitions in our high schools and colleges, in parenting classes, and certainly educating our national, state and local legislators on the implications of our decisions.

 

Physicians, nurses and others need better training in communicating bad news, and leading discussions about options and opportunities. The mainstream media must be involved, so our society can move on to a more sophisticated understanding of the physiological issues. Even if some of the spiritual issues cannot be answered, at least we can help people understand what happens in death, what does it mean to lose all of one's brain function, and how that is different from a terminal illness, a persistent vegetative state, and being in a coma.

As always, I look forward to your comments to help further elucidate this issue, and I welcome the discussion that you will foster.

 


photo credit:

Premie: mbohlmann via photopin cc

Comments

Politics and medicine an explosive mix

Thanks a lot Dr.Ackerman for raising this very important issue. I believe we need to have a much more substantive discussion in this country regarding medicine, death and unfortunately politics also in the mix. People shy away from talking about the real issue but the fact is medical decisions are unfortunately being clouded over by political viewpoints, people trying to score political points. I believe that there is a lot of areas even just within medicine which are open to debate that we do not need politics in the mix. I personally grew up in the era when brain death was an accepted form of death but if we look at even brain death critically, the real reason it came into existence was to keep the hospitals from being filled up with patients on the ventilator and also let me say it aloud…. to suit the purpose of organ donation ( I know I may get a lot of flak for that. Let me clarify I support organ donation). And now we are moving towards donation after cardiac or circulatory death ( again a very controversial issue and here I believe the medical community is at fault for being over aggressive and tinkering with defining death to suit organ donation again). We should be honest with ourselves as a society and think for ourselves rather than let political groups think for us. both the situations in California and Texas are extremely sad situations as you have very aptly pointed out. And I believe the one in California is because of lack of community education ( and may be political mischief involved….. I don't know) and the one in Texas is because of politico-legal issues not medical ones. I can go on and on but will hold back.

Re: Politics and medicine an explosive mix

So nice to see your comments here, Krishnan. Thanks for taking the time to write.

I agree that many of our medical issues have become politicalized (is that a real word?), as we argue about everything from insurance coverage to end of life issues. Our political leaders should not be making ridiculous statements about vaccines, or brain death. But then again, I have seen it written that some people do not "believe" in science.

I believe that one of the thngs the Society of Critical Care Medicine could do would be to really start and maintain an open, transparent discussion about some of these thorny issues. Not sure how I would feel if my job depended upon voters understanding complex issues. It is difficult to make people read past the headlines to try to understand the details. They hear about someone waking up after a prolonged coma and believe that means we don't know how to diagnose brain death. Even some physicians and other providers are unprepared to address EOL issues in a calm and forthright manner.

Hoping to see you in San Francisco next week for the SCCM meeting. Perhaps this conversation can lead to some form of action on the part of our major professional organziation.

Dr. Discomfort r/t DNR

I made up my mind, when I was in my 50's and healthy, to sign a DNR. I wanted to claim my right to a natural death with dignity. This decision has been very uncomfortable for doctors. I had pneumonia and the doctor wanted to ignore my DNR. I told her as long as I was able to agree to a limited stay on a vent there would be no problem, but if my heart stopped that was the end. I have had doctors play the "what if" game. "What if" you have an accident or "what if" you have a stroke. I have just about had to demand my "right to a natural death." If I were not a nurse with a stubborn streak I would probably have been swayed by the pressure.

Re: Dr. Discomfort...

Elizabeth, thanks so much for sharing this part of your life with us. As we doctors learn better how to partner with patients and families, hopefully more of us will be more comfortable collaborating with patients instead of dictating to patients according to our standards and values. However, we do reserve the right to discuss with you to ensure that you understand exactly what you say. So, as a nurse I am certain that you have seen enough to understand, but not all patients have been there. So I would want to ask you enough to be certain that you have considered every aspect of the potential situation. I fully support advanced directives and living wills. Many states have started to mandate that upon admission every patient have this discussion wtih his or her provider (doc or NP/PA) and that a specific order is written for each patient regarding recuscitation and life support. In Maryland, the law even applies to children. This is requiring additional education for many folks, as there is great lack of comfort on the part of many providers to have such a frank discussion. 

Thank you for your comments. I am glad you have had the courage to demand what you desire. 

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