Sunday, March 8, 2015

Why is diagnosing brain death so confusing?

See:  http://yaledailynews.com/blog/2015/03/03/hospitals-should-adopt-uniform-brain-death-standards-article-argues/ 

Ghoshal S, Greer DM. Why is diagnosing brain death so confusing? Curr Opin
Crit Care. 2015 Apr;21(2):107-12.

Abstract
PURPOSE OF REVIEW:
Although detailed practice parameters have been developed to help guide physicians in brain death determination, guidelines based on these parameters widely vary. The recent case of Jahi McMath not only highlights social misconceptions but also serves as a call to action to decrease medical variability and confusion regarding brain death determination. This review discusses common sources of variations in brain death determination - we divide these sources into before, during, and after brain death declaration.
RECENT FINDINGS:
We use four key studies to elucidate variable practice in brain death determination. Poor training of examiners and patient qualifications for brain death examination prior to testing, incomplete apnea testing, repeat examinations during testing, and the sometimes unjustified use of ancillary testing are highlighted as main areas for improvement. Improved physician training and certification, as well as better standardization of hospital protocols, may be answers to more universal practice.
SUMMARY:
Diagnosing brain death is confusing because of numerous variations in practice, but this variation can be improved. Improved and standardized physician training can help create a formal certification process for examiners and help create uniformity in brain death determination. National standards will also help decrease variability of practice.
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6 comments:

  1. Galen Breningstall, MDJuly 6, 2015 at 10:29 AM

    In California, in the last week, there have been further motions in a long running lawsuit relating to a brain-dead child. Oakland teenager Jahi McMath died after a tonsillectomy in December 2013. However, her parents rejected the medical diagnosis of brain death, and despite a Californian court providing judicial backing for doctors’ determination, organized for her to have a tracheostomy and be transferred to another medical facility. More than 18 months later it appears that Jahi’s heart is still beating and she is still connected to a breathing machine somewhere in New Jersey.

    There are a host of challenging ethical questions in this case. One of these is raised by a curious inconsistency in US law around brain death. It isn’t a coincidence that this is where Jahi now resides. In New Jersey, statute specifically allows a religious exemption to the process of determining brain death that applies everywhere else in the US...

    One practical challenge of the New Jersey exemption is that it could appear to make death a contingent matter of location. Did Jahi McMath come back to life when she crossed the New Jersey state border? (This is not strictly speaking correct, since the NJ statute only refers to the ‘declaration of death’. Had Jahi had her surgery in New Jersey she could not have been declared dead. However, having been declared deceased elsewhere there is nothing in the NJ statute to undo the previous determination)...

    It is possible that actual reincarnation, and eternal life is confined only to believers of a particular religious tradition. However, down here on Earth, we have the option of being more impartial. Cross-border reincarnation, and eternal ‘life’ on a ventilator, should be open to all, or to none.

    See: http://blog.practicalethics.ox.ac.uk/2015/07/reincarnation-and-discrimination/

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  2. Galen Breningstall, MDJuly 29, 2015 at 10:09 AM

    The law professor and bioethicist, Thaddeus Mason Pope, and I disagree about most issues. But I have to say, he sure keeps up on legal affairs of mutual concern.

    Through his Medical Futility Blog and Twitter feed–as far as I know, it hasn’t been reported in the papers–I discovered that there is a hearing on July 30, in the medical malpractice suit filed against Children’s Hospital and the surgeon in the Jahi McMath case, to determine whether the case can go forward.

    One of the primary issues in the case concerns whether Jahi is still alive, or dead because an earlier court ruling found that she was and a death certificate was issued.

    I agreed initially, but concluded that the case should be reopened based on written declarations by respectable physicians that she is not brain dead. At the very least, there should be another thorough examination of Jahi since her body has not deteriorated, which happens in almost all brain death cases.

    Children’s Hospital and the doctor are fighting this. And for a good pecuniary reason: If her terrible injury was caused by malpractice, the damages will be much higher if she lives than if she is dead. Of course, that is a sword that cuts both ways.

    In any event, the medical malpractice case will go forward as a wrongful death case if her “death” can’t be overturned, of that I have no doubt (having no opinion on the outcome). More when I know more.

    A huge HT to Thaddeus Pope for keeping abreast! This could be a very important case. Because if Jahi isn’t dead, it will make history.

    Editor’s note. This appeared on Wesley’s great blog at www.nationalreview.com/human-exceptionalism/421682/jahi-mcmath-lawsuit-percolates-under-surface-wesley-j-smith

    http://www.nationalrighttolifenews.org/news/2015/07/jahi-mcmath-lawsuit-percolates-under-the-surface/

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  3. Galen Breningstall, MDJuly 30, 2015 at 1:09 PM

    In California, Jahi has been declared dead by two neurologists at UCSF Benioff Children’s Hospital Oakland, a county court judge, and an independent and respected neurologist at Stanford Hospital. The family fought and won the right to move Jahi out of the Children’s Hospital, where she died after a Dec. 9, 2013, surgery, but that agreement included the coroner’s office in Alameda County issuing her a death certificate.

    That death certificate and an agreement to bring Jahi to the county coroner’s office for an autopsy if she comes home are what keep the family out of the state. If those did not exist, she could be hooked to life-support machines in California, as she is in New Jersey.

    The family’s attorney, Christopher Dolan, filed two requests in May asking the state to wipe Jahi’s certificate clean, erasing the date, time, place of death and medical information, but the California Department of Public Health denied both.

    Dolan now plans to ask a judge in an Alameda County court to decide the matter. It could be his final attempt after a judge last year denied his request to bring in his experts to testify that Jahi has some brain function, months after she was declared brain-dead.

    Such a request is rare. The state routinely receives requests — 36,284 last year — to amend death certificates, but it’s almost always to fix spelling errors or remove a manner of death, such as suicide, that a family does not wish to have public. While the state does not track requests to revoke or void a death certificate, a department spokesman said it knows only of the two requests related to Jahi in the past two years.

    “If (her lawyer) really has the evidence, then I suppose he should have the opportunity to do that,” said Thaddeus Pope, director of the health law institute at Hamline University. But although missing and declared-dead soldiers have been found, Pope said the revocation of a death certificate in a case like Jahi’s has “never happened, ever, on Earth.”

    “It’s unprecedented to my knowledge and experience,” said Lawrence Nelson, a lawyer with a background in end-of-life issues and an associate professor of philosophy at Santa Clara University. “This is a desperate legal move.”

    Even Dolan called it an “uphill battle” but not insurmountable.

    “I think we have a good opportunity to have this overturned. I want to try and get this woman and her child home,” he said.

    http://www.santacruzsentinel.com/general-news/20150729/jahi-mcmath-girls-mother-speaks-on-legal-battle-over-brain-death

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  4. Galen Breningstall, MDAugust 2, 2015 at 8:54 AM

    Doctors ruled her dead just before Christmas in 2013, but her family does not agree, saying there is evidence of brain activity.

    “You couldn’t tell if there was anything there because of how much swelling there was,” said uncle Omari Sealy. “Since then the swelling has gone down tremendously and we’ve had other physicians come in – privately, multiple physicians – and they’ve all declared that she’s not brain dead.”

    Attorney Christopher Dolan has requested the state and the coroner vacate the death certificate.

    “If they reject that request, then I’ll be returning to the courts, maybe the federal court, based upon what we call the deprivation of one’s rights without due process,” said Dolan. “Because, in essence, under the color of law they are continuing to declare Jahi dead in face of the evidence to the contrary.”

    McMath is currently hooked up to life-support machines in New Jersey, a state which allows families to reject brain-dead diagnoses on religious grounds. Her family claims she occasionally responds to verbal commands, although doctors have called such movements spontaneous.

    http://sanfrancisco.cbslocal.com/2015/07/31/attorney-for-jahi-mcmath-to-fight-brain-dead-declaration-decision-could-cost-family-millions/

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  5. Galen Breningstall, MDAugust 3, 2015 at 12:14 PM

    “The Tell-Tale Heart” is a chilling 1843 short story by Edgar Allan Poe about a man whose disturbed conscience is haunted by the sound of a heart that will not stop beating. The real-life tell-tale heart is the tragedy of now 14-year-old Jahi McMath, diagnosed as “brain dead” in 2013 but whose heart still beats. The outcome of a July 30 court hearing in Alameda County Superior Court could overturn a half-century of established belief, change medical practice, and haunt the conscience of medicine.

    While a brain-dead patient’s heart can beat briefly, Jahi’s heart and blood pressure have been stable for 18 months, something virtually unprecedented with the diagnosis of brain death. The original diagnosis may have been wrong — a disconcerting possibility — or the concept of brain death must be updated for the 21st century...

    When Jahi’s family initially went to court, most doctors familiar with brain death felt the family’s interests, while understandable, should not supersede the law and that the judge’s decision to keep Jahi on a ventilator was wrong. Once Jahi was declared legally dead, conventional thinking was that her ventilator should have been disconnected. Without it breathing for her, her heart would have stopped in minutes. But the possibility exists that the diagnosis was erroneous, and a medical malpractice lawsuit filed in March may revisit whether Jahi is alive or dead.

    Here’s why: In cases of properly diagnosed brain death, no patient has ever recovered to come off a ventilator. The heart continues beating only because of the ventilator and drugs occasionally given to sustain blood pressure (usually if patients are organ donors).

    However, even in brain death, machines and drugs ultimately will not sustain the heart. Even with patients on the ventilator, the heart usually stops within hours to days, and patients “die” in the widely understood sense. There are occasional cases of pregnant women, brain dead but kept on life support until they delivered. Outside of those, there are only a handful of reports of brain-dead patients on ventilators with heartbeats for more than three months, and in those cases the diagnosis of brain death has been questioned...

    Alameda County Superior Court Judge Robert Freedman said in a tentative ruling Thursday that he was inclined to dismiss the part of the suit filed in Jahi’s name, presumably because a dead person cannot file suit.

    Unlike the cases of Terri Schiavo and Karen Ann Quinlan, who were not brain dead and could breathe without ventilators, the question here is not strictly whether Jahi will regain consciousness but the meaning of brain death as death of a person, and whether traditional diagnostic criteria require re-examination. The answers are essential to neurology, organ transplantation and public policy...

    The exact moment life ends is a conceptual question: It can never be settled conclusively. Albert Einstein once observed that a single experiment could prove his most elaborate theory wrong. Likewise, the sad case of Jahi McMath and her “tell-tale heart” could fundamentally change the meaning of brain death.

    http://www.sfchronicle.com/opinion/letterstoeditor/article/Jahi-McMath-s-tell-tale-heart-could-change-6420669.php

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  6. Galen Breningstall, MDAugust 30, 2015 at 9:39 PM



    It was reported earlier this year that local surgeons had noted a drop in the transplantation of organs taken from the brain dead. One reason they suggested was doubt among family members that the brain-dead patient is really biologically dead.

    After all, the person on the ventilator is still warm, makes spontaneous movements, digests food, urinates and defecates. He bleeds, his wounds heal, he can grow a beard and become feverish with an infection.

    Live babies have been born to brain-dead mothers. So while doctors euphemistically call them "cadaveric" donors, these patients do not look or behave like cadavers at all. They appear alive, just asleep. It may be time to review the harvesting of organs from the brain dead...

    But to this day, no one can show why brain death, when thus diagnosed, is really equal to death in a biological sense…

    Four decades after that report changed the meaning of death worldwide, the United States President's Council on Bioethics issued a study in 2008 acknowledging that the question why brain-dead patients are to be considered really dead had never been satisfactorily answered anywhere.

    It admitted that some brain function continues even when brain death is correctly diagnosed. Nevertheless, it decided that brain death was to be considered death because the patient would no longer be able "to act upon the world" in ways that he must if he is to fulfil his own needs. It then reiterated the Harvard idea that the brain-death diagnosis was sufficient to justify organ harvesting. That is, the end justifies the means, even if the brain-dead person is not really biologically dead.

    Proponents basically depend on the idea that brain death entails the loss of personhood, which they say means that you're as good as dead.

    While death has a commonsense biological meaning, it also has non-biological - or moral and legal - ones. But physicians whose expertise lies in the biological, physical or medical cannot rule on the non-biological in which they have no particular expertise.

    They make a value judgment when they say that the loss of personhood in brain death makes it really death.

    I may not agree with your values.

    So what is a moral issue involving life and death has been surreptitiously changed into one about a biological fact to be discovered medically.

    If so, doctors have obscured what is a moral decision, thereby usurping from kin the power to decide when to pull the plug...

    If you cannot cure cancer by just changing the definition of the biological condition called cancer, then you also cannot say that death has occurred when the person is still biologically alive just by simply altering what the word means. Yet this is what doctors have done...

    If families are resisting organ harvesting from the brain dead, it is a sign that this issue remains fraught with doubt.

    It deserves being reopened for debate by all.

    It should not be left to doctors who have no particular expertise in philosophical endeavours…

    One outcome might be to change Hota into an opt-in system where people proactively agree to be cadaveric donors.

    This might see more organs becoming available if more are persuaded. Above all, transplant surgeons would have real prior consent from the brain dead, putting the system on a more morally sound basis.

    http://www.straitstimes.com/opinion/do-not-leave-definition-of-death-just-to-doctors

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