To be or not to be

January 2, 2014

Thursday, January 2, 2014

Happy New Year to everyone!

I have been following developments in the Jahi McMath tragedy in Oakland. She is the 13-year-old girl who went to the hospital last Friday to have her tonsils removed. She went into cardiac arrest in the recovery room after the surgery. Efforts to revive her were unsuccessful. The medical staff pronounced her dead after determining that she had no electrical activity in her brain or brain stem. But for vehement objections from her mother, the medical staff would have disconnected Jahi from the ventilator and transferred her body to a funeral home to be prepared for burial.

Pursuant to a court order obtained by her mother, Jahi will remain attached to the ventilator and receive nourishment by tube until January 7th, unless her mother finds a hospital willing to accept her before that deadline. If no hospital agrees to take her because she is brain-dead and/or her family cannot afford to pay for her long term care, the court will have to decide whether to accept the decision by the medical staff and dissolve his order or find some other solution.

The case presents several interesting issues for us to consider. I am going to start with the end-of-life issue today and reserve discussion of other issues for a later time.

We used to determine whether someone had died by checking for a pulse. No pulse meant the person was dead or soon would be, unless we restarted the heart. First responders and others trained in emergency medicine use electric paddles to shock and restart the heart. If paddles are unavailable, they will place the palm of one hand over the back of the other and alternately press down with both hands against the flexible breastbone directly above the heart and then release the pressure allowing the bone to return to its normal position. Repetition of this process mimmicks a beating heart and it can circulate sufficient oxygenated blood to the brain and back to the lungs to prevent or minimize damage to brain tissue.

Sometimes a heart will restart on its own after a person has been declared dead. For example,I recall reading a story within the last month or so about a man in Brazil who sat up in his coffin during his funeral and demanded to know why people were attempting to bury him alive. This provoked a rather awkward moment of silence as people attempted to figure out who was playing whom.

Doctors now believe that death inevitably results when the brain is deprived of the oxygen that it needs to continue functioning. They would explain the apparent miracle that people witnessed at the man’s funeral as a practical joke or an erroneous interpretation of insufficient data or flawed data recorded improperly. They would opine that the brain must have been alive when the person was declared dead.

Absence of a detectable heartbeat could mean that a person is dead, but a final decision should be delayed until doctors determine whether any brain activity is present. The brain will not regenerate dead cells. Therefore, absence of brain activity is a more reliable indicator of death than an absence of heartbeat.

As we know from the Terry Schiavo case, a brain-dead person can be kept alive indefinitely by hooking them up to a ventilator and feeding them nutrients through a tube. I question the wisdom of a decision to use a machine to extend a life indefinitely knowing that the person will remain in a persistent vegetative state without regaining consciousness until the machine is turned off.

I understand and sympathize with Jahi’s parents. Despite a persistent and shameful record of 100,000 preventable deaths in our nation’s hospitals each year, I do not believe any parent would have foreseen that their child would die following a routine surgery in a hospital to remove tonsils. Shock, dismay, stunned disbelief, and rage probably would overwhelm capacity to reason.

I think I would cling to hope as her mother has done.

Easier for us to see that prolonging her brain-dead child’s life under these circumstances is magical thinking that will not bring her back. Moreover, creating an opportunity for a miracle to happen by extending her life with a machine is irresponsible Frankenstein behavior.

No matter how much it may hurt, sometimes you have to say goodbye and let a loved one go.

Jahi’s mother made some serious allegations of misconduct against the hospital that I am not going to discuss, except to say that I believe the anesthesiologist may be liable for her death. Res ipsa loquitur.

I also have not discussed the cost of indefinitely prolonging Jahi’s life and who will have to pay for it.

Jahi’s case has provided us with a wonderful opportunity for context in considering and discussing end-of-life decisions regarding yyour child. They are gut-wrenching and no answer can fully satisfy.

Although the Terri Schiavo Foundation has offered to assist Jahi’s family, no decision that must be made at the intersection of a brain-dead child and the cost of extending her life in a permanent vegetative state is going to be easy to make.

Should an insurance company, the patient or the patient’s medical professional decide when to disconnect the patient from life support.

What would you do, if Jahi were your child?

Would you sign a DNR (i.e., do not resuscitate)

What role, if any should religious faith play in the decision?

Who should bear the cost of paying for long term care on a vent?

Should rich and poor receive different care or should it be the same?

I do not believe the right-wing hate machine will involve itself in this matter since they place little value on the life of a child with black skin.

CNN is reporting that Jahi’s famiy:

“Together with our team of experts, Terri’s Network believes Jahi’s case is representative of a very deep problem within the U.S. healthcare system — particularly those issues surrounding the deaths of patients within the confines of hospital corporations, which have a vested financial interest in discontinuing life,” the Terri Schiavo Life & Hope Network said in a prepared statement.

The organization said it has been overseeing the efforts of several groups to help get Jahi transferred out of Children’s Hospital Oakland and brought “to a safe place.”

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