This is a tough one.
Readers will remember the case of Jahi McMath, the unfortunate 13 year old who underwent an operation to treat sleep apnea, including tonsillectomy. Post-op Jahi was coughing up blood. The following morning her heart rate dropped and she went into cardiac arrest. Three days later she was declared brain dead. The family challenged the hospital’s decision to take the patient off the ventilator. The family won the right to transfer Jahi to an undisclosed location in New Jersey.
The family just filed a medical malpractice lawsuit naming the ENT surgeon and UCSF Benioff Children’s Hospital as defendants. That lawsuit comes as no surprise.
What does come as a surprise is:
Since Jahi was moved, three doctors have signed a declaration stating Jahi McMath is not brain dead, according to bioethicist Wesley Smith.
They include Charles J. Prestigiacomo, director of Cerebrovascular and Endovascular Neurosurgery at University Hospital in Newark and chair of the neurological surgery department at Rutgers and two internationally respected neurologists Dr. Alan Shewmon and Dr. Calixto Machado.
Another post noted:
The brain structure evidenced in the MRI is not consistent with an MRI of a patient that has been brain dead over nine months,” Prestigiacomo wrote in his declaration after reviewing tests on McMath conducted at University Hospital. He added that McMath has a “very significant brain injury but she doesn’t meet the criteria for brain dead.
The family attorney will petition the California Secretary of State to rescind the death certificate. The attorney stated if this petition is denied, he will sue.
Brain death criteria were designed to be conservative. Brain death is defined as the irreversible loss of all functions of the brain, including the brainstem. The three essential findings in brain death are coma, absence of brainstem reflexes, and apnoea. An evaluation for brain death should be considered in patients who have suffered a massive, irreversible brain injury of identifiable cause. A patient determined to be brain dead is legally and clinically dead.
The diagnosis of brain death is primarily clinical. No other tests are required if the full clinical examination, including each of two assessments of brain stem reflexes and a single apnoea test, are conclusively performed.
Brain death can typically be certified by a single physician privileged to make brain death determinations.
Once a person is declared brain dead, can that determination be reversed? What about after 9 months? It would be helpful to better understand what the patient’s clinical exam revealed.
I have been doing Trauma Ophthalmology for 15 years, I have seen patients that Docs simply jump to fast in their conclusions. As an expert on pupils I do not ever rely on a one time exam and realize even fixed dilated pupils can some times be some thing else!!!!!!!!!!!
ITS IS PERFECTLY ACCEPTABLE TO SAY THAT YOU DO NOT KNOW AND YOU WILL CONFER WITH ANOTHER DOCTOR OR YOU NEED MORE TIME.
WHY DO SOME DOCS THINk THEY HAVE TO ANSWER DIFFICULT FAMILY QUESTIONS RIGHT AWAY! I HAVE SEEN PEOPLE LOOK REALLY STUPID AND WISH THEY PRACTICED HUMILITY!
We now know that a lot of things about brain they told us in med school maybe only 90 percent true.
I have even seen pupils that once believe to rock solid SIGN OF OPTIC NERVE DEATH even reverse !
PLEASE TAKE YOUR TIME AND DO SECOND EXAMS BEFORE YOU INFORM A FAMILY OF A MAJOR BAD NEWS.
Grasping at straws
The likelihood that this child will ever recover to live a normal life is very very slim.
The family will likely keep hoping for recovery and is trying to get the death certificate revoked so that insurance will pay for the medical care. More cynically they are working to have the death certificate revoked so they can obtain a larger malpractice award. It is likely that when all the legal wrangling is done in another 3-5 years and the case is settled legally the child will still be in the same state of existence hovering between death and life. We all hope and pray that we and our family members never wind up in this state.
Having been in this same exact situation with both a close friend and my father in law at different times, it is a heart wrenching event. In both cases the families recognized that the chances of full or even significant recovery despite the absence of brain death were slim. They elected to pull the plug.
In another situation that I was aware of 35 years ago, a young gentleman was declared brain dead after a traumatic accident. His heart continued to beat. The family refused to accept the inevitable despite several EEG’s that showed no brain activity. The insurance company refused to continue to pay for care for the patient. The family (of modest means) was prepared to mortgage their home in order to continue to pay for the hospital care of their loved one. Then one evening a pipe burst flooding the ventilator unit and cutting power to that entire unit of the hospital. The ventilator of course stopped. In the commotion that ensued, this gentleman’s heart stopped and the family finally accepted his demise. One could say that providence stepped in, to prevent the impoverishment of this devout family.
Sadly, I fear for the future of all of us. The decision,literally,of “Life and Death” should never be entered into quickly,nor by one person.This becomes more important as hospitals “OWN” the physicians, and begin to loose money on many critically-ill patients.I have seen ICU specialists pushing for HOSPICE,D/W MY PATIENT’S FAMILIES,never having given me a “heads-up”,(I was a Gen./Vascular surgeon). The families see a “loved-ones”,often unresponsive,”tubed”,swollen,(third space fluid),and too often,convinced,that “letting go” is the humane thing to do.One of these pts. sent to hospice,was the mother of an ICU nurse.I was quite upset with this particular case as I had explained to the daughter,(nurse),that it was too early to make that decision.Her mom was brought back from hospice,got better,and,to the best of my recollection,lived at least three to four more years,even traveling with her family,and enjoying LIFE. When I began my surgical practice in 1989,in Lake Worth,Fl.,there was a large Finnish population.Many would tell me that they would not go to hospitals where they came from as they considered the hospital as a place to die. We have seen a steady decline in this country regarding the “sanctity of life”.It becomes easier and easier for the physician,as it has for society as a whole,to rationalize they are making these decisions based upon sound medical judgement. Now,with an ever aging population,a bankrupt government,(Social Security,Medicare/medicaid,etc.),and the hospital loosing money on many critically-ill pts. as DRG’s “run-out”,the only real “checks and balance” to the system are the “checks” the hospital writes to it’s physicians. If what the “Finns” told me 25 years ago was true,well,I guess we have “progressed” to that level.Maybe this is only happening here,(SURE!)…we have stood by and let the greatest medical-care system in the world,die,and now,many of us will be sure to die,prematurely.What a disgrace! Forget about the definition of “Brain Death”,if you are perceived as “too sick”,you will not get the chance you would have had in the past,to get well.Finis.
Brain death determinations do require the three elements aforementioned: coma, absence of brainstem function, including apnea by a formal test. One must also consider and exclude scenarios that simulate brain death such as hypothermia and drugs. However, even with these excluded, the aforementioned tests are not always sufficient and, in those circumstances, the cerebrum and thalamus may retain function. Determining this requires additional testing.
There is a lot of misinformation about brain death determinations. The statement above by the trauma ophthalmologist is an example. The pupils of a dead person are dilated.
In writing this, I have no opinion about Jahi McMath. I do not know the specific details.
Thank you Dr. Damien Joy. Well done!
The phrase brain “death” should probably be modified to brain injury, brain failure, anoxic encephalopathy, or cerebral infarction. People die, but organs fail. Declaration of brain death only enables the physician and state to end life prematurely. I believe it is our job to keep our patients alive while nature takes its course.
I believe if a patient suffered an insult that resulted in a large cerebral infarction (dead brain tissue), multi system organ failure and death would ensue in days – life support would not sustain.
Wasn’t there a forty seven year old man recently declared “dead” who awoke in the morgue? Hard to believe that could happen, but easier to understand how brain death could be open for scrutiny. Very sad case.
The question can easily be answered with an angiogram or radionuclide CBF study. If there is no blood flow the brain is dead.
interesting. thanks for sharing