I have rarely been asked to assist in declaration of death situations, since I am Doctor Lawyer. Mostly Doctor, though, inactive member of the Bar of Texas.
I assist, or advise when asked, but the Neurologist is the expert.
The neurologists are familiar with and expert in the methods for determining brain death, including the state rules that might apply.
In their residencies they are required to know the rules and the tests that are considered determinative.
The Terry Schiavo case has nothing to do with determination of brain death–it was a case of persistent vegetative state, which is on the spectrum of consciousness close to coma, and severe disability.
In the legal case there was a petition by the husband to withdraw life support of food and water being given by feeding tube, with the Schindler parents battling against the withhold until dead decision, asking she be released to their care, the husband arguing she had said she never wanted to live that way, no written confirmation.
Terry Schiavo was not vegetative, but she was severely disabled by brain damage and blind, based on the video I saw of her before her death.
http://www.search.ask.com/videos?q=video%20of%20terri%20schiavo&o=102807&gct=tab
A non medical person would be shocked at the level of her disability, but it was similar to many demented persons or persons who have suffered brain damage or or strokes.
She was awake and severely disabled but breathing well. I saw nothing in the records to indicate why she had a feeding tube, since she had no history of aspiration pneumonia or a big deal would have been made about hospitalizations for pneumonia.
In addition, although Ms. Schiavo was awake, able to breath and had no terminal illness except her severe disabilities–her husband ordered no dental attention, no physical therapy and hired George Felos, a euthanasia/right to die advocate, attorney, who arranged for transfer of Terri to Woodside Hospice, where he was chairman of the board.
http://www.ask.com/wiki/George_Felos?o=2800&qsrc=999&ad=doubleDown&an=apn&ap=ask.com
A hospice is defined as a place of comfort care for the terminally ill, but Terri was not terminally ill unless you consider her life expectancy shortened.
In spite of the fact that at a hospice nothing but comfort care is offered, Terry lived without a deterioration or need for medical care, proof that her disability was stable and the petition to remove food and water was to kill her when her disabilities didn’t.
At a trial before the probate court, which is responsible for the disabled and their estates, the husband, already living with another woman with whom he had children, won a withdrawal of food and water order based on the battle of the neurologists. Judge Greer notably failed to ever visit Terri, a requirement for Probate Judges, but he found in favor of Michael the still husband, living a common law marriage with another woman.
After that all the appeals and the noise was worthless–appeals courts do not reverse a trial court finding unless they find it arbitrary and capricious, so all the hoopla created was bound to achieve nothing. Nothing was going to reverse the probate judge opinion.
She was dehydrated to death, but was tough and it took much longer than predicted.
All the left could talk about what she had no life, no quality of life and no one would want to live that way.
My reminder is what Churchill said–always choose life. Plenty of people out there whose lives are compromised, but should they all be dead? Go to a nursing or have a debillitated parent, then tell me what the right thing is? However I would always advise, do not go with a feeding tube in cases of deterioration and terminal illness, since it will alter the natural events. Also consider decisions about hospitalization and intensive care for infections, since infections are often the terminal event in the very debilitated, and that’s the way its supposed to be whether you are religious or secular.
Read the essay on the Culture of Death by my favorite psychiatrist and ethicist in the mag Commentary June 2005. Paul McHugh MD, is Emeritus Prof and former Chair of Psych at Johns Hopkins Medical School.
http://connection.ebscohost.com/c/articles/17136898/annihilating-terry-shiavo
Here is his closing paragraph in a long essay.
Contemporary bioethics has become a natural
ally of the culture of death, but the culture of death
itself is a perennial human temptation; for onlookers
in particular, it offers a reassuring answer (“this
is how X would have wanted it”) to otherwise excruciating
dilemmas, and it can be rationalized
every which way till Sunday. In Terri Schiavo’s case,
it is what won out over the hospice’s culture of life,
overwhelming by legal means, and by the force of
advanced social opinion, the moral and medical
command to choose life, to comfort the afflicted,
and to teach others how to do the same. The more
this culture continues to influence our thinking,
the deeper are likely to become the divisions within
our society and within our families, the more
hardened our hatreds, and the more manifold our
fears. More of us will die prematurely; some of us
will even be persuaded that we want to.
Here is Michele Malkins essay in support of Jahi’s parents desire to wait for a miracle.
However, Jahi has been judged brain dead and not able to live off a respirator, so her case is much more clear.
I have no knowledge of the brain death diagnoses made in the extraordinary cases Michele Malkin narrates.
I just know that if you do the tests properly and then repeat them after an interval of a day or more, you can usually establish irreversible brain death.
http://www.frontpagemag.com/2014/michellemalkin/the-gifts-of-jahi/print/
A Doctor friend Jerry Arnett and I wrote an essay on bioethics for American Thinker that may expand your understanding of the problems we face now, and the economic and ethical issues related to brain injury and brain death or even disability and “quality of life” or “life scores.”
http://www.americanthinker.com/2011/12/the_danger_of_a_new_medical_care_bioethics.html
Look at the video of her following a balloon.
So let’s take Michael down a peg or two. At the trial he promised the jury he would go to nursing school to learn how to take care of her–that was a misrepresentation. Soon he was living with another woman and Terri was a terrible inconvenience and burden for more than one reason.
Terri went to 3 nursing homes and got good nursing care but Michael took her out of those homes and was antagonistic to their efforts to provide what they normally provide for there disabled patients.
He engaged a lawyer who was an advocate for euthanasia and transferred Terri to a hospice where the lawyer was Chair of the Board.
Michael wasn’t a nice guy, why do people have such a hard time accepting that there are bad people in this world?
Your analysis and comments are biased by your belief that it would be natural for Michael to run out of patience with what Terri was. And your underlying belief that someone as disabled as Terri should be killed.
Well that is your position. Many agree with you, on the mantra that went out across the country at the time–I would never want to live that way.
Terri was a terribly disabled person, but death versus life is a pretty hard difference. Churchill said, always choose life–what does that mean–what should we say to those who are severely disabled–get you gone?
I am not prepared to argue that the people who thought she should be allowed to live were wrong.
I can say that Michael was prepared to kill his severely disabled wife because she was an extreme and constant problem and difficulty for him.
Probably because of familial ties, particularly mother stuff, the Shindlers were willing to accept her alive rather than wish her dead. GET IT?
Sorry, John, but the “not a nice man” comment is irrelevant. Let’s not distract the issue. Opposition to “care” when it is not in her best interest is not evil. It’s wisdom. If he got angry and bitter at times, I can understand. Being called a murderer on international news would interfere with one’s mental peace.
And what, physical therapy, pray tell, can you give to a person without a brain? You claim that she was alive and awake when several sources, including the autopsy report on her brain’s state, state that she had nothing with which to be “awake” with. Instinctual neurons firing in an empty shell does not “living” make.
Probably was stunned brain. But this was a while ago and the doctors were talking to the family about ‘pulling the plug’. I wasn’t part of those discussions so couldn’t ask any of my questions. The guy is a real inspiration to me. Thanks for your comments, doc.
You gave away the store when you used the phrase “after many years”. These vegetative state cases are heart rending. The Quinlan family took Karen Ann home for Thanksgiving and Christmas in the hope that aromas and sounds of the seasons would kick start her brain. It took some time for the family to fully comprehend Karen Ann’s state. They loved their daughter and were terribly upset by fanatics who hassled them.
I believe it to be immoral to continue life in a vegetative state. My ex had a client who lost the mental ability to even chew food. She would prepare a nutrition mix that was put into his stomach through a feeding tube and then change his diaper some time later. The man’s wife insisted on the treatment. The man himself had a good life prior to losing his mind. and got good care as his mind slipped away. There was no way to justify continuing his life at the end.
What a wonderful story. Stunned brain.
The fact that judges, and by extension lawyers, can create law is a serious flaw in the USA. One that I believe goes against the intentions of the original separation of powers. Some policies make sense when evenly applied across the entire country (driving on the same side of the road for instance). All other situations should be taken on a strictly case by case basis. If that requires a judge for arbitration, that’s fine. The problem, to me, arises when a judge’s decision in one case becomes elevated to the status of policy either through case law or eventual legislation. I don’t know enough to say whether the courts made a mistake in the referenced cases, but if those cases are then used as rallying cries to lobby congress to pass restrictive guidelines that limit individuals and doctor’s ability to choose for themselves, I predict more harm than good would come of it.
I don’t know how rare or common recovery from a pronounced brain death is. Lots of people who are passionate about it have an anecdote, but anecdotes aren’t data. What percentage of people pronounced brain dead later make reasonable recoveries? Is “reasonable recovery” even something that can be defined? One person may feel lucky to still have their child with them even if the child never regains consciousness. A warm hand to hold and the constant, reassuring beep of a heart monitor sufficient proof that their child is alive. Another may feel unreasonably burdened by a wheelchair bound child that requires spoon feeding and changing despite the child clearly recognizing their face. I certainly can’t say how I would feel if this conversation left the hypothetical for me and my loved ones. There but for the grace of God go I.
Sometimes there just isn’t a right answer.
When I was in Family practice I had a practice in a poor part of Omaha and at one point I was the medical director for 5 nursing homes and had a lot of patients that I took care of–200 hundred or more. My nurse wife and I even had Nursing Home Administrators’ licenses because we had so much nursing home activities. Being a nursing home doc is not that attractive to many, but we knew it was necessary someone do it.
So I know the problems of chronic care and why many lay people are very uncomfortable with the severely disabled. Why nursing homes are so upsetting–why people say things like–I would never would want to live that way.
Terri Schiavo was alive, just severely disabled. Michael was, by the reports I read at the time of the trial from the 3 nursing homes that took care of Terri before she was transferred to the hospice, not a nice man. They described him as antagonistic to any efforts by the nursing homes to do much for Terri, a bully who was angry, for example about efforts to provide physical therapy and the nursing attentions that normally are given to a very disabled person in a nursing home to make them more comfortable and reduce contractures assure good ,mouth and dental care, prevent skin breakdowns and ulcers.
As for offing her, that was exactly what he was doing by asking that food and water be witheld. Terri’s severe brain damage was stable, hadn’t changed much but she wouldn’t get sick and die, so he conjured up, after many years, a claim that she had always said she didn’t want to live that way. The Shindlers said that wasn’t true, and were willing to take her the way she was, there is no information I have that they thought after all that time she would recover, just that they didn’t want to kill her and that she would benefit and improve with better nursing attention. Hospice care is comfort care for the terminally ill. Terri Schiavo was not terminally ill. She didn’t have cancer or any measurable known life expectancy so you might say a hospice was not the proper place for her, unless someone had a plan for a terminal illness.
Well pulling the plug is frequently just family and doc.
However when there is a disagreement, guess what–judges and probate court proceedings for disabled person’s interests commence.
Then you end up with rules and rulings and such.
As for the heart and lungs thing, sort of, except that the brain is the determining factor and brain death means not breathing so the heart won’t last long without oxygen.
For Jews heart and lungs are still traditionally the traditional factor, and culturally for some groups, they consider heart the measure of life so if a person is ventilator dependent, there is a problem, since a brain dead person’s heart will keep on going if they are on a ventilator and getting fluids.
Persistent vegetative state creates problems–severe brain dysfunction, breathing and alive, requiring food and nutrition and unable to eat and drink, for example.
Oh, by the way, I will not allow transplantation of my organs. I’ve come to distrust this ‘medical’ criteria.
The issue is with respiratory support and a continued heart beat. That’s also the way they keep organs alive (perfused) til tranplantation. We’ve had organ removal from a respirator supported patient and when surgery was over, the machine was turned off. Of course with the heart gone…
I agree these health care decisions are best decided by close family members and physicians. But not physicians alone.
Good luck with government staying out of our health care. Government and attorneys. That toothpaste isn’t going back in.
Addendum: I have a 2nd cousin who, in his 20’s had a horrible stroke. He was unresponsive for a long time. They thought it was brain stem. My aunt called me and asked if they shouldn’t pull the plug. It’s so hard going through such an event and the energy needed to go to the hospital every day with little children…I told her he was very young. They should give him a big chance. They did. Today he does everything you or I can do. He has trouble with his one hand and arm and leg but walks with a limp, drives his car, hunts, works 3 jobs and took care of his kids along with his amazing wife.
These stories aren’t so unusual nor miraculous.
The Schiavo was arguably about euthenasia as her “brain death” was debated, but I have to agree with you, Bill. The autopsy report concluded that there was no possibility of recovery to even a minimum of anything that can be called “life” as the majority of the brain was gone. I also have to object, John, to you Schiavo for moving on with his life. He was effectively widowed years prior to his wife’s official death. The clear implication of “offing his wife” to go live with another woman is despicable.
http://www.washingtonpost.com/wp-dyn/content/article/2005/06/15/AR2005061500512.html
use=us
I thought the issue was with situations where the heart and lungs could be kept going indefinitely. That’s certainly been mischaracterized to use lay people. Unfortunately, it just doesn’t make sense to establish policy based on the rare “miracle” cases. That’s why I don’t support any form of blanket policy and think the government should stay out of it. These decisions are best left to close family members and trusted doctors.
I agree with wpress2013.
I am an RN and have been there through the change over to laws governing ‘brain death’ criteria. I’ve helped with the determination in ICU’s and other nursing floors. I have believed it.
Now, I wonder. And there is too much pressure on doctors, hospitals and nurses to help make organs and tissue available for transplantation.
I have read of some who return from ‘brain death’ determination. I just wonder…
Are we correct? Before ‘brain death’ we waited for the heart to stop. maybe we should do that now.
http://www.thestar.com/life/health_wellness/2008/04/13/when_brain_death_isnt_terminal.html
Indeed, why refuse a request for transfer if there is a receiving facility?
And all the points made deserved at least a little more info, so I provided the info from the neurologists on brain death and from the NIND on persistent vegetative state.
The Schiavo case also swung on the claim of Michael Schiavo that she had said she didn’t want to live that way.
A couple more things. Michael said at the malpractice trial that he was going to go to nursing school and would care for her–but that was not what he did, and he did move her from 3 different nursing homes that he put her in because he disagreed with their efforts to provide physical therapy and nursing care.
Terri was too damn tough for Michael’s plan to work–she didn’t even get sick from aspiration or decubiti or urinary tract infections.
And, for all you who are paying attention, if you watch the video she is reacting to her surroundings and that is one criteria for consideration of Persistent Vegetative State. In addition, since her vision was severely impaired, she would be less reactive, but it appears from a video I watched, that she was following a red balloon. Not the demeanor or behavior of one with PVS.
No doubt she was severely disabled. PVS? Judgment call. The parents were not unrealistic, but they were convinced that she had suffered from a lack of rehab and physical therapy that would prevent contractures.
Most important in regards to public reaction is that the culture doesn’t think severely disabled persons have a quality of life that they could justify, now that means that many in favor of terminating food and water think she was better off dead. That’s the nut of it.
No opposition here, stunned brain make any sense? Neuro tissue can be stunned and dysfunctional, so that’s why the brain dead criteria require an interval and repeat for confirmation. One might say, how much of an interval.
Death is final. There is no coming back from it so you had better be 100% correct in your assessments before taking any non-reversible action. The more Medical Science advances the more it seems to forget. Doctors all always working from ignorance as they can never have the complete picture or knowledge of the person they are treating.
Hubris is the real problem here and the medical profession is full of it. Doctors may know more but it seems to me and many others that they only rarely know best. We do not sign over our lives to them when we go to get treated and they should not have the ability to make those decisions.
I would be interested to know why the hospital and the doctors treating this young girl were so insistent on not co-operating with the transfer to another facility? This smacks of trying to hide something or some other motive. There is more than we know going on here.
That’s the version I recall as well. It struck me because my wife’s family are right-to-life catholics and she is not. I found the idea that her family could sue me for carrying out her final requests quite unnerving.
The more medical science improves its ability to bring people back from the dead, the fuzzier this line is going to become. The only sane solution, imho, is to protect the individual’s right to choose and make sure your legal documents are up to date if you change your mind.
My recollection of the Schiavo case differs markedly. The parents were talked into a possibility that their daughter could be rehabilitated by certain experts. The husband devoted years to caring for Terri and finally concluded that she was never going to get better. It just isn’t right to throw dirt at the man. I wish him the very best.
An autopsy showed the courts and the husband to be correct in saying that most of Terri’s brain was pea soup.
Even if we embrace “brain death” as “death of the individual” it is still a sticky wicket. http://www.radiologydaily.com/daily/diagnostic-imaging/shocking-pet-scan-explains-dead-feeling/
Imagine a patient who walks about and claims vociferously to be dead. Imagine that his brain scan supports his statements.
The fact is, after 3,000 years of Western Civilization, we have made very little progress on understanding the basis of consciousness.
The real issue here is that no two cases are exactly alike. Therefore, there can be no blanket answer. Only the surviving parties closest to the patient can say with authority what the patient’s desires may have been. Everyone else is just sticking their nose in. Often, I find, if you discuss the matter long enough you’ll find that those making vehement arguments one way or the other are merely speaking from their own fears about how they will be treated at the inevitable end. Some are scared they’ll be consciously aware of slowly dying as the machines are turned off. Some are scared they’ll be consciously aware of being trapped in a broken body. If you have a preference, get it notarized and tell everyone you know.
Putting aside the emotional issues here about, to put it crudely, accepting the (presumed – please read further) fact that their kid is dead and it’s only a hunk of meat being kept functioning courtesy of machines… there are cases of such folk who do, in fact, wake up.
I have a personal acquantance who “died” in this same manner, courtesy of complications of a tonsillectomy. Flat line EEG and the whole works.
– I don’t recall the time frame, but after a few months she was awake and semi lucid, and has continued to improve in the past couple of years.
I don’t want to go into details but she’s pretty much fully alert and cognizant, and can get on buses herself, etc.
In my own “living will” I basically state that if I’m dead, I’m dead. If I’m close enough to being dead that there’s little question, then give me 48 hours before pulling the plug.