On brain death and the Jahi McMath story
So what is brain death? It means no function at the level of the brain stem or above. Function stops where the spinal cord joins the base of the brain. How do we know somebody is brain dead? There are a series of standard and relatively low-tech bedside tests to determine that. We first make sure the patient has a normal body temperature and has no sedating drugs in their system. There should be no purposeful response to any stimuli. The muscles are flaccid. Then we test for brain stem reflexes. One of these is response of the pupils to light — there should be none. There needs to be absence of normal movement of the eyes to motion of the head (called doll’s eyes) or no movement when we put cold water on the ear drum (called cold calorics); both of these measure the same reflex. There should be no blink reflex, called the corneal reflex, when a wisp of cotton is brushed on the eyeball. There should be no gag reflex when we stimulate the back of the throat with a wooden tongue depressor. Finally, the last test of brain stem function is the apnea test: we allow the blood carbon dioxide level to rise and look for any effort to take a breath. Rising blood carbon dioxide level is a strong trigger to the normal brain to breathe, and failure to do so means this ability is lost.
What happens after the bedside brain death determination varies a little from hospital to hospital. Many hospitals require 2 tests 24 hours apart; if both show no brainstem function, the patient is legally dead at the conclusion of the second test. As an alternative, we can do the bedside test followed by a simple scan to determine of there is any blood flowing to the brain. These two tests together give us an immediate answer, and many hospitals require the flow study for children. If the bedside examination shows no brainstem function and the flow study shows no blood flow to the brain, the patient is legally dead. I write the time of death on the death certificate as the time of the scan.
When I do these things I always want the family with me and watching what I do as I explain what is happening.
That all seems straightforward. As with this case, sometimes it’s not. For one thing, not all cultural traditions recognize brain death as real if the heart is still beating. I’ve been in that situation. For another, sometimes there are reflexes at the spinal cord level that look as if the patient is alive. That’s a difficult thing to watch.
The upshot is that I have continued support — mechanical ventilation, often medicines to support heart and other organ function — on a brain-dead patient for some time. Usually this is because the family wants some time to cope with things, or else there is a family member traveling to the hospital. I’m always OK with that, up to a point. A key principle here is that a family cannot force me to behave unethically, and continuing organ support of a dead person is disrespectful of the dead — mutilating to the body. Many ethical traditions, including my own, refuse to do that.
The longest I have ever continued organ support on a dead person was 6 weeks. We had a huge court battle similar to this case, with the court ultimately allowing us to withdraw support. A family member then attempted to enter the hospital with a gun. It was ugly.
The bottom line is that, with the exception of the one case above, I have always been able to mediate the situation by listening to families, being frank about my own duties (both legal and ethical), and allowing them time to grieve. I have always regarded caring for dying people and participating in their death as an honor granted me by the family.
I think there is more going on in this case than we know. Why this case became so adversarial is probably a complicated issue, and these complexities do not translate well to the evening news. At the very least, clearly the hospital and doctors failed to establish a relationship of trust with the family.
Regarding the child’s cause of death, I’d lay odds she had sudden bleeding from the tonsilar bed, the tissues under where the tonsils were. This is a well-known complication after tonsillectomy if the clots fall off. After that I think she probably lost her airway, either from obstruction from blood clots or some other reason. She was a large girl undergoing the procedure because of sleep apnea. Such people often have difficult upper airways to access and control with a breathing tube in a hurry, and that was what she probably needed. The back of the throat is also quite inflamed immediately after this kind of surgery and a rebleeding tonsil site can obscure everything with a large quantity of blood. I know this from experience. It’s a difficult situation to manage. I assume she went 4-5 minutes without an adequate airway, leading to brain damage and subsequent brain death. This is a common progression after anoxic brain injury — lack of oxygen — from any cause.
There are some directly antagonistic ethical issues in play here. Patients, and their families, are in charge of medical decision making. But they don’t have the right to demand whatever they want. This can be as simple as requesting a test that is not medically indicated or as complicated as this case. Futile care is unethical, particularly if it causes pain to the patient. Of course in this case the patient is already dead, so one could argue that there is no harm in persisting. But there is ethical harm, I think.
I have been in the situation of requesting, on behalf of a family, transfer of their brain dead child to another facility when we have reached an impasse. That is my obligation to them. But no facility I have ever dealt with would accept transfer of a dead person; I wouldn’t, and I am surprised the family was able to locate one.
One other thing I’m occasionally asked: Has anyone who was declared brain dead ever been found later not to be dead? I am unaware of any cases of this. If you hear of such things you need to understand that a patient in a deep coma, totally unresponsive to the world, is not dead. They still have the reflexes I described above intact. Once in a while such a person awakens.
At any rate, nature has a way of deciding these things no matter what we puny humans do.
Sachin on 
Thank you for this. Here is the mother’s account of what happened in the little girl’s last moments, and I wonder if this jives with what you consider to be normal care in this situation. Realize also that it was not a simple tonsillectomy. She had a complicated procedure (don’t recall the name) that involved the uvula, and the sinuses, and is apparently done to treat sleep apnea.
Nailah Winkfields account of Jahi’s last moments:
Jahi had an operation. I was told it went well.
Then she started bleeding from her mouth. They gave me a cup for her to bleed into and said it was normal.
She bled more and more. I couldn’t keep up with it. I asked for help, they gave me a bigger bucket.
She bled more. They did not answer our pleas for a doctor.
Her surgeon never came back. She had a heart attack and her heart stopped beating.
Then they came- then. They shocked her back into life. Now they say she is dead.
Also it has been reported that the family was given a suction device and was told to suction her. Is this standard? I don’t know whether this has been substantiated.
Hi Dave — thanks for your comments. I hadn’t seen those statements from the child’s mother.
You ask some difficult questions, difficult because we weren’t there to see the details. And the details are everything. Yes, some bleeding after a tonsillectomy and adenoidectomy is common. As you say, she also had what I expect was what we call a palatoplasty. This is a procedure designed to trim down and stiffen the soft tissue at the back of the throat, the area around the uvula, to open up the airway further in someone with sleep apnea caused by partial obstruction of the upper airway. These days that is often done with a laser. Again, I don’t know where all the bleeding was coming from, but most likely it was the tonsillar bed because we see that sometimes. But we don’t really know.
I really don’t want to critique precisely how things were handled in the post-anesthesia recovery room, particularly because we only have one side of the story. A key detail is we don’t know if and when her airway was blocked, although severe brain injury usually takes several minutes of insufficient oxygen at least. In children with no preexisting heart problems, a cardiac arrest nearly always is preceded by a respiratory arrest — some problem with the airway.
But I will say this: on general principles I would never hand a parent a suction device and tell her to suck out the blood and clots — that’s the nurse’s job. And if large amounts of blood are coming out, beyond the usual, than the surgeon should be called because things aren’t right.
Christopher,
Once again, thank you. I’ve followed this case very closely, and, you’re right, because of, I guess, HIPAA, the hospital (Children’s of Oakland, highly respected), has not released any details of the child’s care or what happened. However there are two documents you might also want to look at that are public: one is the court-appointed Stanford neurologist’s report confirming the declaration of brain death:
http://media.nbcbayarea.com/documents/Fisher+-+Redacted+Rpt_1.pdf
Here is the account of the head of the Children’s Hospital pediatric ICU that was part of a statement filed in the court proceeding:
http://www.scribd.com/doc/196756012/Children-s-Hospital-Oakland-Supplemental-Declaration-of-Dr-Heidi-Flori
Regarding the mother’s account, I find aspects of it difficult to reconcile with the high quality of care that Children’s is known for. My guess is that they did everything possible to stabilize the child, once they became aware of the bleeding. My guess also is that the mother waited too long to inform them of the bleeding (“they did not answer our pleas for a doctor”).
I think there is suspicion among many that the family started the bleeding by not following post op instructions, and then not informing staff quickly enough once the bleeding had become profuse. I suspect that by the time they were calling for help, she had already stopped breathing.
Perhaps you can clarify something. With a surgery like this, is standard procedure to move the patient to the recovery area, or to the ICU? My guess is that she was in the recovery room, or in a room, until she coded, then was moved to the PICU.
However, this is all just total speculation.
@Dave-Are you aware that Jahi grandmother is an LVN, but has been referred to as an RN? Are you aware that the grandmother said SHE, AND Jahi mother AND stepfather were suctioning the blood? I do NOT for one second believe ANYONE employed by CHO handed the family a suction device to use. What I do believe is that a suction device was already mounted to the wall in the room, and Granny took it upon herself, as a “nurse” to suction.
Did you hear that there was a father in the room with his child in the PICU, and he witnessed Granny AND the mother giving Jahi bites of their Big Macs, after the surgery? Jahi was also supposed to be not talking, and the mom said on video that she was “laughing and talking after the surgery.” The father of the other child also said there were around 15 people in Jahi’ room, while he and his wife had to take turns in the room with their son.
It’s incredibly sad that a child is gone, BUT it’s just as sad that a facility is being drug through the mud AND is bound by HIPAA to stay silent. WHEN is someone going to stand up and demand that this child is buried? She is a corpse. WHY is the family allowed to keep her at home?
Usually they are in the recovery room. And yes, Oakland Children’s Hospital is one of the premier children’s hospitals in the country.
@Blanca – I had heard these stories, but have not been able to find actual sources for them. Can you point me to any public statements by the grandmother or the father that corroborate these stories? So far, all I’ve been able to determine is that these are hearsay, and have not been able to find the actual quotes from these individuals.
Thanks.
Christopher, here is the source for the mother’s account. It is an “open letter” that was published in the news on 12/21:
http://www.ktvu.com/news/news/local/open-letter-mother-jahi-mcmath/ncRkn/
The Grandmother’s account: http://www.dailymail.co.uk/news/article-2532210/I-told-OK-Grandmother-devastated-final-words-teenager-moments-routine-tonsil-operation-left-life-support.html
The odd thing here is that the grandmother states they were in the PICU when the bleeding began…
‘I was with her [when] the complications began, when the blood started to come out of her mouth. I was the one holding her hand and reassuring her that everything was going to be OK.’
‘She said ‘’Grandma this hurt so bad” and I said everything would work out and it hasn’t.
Mrs Chatman, 50, a grandmother-of-four, said that when the complications began she told the nurse to get a doctor, but claimed that no one took her seriously enough.
She said that it was only when she noticed that Jahi’s vital signs were slipping away and she shouted across the intensive care unit that any proper action was taken.
By then it was too late for a crash team to resuscitate her in time to stop devastating brain damage – damage so severe that the hospital wants to turn off her life support machine because it claims there is no chance of her recovering.
Here is a comment from this blog: http://frederickleatherman.com/2014/01/03/liability-issues-for-the-death-of-jahi-mcmath/
@Christopher, I wonder if you have a comment on this.
In my experience, it is standard of care for children undergoing this type of surgery to correct obstructive sleep apnea to be observed at least overnight in an intensive care unit post surgery – specifically because they are at higher risk of post-operative complications.
Her presence in the ICU does not imply a mistake was made. There are indications that she had multiple risk factors for complications, including OSA and obesity. Diabetes, if she did indeed have this condition, would be an additional risk factor. We know very little about the true medical facts of this case, but enough has been acknowledged by all parties to conclude that this was not a “typical” or “routine” tonsillectomy.
The speculation that the anesthesiologist or surgeon must have done something wrong is absolutely specious and shows a lack of knowledge of the risks inherent in this type of surgery. There is no such thing as a surgery without risks. Excessive and life-threatening bleeding is a known complication of this procedure.
Additionally, it is also completely incorrect to assume she would have had to be still intubated. Frequently, someone undergoing this procedure would be extubated in the post-operative care unit, before reaching the ICU.
It is also incorrect to assume that she could not have had an endotracheal tube because it would obscure the operative site.
One can be nasally intubated, for instance.
@Christopher, this is the family’s account from their court filing. I wonder if this makes any sense to you whatsoever, given standard practice.
http://www.contracostatimes.com/news/ci_24819771/document-appeal-describes-jahi-mcmaths-post-surgical-bleeding
Ms. Jahi McMath, 13, is a patient at respondent Children’s Hospital, California. On December 9, 2013, she underwent an elective tonsillectomy and adenoidectomy. Dr. Frederick Rosen was the operating surgeon and Dr. Thi Nguyen is McMath’s pediatrician. Originally the surgery was uneventful and McMath awoke from sedation in the recovery room speaking with her mother, Petitioner Latasha Winkfield asking for a popsicle. Not long thereafter, McMath was taken to the ICU and her mother was told to wait several minutes while they fixed her IV.
After being told several times that it would just be another 10 minutes, approximately 25-45 minutes after McMath was brought into the ICU, Winkfield went back and found her daughter sitting up in bed bleeding from her mouth. It was evident that this had been transpiring for some time. The nursing staff said “it was normal” and the mother stayed bedside as the bleeding grew increasingly worse. The nurses gave Winkfield a cup/catch basin for McMath to bleed from her mouth into. Winkfield asked for assistance and was told that this was normal and was given paper towels to clean the blood off herself and McMath.
The bleeding intensified to where copious amounts of blood were being expelled from McMath’s mouth and then nose. McMath’s stepfather was also present and assisted in the attempts to stem/collect the blood.
Again, Winkfield asked for assistance, and a doctor, and was only given a bigger container to collect the blood and later, a suction device to suction the increasing volume of blood. The stepfather continued to suction while the mother went and got her mother, a nurse, to take over for her. The grandmother saw what was happening and made multiple requests, and then a loud demand, for a doctor.
McMath shortly therafter suffered a heart attack and fell into a comatose state.
Hi Dave:
Regarding the location (PACU vs PICU), etc. I was unaware from the news reports as to where her deterioration happened. I had assumed it was in the PACU (recovery room) but apparently she had already been sent up to the PICU.
Where a child such as her would have been observed overnight would vary depending upon the institution. That is, the relative capabilities of a hospital’s pediatric floor, intermediate care unit (if there is one, often called progressive care) and the PICU. It would be perfectly appropriate for a child like Jahi to plan to spend the post-operative night in the PICU. Really, a lot depends upon local practice. So admitting her to the PICU post-op is often routine.
It is also correct that it would be highly unusual for a child like Jahi to come to the PICU still intubated — typically the endotracheal tube is removed in the operating room when the child awakens from the anesthetic.
@Christopher, so, given that she was probably in the PICU, is the family’s account of increasing blood flow first from the mouth and then from the mouth and nose credible, given the typical level of attention and care given in the PICU? Is it credible that PICU staff responded to continued and increasing blood flow by giving the family a larger container, paper towels and finally a suction unit?
That seems utterly fantastic to me.
I can’t help but speculate that the family violated post op instructions, caused the bleeding, tried to stem the bleeding on their own, and didn’t call for help until Jahi stopped breathing. That is the only scenario that makes any sense to me.
Dave:
I guess all I’m willing to say is that details of the events are still unknown to us. Hospital records would show all those things you ask about, because PICU nurses are pretty compulsive about documenting things, but we don’t have those.
My main reason for posting my essay was to clarify what brain death is and how we determine it, since in my experience many people are confused about that.
We probably never will know the fine details of this case.
@Christopher, thank you very much for your willingness to discuss this. It’s been very enlightening.
Best,
Dave
Thank you so much for providing in laymen terms the process that is required to determine brain death. It is clear and succinct and easy to understand.
Ann
I haven’t read all the comments above, but I am very familiar with this case. I have questions. First of all, my daughter was declared brain dead for three days without any treatment for the brain injury. The doctors came in did all the bed side tests and just kept saying she was brain dead and refused to do a cerebral blood flow test or an eeg because they said she was dead determined from exam. Well, a respiratory therapist said all you need to do is turn down the O2 and see if she takes additional breaths. Sure enough she took more breaths than the ventilator was set for. This is three days after her accident and a repeat CT then given showed a midline shift when there was none on the first CT on the day of her accident. What I am trying to say is to declare someone brain dead right away is dangerous, a deep coma doesn’t have reflexes as with my daughter’s case. She now walks with assistance and can eat thickened food, but is very disabled. I can’t help wondering if they treated her brain injury promptly she would be less disabled. If the brain stem controls heart beat and the hypothalamus controls body temperature, why would someone be considered brain dead when these functions are still working? My daughter is not the only person declared brain dead when not. There are many documented cases. Don’t you think the guidelines should be changed?
Hi Vivian:
Thanks for your note. I have a couple of thoughts. First, if your daughter was declared brain dead but breathed, that is just wrong — the doctors didn’t know what they were doing. But I do think the change I would make in the criteria is to require a brain blood flow study in all cases. I always do one, although most hospitals list it as optional, or “confirmatory.” In my opinion, the cases you hear about similar to your daughter’s happen when people doing the bedside test don’t know how to do it properly and there is no confirmatory blood flow test.
Regarding the EEG, that is not helpful for brain death determination for a couple of reasons. The first is that the sensitivity of the machine needs to be turned up so high that there can be interference from other things. The other is that the EEG measures cortical activity, what is going on over the surface of the brain. A person can have a flatline EEG but still have brain function deeper down.
I’m sorry to hear about your daughter’s experience.
@Christopher – I noticed one of the observations in the court-appointed neurologist’s exam notes was “electro-cerebral silence”. Apparently he also did a blood flow study, or one was done. “No blood flow in brain.” These are listed as “ancillary testing” on the “Brain Death Examination for Infants and Children” that was attached to his notes. (from the link above).
One thing that puzzles me – in his notes, he says, “irreversible brain injury, and non complete absence of cerebral function and complete absence of brainstem function…”
Why would he say “non-complete absence of cerebral function” (unless I’m misreading his notes)?
http://media.nbcbayarea.com/documents/Fisher+-+Redacted+Rpt_1.pdf
Dave:
I realize you are very interested in the details of this case, but I really don’t want to get into second-guessing the language of clinical notes.
@Christopher – OK, I appreciate the information and analysis you’ve done.
Just FYI, though, those notes and the brain death examination were conducted by court order by a court-appointed neurologist to confirm the declaration of brain death. The notes and the brain death examination checklist are in the public record.
Best,
Dave
Why doesn’t anyone know where Jahi McMath was transported to ? What kind of “facility ” would accept a person declared dead ? Organs failure sets in….it gets nasty. I have had adult patients declared brain dead on vents in the ICU and they start to look worse for the wear in a matter of days….I can’t understand why this was allowed by the judge. How can a family remove a body from the hospital ? And again…where is she ? Where are the questions ? In my mind, I believe this has become a criminal act.
Dave: Dr. Fisher’s note says “now complete absence. . . “
That would explain it all quite easily, and it makes sense.
Here is a video of the grandmother’s version of events from HLN. Around 1:40 she mentions the suctioning. Very suspect. Especially how she mentions it and then doesn’t finish the sentence and quickly says something else.
http://www.hlntv.com/video/2013/12/18/grandma-just-pray-jahi-please
@George, thank you. That makes total sense.
@LeeAnn – I’m not a lawyer, but as I understand it, the initial restraining order was granted in order to allow the family time to obtain confirming examinations by “outside” neurologists. They tried to have their own personally selected doctor appointed but he was rejected by the court. They were then granted an extension because they filed multiple appeals in multiple courts. It was really messy, but frankly, it was a mess created by the family. If you want a really good, clear timeline and legal analysis go here: http://sprocket-trials.blogspot.com/2014/01/legal-history-of-jahi-mcmath-case.html. I think the judge’s hands were basically tied by the legal maneuverings of the family’s @#$@ lawyer.
Thanks Dave. The family sounds like a hot mess. I do not believe that any PICU nurse “instructed ” the family members to suction Jahi. If they took it upon themselves to really do that, then the suctioning could very well have set off this tragedy. A healing clot could have been dislodged, and in that airway, what a disaster. We probably will never know what really happened though. Not for a long time.
I absolutely believe this child has been dead as of December 12, 2013. However,I absolutely believe members were virtually ignored when they brought the early incidence of extraneous bleeding to the nursing staff. As much as I’d like to hope that no nurse handed the grandmother a suction wand with instructions to “suction her”, I’ve been a registered nurse for 34 years and I’ve seen some awful judgment calls by nurses and physicians. If the family was behaving loudly and/or boisterously and had more visitors than was recommended, it is highly likely that the staff were agitated with them and may have casually dismissed any concerns they voiced. I’ve seen that happen dozens of times in my 34 years of employment. We all have opinions, but we obviously don’t know exactly what happened. Medical records are frequently altered and sometimes purposely lack information that might indicate negligence or maltreatment. “Real-time” entries are changed to benefit the author. The family may be kooky and the hospital may be stellar, but that doesn’t mean that something awful and completely unnecessary did not happen with Jahi’s post-operative care. I hope that any minute now, the family will realize Jahi is not coming back and will plan a beautiful memorial service for her. But I do not, for one second, believe that Jahi’s medical management was top-notch or that this situation was handled properly from the start.
Your assessment may be correct. I, too, have seen that sort of thing happen, although fortunately without a fatal result. Perhaps we will know eventually, perhaps not.
Truthbeliever: as a practicing physician for 34 years and no little ICU experience I have never seen ICU nursing staff act in a casual manner when visiting family become agitated over medical events, particularly in an acute postoperative setting. You realize that you have heard exclusively from the family in this matter, and, as noted above when the grandmother slipped on her live interview and admitted performing suctioning, there is high likelihood that family intervention provoked this scenario. CHO uses the EPIC electronic health record system; any alterations are date and time-stamped with the ID of the person making the change, and revised records are preserved. There are also contemporaneous written records, such as Dr. Paul Fisher’s assessment of brain death on December 23, that are later scanned in. Are you implying collusion among the nursing and medical staff to record fraudulent findings when you say “real time entries are changed to benefit the author?”
George, I said exactly what I meant. I have not heard exclusively from the family. As a matter of fact, I’ve not seen or heard any of the commentary the family has given except what has been written on sites such as this. I stated I absolutely (neither do you) know what happened (unless, of course, you were present for the entire ordeal). My surmisings are my opinions, as are yours. As a hospital employee I’m very familiar with the electronic health record system- I use one on a daily basis. Addendums ARE made and notes added regularly. Also, there is nothing in my note that questions any findings regarding the date and time brain death occurred for this young lady. I don’t know what (neither do you unless you were there) or where something went wrong. I am not implying, but rather, stating implicitly that nursing and medical staff are not above documenting in such a manner that withholds or skews certain information. I have worked with many nurses and physicians over the years. By far, most are honest and aboveboard and genuinely have their patients’ best interest at heart. But if you think that I have not witnessed callousness, prejudice, classism and religious persecution on the medical ward, you are greatly mistaken. Just like not all patients are not wonderful, tenderhearted, intelligent public servants, neither are all physicians and nurses. The medical field inherently draws narcisists. And your opinion is of no greater merit than mine.
Truthbeliever: your quote: “However,I absolutely believe members were virtually ignored when they brought the early incidence of extraneous bleeding to the nursing staff”. Your basis for this assumption can only be from family commentary, through their attorney, or as given on their numerous media appearances (unless you were personally present). Dr.David Durand as chief of Pediatrics has repeatedly requested permission from the family to address issues not violating HIPAA regulations, and has been repeatedly denied. My opinion is that this will most likely play out in the appropriate medicolegal venue, including reviews by the Dept. of Health, the Medical Board, and the civil suit on file in Alameda County Superior Court. What I object to are unfounded assertions such as your quote that propagate the very one-sided view from the family and tend to stir up a storm of misinformation and mistrust for CHO.
George, my basis for this assumption has nothing to do with anything said by a family member. I made that statement because it is apparent to me that Jahi had been bleeding heavily for more than a very short time, hence the cardiac arrest. Since I was not there, I do not know what that absolute time frame was. However, I am still entitiled to draw my own conclusion. I don’t work under the auspices of anyone involved. You can object all you like, but you don’t call the shots for opinion boards.
You are absolutely right my view is one-sided: I’m one person.
Too, I’ve worked in this field long enough to know that totally unsuspecting people had better have a certain amount of mistrust. As I stated before, I’ve seen what happens in hospital ERs, ORs, ICUs, wards and clinics. I will reiterate, most health care workers are conscientious, but I’ve gone toe-to-toe with some reckless nurses and physicians who didn’t give a shit about anybody but themselves. I’ve loved my years as a nurse. I’ve given far above and beyond what is good nursing care with little or no recognition. I’ve saved a few docs’ asses. And I call it like I see it.
Truthbeliever: again,your quote: “I made that statement because it is apparent to me that Jahi had been bleeding heavily for more than a very short time, hence the cardiac arrest” It is at least equally and probably more likely there was posterior dislodgement of a clot causing abrupt airway obstruction. It’s interesting that your rather exclusionary conclusion is based on no other evidence than family hearsay regarding the timeline, as neither of us has access to the record and a postmortem exam is not going to answer that question now.
George, you are now, and will forever be, correct.
Truthbeliever- As an RN with 22 years of experience, I find your opinions and assumptions frightening, especially coming from a medical professional as you claim. I won’t go into detail here with all the specifics with mistakes in your thought processes, but you did get one thing right…….Yes, George is correct.
What I have found interesting on this blog is to be able to compare the family’s account of what happened to the standard protocols of care in a PICU of a reputable institution like CHO. I appreciate Chris and all the practitioners weighing in. I’m not a medical professional, so I can just say without qualification that it appears to me that the family’s story is largely made up, most likely to hide their at least partial culpability for what happened, as in, “thou dost protest too loudly. But, as had been pointed out repeatedly, we don’t know the actual facts and may never know. Hopefully, for us truth junkies anyway, at least CHO will get to tell its side of the story.
Dave:
We may well never know. For example, if there is a lawsuit that is settled before trial the details will never come out.
Christopher,
What are the reasons that brain dead people, suxh as Jahi, cannot survive long term on a ventilator? I have read elsewhere that her caregivers are giving her the nutrients and hormones that the brain stem normally manages. So it seems that as long as adequate testing is done and the “feedings” are adjusted accordingly, I don’t understand why the body would not live out a normal life span.
In Jahi’s case, Heidi Flori stated to the court that there were signs of Jahi’s decay already underway. So in her case, I would have to assume that her life on the ventillator is going to be less than someone without these problems. Is this a reasonable assumption?
It also seems that her care givers could give Jahi cranial MRI to see what’s there. If it’s nothing but mush due to autolysis, then that’s absolute proof that she was not misdiagnosed. I don’t see how a family could possibly dispute facts like that? But I see how a family could be confused by movement due to Lazerus(sp?) effect. It’s understandable how a family could mistake increases in Lazerus movements for “getting better.” Thank you for the descripion about brain death
Hi Jeff:
I can’t answer your question precisely but I can give you my experience. In theory, you’re correct, the body should be able to go on indefinitely without the brain. In practice, though, things just seem to fall apart. It’s far more than just the ventilator. When I was involved with the case we kept going for 6 weeks there was a cascade of daily problems — electrolyte disturbances, intestinal issues, liver issues, and others. As one example, virtually all brain dead people develop diabetes insipidus, a disorder of water balance from the lack of vasopressin, a hormone. Yes, we can give vasopressin, but it’s not the same. Other details arise nearly daily. It’s complicated. My own hand-waving way of explaining this is that the brain does many things to the body, interacts in many ways, that we just haven’t discovered yet. Not an answer, I know, but that’s how things generally go.
You’re correct about the MRI. They could do one and I expect the images would be dreadful. But I don’t know if that would affect the family’s decision more than the brain blood flow study.
There was one case noted in the Japanese medical literature of a brain dead individual maintained on ventilator and pressor support for 165 days, finally dying of cardiac arrest. Interestingly, they continued to document automatisms such as foot withdrawal and hand movement for much of the time. So, prolonged support is certainly viable. Is it tantamount to supporting “life”? Reasonable people would say no.
Additionally, with continued ventilator support, the individual may develop a form of positive pressure barotrauma. Normal breathing is a negative pressure exercise, and continued positive pressure from a mechanical ventilator will eventually cause complications related to alveolar and bronchiolar damage. Some subjects may be more resistant to that type of trauma.
That’s true, George, but a lot depends upon pulmonary compliance. If the lungs are not stiff there is very little barotrauma. I’ve ventilated children for many months, as have most pediatric intensivists.