Sunday, February 23, 2014

Jahi McMath: Poster Child for Medical Futility, or Scapegoat?

I periodically check for news updates on Jahi McMath, and today I found this news report that suggests that Jahi McMath is still alive, or at least that her heart is still beating, more than two months after she was declared dead on the basis of "brain death."

Based on the commentary on previous posts here and on PCCMcentral.org debating this issue, I can say the following:
  1. Jahi McMath is legally dead on the basis of an incontrovertible and unequivocal diagnosis of brain death.  I have no doubts in this regard.
  2. Jahi McMath has a beating heart and thus is not considered to be dead on the basis of the intuitions and opinions of her family and some others.
You may choose #1 or #2 above.  I personally don't care how you choose.  But I'm interested in the differences in reasoning and opinions among those who choose #1 and those who choose #2.

In the last month, I have dealt with two brain dead patients.  Both had organs harvested for donation, and thereafter, there was no distinction between #1 and #2.  Brain dead patients fulfilling the criteria for #1 entered the unequivocal realm of #2 after their organs were harvested.

And in the cases of both of these patients, we kept the patients "alive" for several days after the declaration of brain death, for two reasons:
  1. To allow their families to "come to terms" with the end of the life of the index patients; and
  2. To support their organs, to wait to see what the kidneys would do, to give "treatments" to normalize metabolic and physiological parameters to see what would happen to the physiology of the organs (to determine their suitability for transplantation) and the organism "sans brain"
So I beg you, dear reader, to tell me what is the difference between the two cases I have recently cared for and the case of Jahi McMath?

Since you may be struggling, allow me to answer:
  1. Allowing the families to come to terms with the end of the life of the brain dead patient entails a certain amount of time and patience
    1. If we're going to harvest organs, the amount of time becomes a flexible thing, something that we're willing to compromise on as a courtesy for the privilege of harvesting the organs
    2. Regardless if whether we harvest organs or not, we will allow a certain amount of time for the family to adjust, but we get to decide if that amount of time is reasonable.
  2. If "real death" were to supervene before either of the above issues were resolved, and the heart were to stop beating, there would be no further arguments relating to the above two issues.  The patient is unequivocally dead by all accounts.
So, if it's the last situation and the heart stops beating, we have no possible difference in opinion.  But if it's any of the other cases, there is indeed a certain amount of time that is necessary for the family to adjust to the concept of brain death.  And if organ harvest is not part of the equation, as it was not in the case of Jahi McMath, the idea is that "yeah, the family needs some time to adjust", but we get to decide what is a reasonable amount of time.

Even if I were to accept that paternalistic view, as I might be inclined to because I believe in paternalism to an extent as do other commentators, I would then make a logical extension:  I can also decide, paternalistically or unilaterally, or by medical consensus, that any number of other patients is basically a corpse, with no hope of "living" whatever that may mean, outside of the context of advanced life support that keeps air going in and out and blood going round and round.  And as I have previously opined, those patients, who are not brain dead, far outnumber those who are brain dead.

Let's stop hiding behind the legal concept of brain death, and stop using Jahi McMath as a scapegoat for all the frustrations we all feel about futile medical care.

4 comments:

  1. In China they harvest organs at the firing squad. In the US they harvest organs with a pencil on your medical chart.

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  2. Coming from a country where brain death isn't legal death, I felt pretty silly that people making such big deal about this case as if we will have brain dead patients everywhere in the US. As you said, brain dead patients are rare to start with, a situation like Jahi must be extremely rare. I know a few kids living like Jahi in my county, and they are very very rare. Another thing is that such kids may leave hospital and come home with the vent, like Trilogy100. One of parents of brain dead children mentioned in her blog that her brain dead child has fought some minor illness and pneumonia in the past, but recently she's been so healthy that she hasn't even been hospitalized the past few years.

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  3. Sounds like time for all those brain dead organ meltdown theorists to eat humble pie

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