Want to Do Hospital Committee Ethics? (2): Ventilating the Dead
FACTS:
The ICU of the hospital is filled to capacity and there is a patient with a myocardial infarction who is awaiting a bed there. One of the patients already in the ICU for the past 2 days is J.W., a 34 year old white male, who lives at home with his widowed mother. There are no other family members. The patient suffered a ruptured aneurysm of the brain with massive bleeding into the brain and is totally unresponsive, cannot breathe without the ventilator and meets all the criteria for death by neurologic criteria (“brain death”). The patient’s physician and a consulting neurosurgeon has told the mother that even though the patient’s heart is still beating for a while if the ventilator continues to work, her son is dead and the physician is going to write an order to stop all treatments including the ventilator.
THE ISSUE: The mother rejects the conclusion that her son is dead and says that he is warm and pink and “breathing” and that he is still alive and may, if the treatment is not stopped, have a chance for a miracle recovery. She says that under no circumstances should the ventilator be stopped and if necessary she will take her son home with a ventilator. She says she can arrange for him to be cared for at home. The physicians call for the hospital ethics committee to meet and the plan of the committee is to have the physicians, attending nurses and the mother sitting together in a quiet room to discuss the issue with the committee.
THE QUESTIONS:
What should the ethics committee first hope to hear from the mother?
What should the ethics committee ask the mother?
What should the ethics committee ask the physicians?
What ethical issues should be considered?
What other information should the physicians or ethics committee relate to the mother?
What should the ethics committee consider as a reasonable and ethical outcome decision to be made by the physicians and the mother?
If you would be sitting as an impartial ethics committee member what thoughts would be going through your head? ..Maurice.
posted by Maurice Bernstein, M.D. @ 10:24:00 AM
9 comments
9 Comments:
I think that any "directives" must be in writing and properly recorded. A verbal directive shouldn't hold any water when it comes to matters of life and death.
A parent is forever a parent. If there is no written proof from the patient as to how they wanted to be treated in such a situation - the parents should be able to make the decision regarding care. If they can't agree - the decision should be made by any immediate family, if none are available, the doctors.
If he were married - that decision should pass to the wife, then the children - unless they divorced or had no children - then the parents gets the decision back. Teri Schiavo should have been allowed to be cared for by her mother.
If it is a child under the age of 18 - the parent makes all decisions - even if the child says they want to commit suicide and die and is "rescued" before they die. (this opinion is based on the current age considered an adult)
If there are no parents - the decision passes to the immediate family (brothers and sisters over 18, or grandparents). If there is a chance that a relative desires to care for the patient - let them.
If it is an infant of a child under age 18 - the grandparents of the infant if any - get to make the decision.
If the grandparents disagree about pulling the plug and one is willing and able to care for the infant - let them.
If it is a parent without a spouse - the children have the right to make the decision. If one is willing to care for the parent - let them.
All effort should be made toward choosing life and allowing the patient to be cared for by any immediate family, spouse, grandparent, or child who is willing and able.
If no options are available - let the patient die without pain and with dignity.
Death in some countries, even by one's own hand as in suicide, is considered honorable, particularly when the person who wants to die feels they have become a burden in some way, or have shamed themselves in some way.
The living family members talk about it as if the person did the honorable thing as well. They are proud of their family member for doing that. It's hard to describe.
If someone is dying of cancer and has decided they no longer want to live - let them go - and give them the ways and means to do it in a dignified, graceful and painless manner.
Death is not necessarily a bad thing when life has become like death itself.
I am not sure whether this comment by Anonymous is related to this current posting or the previous one regarding the withdrawal of medical nutrition and hydration or just a general comment about termination of life support.
The listing by Anonymous of the potential surrogates if the patient has no capacity to make their own medical decision is similar to what is in effect in most states of the U.S. However, usually the spouse is at the top of the list.
With regard to the issue "Ventilating the Dead" of this current posting, the issue is not so much who is the surrogate or what is stated in the Advance Directive, it is whether a person who is legally dead be continued to be ventilated for an unlimited time.
By the way, hospitals may continue ventilation in patients who are dead by neurologic criteria in order for family members who are not located in the area and who need time to arrive to see the "warm, pink" body before the ventilation is discontinued. Usually, the time limit is set at a few hours at the longest. ..Maurice.
As I understand it, if a patient is determined to be "brain dead" i.e. no brain stem response to carbon dioxide build up (apnea challenge with the ventilator turned off) then they are considered to be legally dead and as such the rights of the patient end. Life support may continue until the family has a chance to say good bye (or until organ donation) but the family has no more right to demand that life support be continued in this context anymore than they can call 911 from the funeral home and demand that the patient be brought back to life. An ethics committee meeting in this case is not appropriate because the situation is clear (the patient is brain dead) and the appropriate path is evident (to discontinue life support). Such a meeting should involve the hospital patient/family advocate, a councilor, and a pastor (if appropriate).
That there are patients waiting for this bed should not play into any of the decisions or the timeline of carrying them out. The awaiting patients can be triaged to other facilities.
This mother is suffering a horrendous loss and must be allowed to grieve. We live in a time when the definition of death is changing to one of brain death from cardiopulmonary death, but the transition hasn't made it out of the medical community yet. Most of the American public still considers death to be when the heart stops. It may take time, but grief knows no timetable. Before bringing out the big guns (ethics committee) this woman needs spiritual and psychological support. Gentle insistence that her son is dead, validating her loss, showing her the evidence will more times than not allow her to make it through the denial. Once she admits this son is gone she is truly alone. She has no one else. We cannot force her to accept this harsh reality. As a healthcare worker, I need to make sure she has some hope. Somehow, I must help her move that hope from one of recovery, to one of seeing a life for herself beyond this tragedy.
Two points I want to make. First is that in a situation as the one I presented, an ethics committee meeting with the mother and physicians and nursing staff is indicated and is essential. The purpose of the meeting is to educate all about the current established law and ethics about death by neurologic criteria. It is true that there are still many of the public who don't understand or agree with this pronouncement of death. Not just the lay public but also some nurses and even some physicians find difficulty accepting this way of establishing death. Part of the problem was the history of how this concept got started; as a means to provide a new and more physiologically reliable resource for organ transplantation beyond patients who were dead by classical criteria.
In addition to education, is the matter which Nurse Margaret presented, and that is the need to provide some emotional and spiritual comfort to the mother. Ethics committees, with their multidisciplinary members including those in spiritual care are prepared through their learned skills and experience to do that. Physicians, alone, may not have the time or their own comfort to do that effectively.
With regard to what Nurse Margaret wrote about "patients waiting for this bed should not play into any decision or timeline.. the awaiting patient can be triaged to other facilities", I would disagree. Whereas physicians fiduciary responsibility is for the patient they are treating and concern about scarce resources or resources for use by others should be secondary, when a patient is dead and a resource is being used which should go to a living patient, insistence in allocating that bed and ventilator to the deceased is irrational and unjust. A myocardial infarction patient dying on the way to another institution or dying because being assigned to a ward with limited skilled observation is intolerable professional behavior. Anyway, these are my views. ..Maurice.
This is not meant to be flippant, but I would just be thinking "the guy's dead."
19 years ago this last October, my brothers and I were in the same position with my father. He had suffered a massive stroke, and required a ventilator to breathe. He never regained consciousness.
What you've outlined is pretty much what happened. We were given less than 24 hours to pull ourselves together, and he was unceremoniously unplugged.
For the last 19 years, his death has haunted me. I know he was gone ... and I also understand that we had to let him go, but giving us the time to let the realization sink in, allowing us, as individuals, to work up the courage to admit he was gone - alone, without the abrasive intrusion of strangers at such a difficult time - would have helped prevent 19 years of nightmares ... which I expect will probably continue until I follow behind him.
Some doctors realize that when they're faced with such a situation, they have more than one patient on their hands, and emotional callouness is no less harmful than physical roughness ... and it leaves just as many scars.
People who are feeling raw and vulnerable can be intimidated into doing something they're not emotionally prepared to face, especially when pressured by medical professionals - it might be expedient, but it doesn't make it right. An extra few hours ... or maybe even a day, some privacy, gentleness, can make a tremendous amount of difference.
You may have to treat the same condition differently in different patients in order to effect the best results ... well, it's not only our bodies that work that way. Your brusqueness may cause some lasting damage ... that just a little bit of patience and forebearance could have avoided.
Moof,you have, through personal experience, brought out an important issue and I agree with your comments. What all healthcare workers need to remember when they are dealing with a patient who is newly diagnosed as dead by neurologic criteria ("brain-dead")is that there is a strong need for compassion for the feelings of the family at this time. There is no need at that moment to be concerned about the patient but great need to be concerned and give attention to the family. It is at this point where there should be a practice of brief "compassionate delay" in removing the previous life supporting therapy until the family is fully informed about the declaration of death and the rationale to disconnect and they have time to express their feelings both to the physician and nurses and to their deceased family member. In addition the family at this time should be provided with spiritual and social service resources as appropriate. Thanks for your insight. ..Maurice.
Since when has the doctor been declared God? At NO time should a patient or patient's family be shoe-horned into making a DEATH decision. When my mother was in the hospital, [Mod.note: hospital name deleted ]KILLED no less than 5 patients. Some were definitely recoverable! I am horrified as how easily you can try to change the definition of death. No one know exactly how the brain works. Only 2 months ago, Scientific American, produced a new test to try to detect brain death and as cutting edge as it may be, it is NOT CONCLUSIVE. Don't be tricked. No one should be forced to kill another against their will. There are more horrifying things occuring that Terri Shiavo. Look at Andrea Clarke and then think of where it all ends. Perhaps your organs should be harvested now. You are ALWAYS in a state of dying since the day you were born. Why wait? I sarcastically suggest they harvest your organs now. There are those that are not so sarcastic and truly mean to hurry death. Next, we will be overpopulated and need to kill off folks. Its already happening with the handicapped, retarded and elderly. Yes, open your eyes! Folks are being withheld the simple treatment of antibiotics to hasten their death because somebody thought they were not worthy of living. I say, KILL ETHICS COMMITTEES! They should ONLY exist to oversee the sloppiness and mistakes of their staff, not to be the faceless committee of DEATH! I should know, I have been involved with ethics committees for months. BEWARE, you could and most probably in the future can expect to be next!
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