Bioethics Discussion Blog: February 2007





Sunday, February 25, 2007

Should Families Be Invited Into the Healthcare Team Treating ICU Patients?

The way I see it, as chair of my local community hospital’s ethics committee, is that most of the conflicts between patient/family and the medical care staff has as its basis the need for better communication. The problem is that patients and families don’t know and understand what the doctors are knowing, understanding and communicating with their colleagues and the doctors don’t know what the patients/families want to know or how they feel because they are not told or, in fact, the doctors are not listening. It seem that there are two distinct groups involved: the patient and family on one side and the healthcare team on the other. A solution to the problem would be that the patient and family could all be together on the same team, meeting together, communicating together, all being aware of the current status and changes and finally making decisions together, in essence working together to the benefit of the patient,

It is in the hospital intensive care unit where many of the conflicts arise. It is there where the patient is usually critically ill and may be dying, unresponsive or poorly responsive to communicate wishes or make decisions and where the family plays an important role of a surrogate in understanding the clinical situation and decision-making. And it is here where often the conflicts arise which comes to the ethics committee.

An important article in the February 2007 issue of Critical Care Medicine titled “Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical
Care Medicine Task Force 2004–2005” is summarized by Medscape Internal Medicine. The consensus of the task force was supported by reviewing evidence-based studies in the literature. The conclusion was that "Including and embracing the family as an integral part of the multiple-professional ICU team are essential for the timely restoration of health or optimization of the dying process for critically ill patients …Support for the psychological and spiritual health of the family is an essential component of patient-centered care for the critically ill.” Some 43 recommendations were presented and Medscape noted the following examples:

Endorsement of a shared decision-making model rather than unilateral decision making by the clinician, which might decrease family stress and help families to cope.

Early and repeated care conferencing to reduce family stress and improve consistency and cultural sensitivity of communication, using terms that the family can understand. Improved communication may also increase the use of advanced directives.

Honoring culturally appropriate requests for truth telling and informed refusal.

Spiritual support, encouraging and respecting prayer and adherence to cultural traditions, which help many patients and families to cope with illness, death, and dying. In addition to formal spiritual counseling by a chaplaincy service, educated members of the ICU staff might help to accommodate the spiritual traditions and cultural needs of patients and families.

Education and debriefing of staff to minimize the effect of family interactions on staff health.

Family presence at both rounds and resuscitation, which might help families cope with the death of a loved one in the ICU.

Open, flexible visitation.

Way-finding and family-friendly signage.

Waiting rooms that are close to patient rooms and that include family-friendly amenities.

Family support before, during, and after a death.

Symptom management and family involvement in palliative care processes to improve ICU care.

I know that the suggestion of integrating the family into the healthcare team with participation in clinical rounds (where the multidisciplinary clinical members gather together near the patient to evaluate and discuss the patient’s current condition and further management) and observation of resuscitation is controversial amongst the physicians and other hospital staff. I wonder what are my visitors opinions about the conclusion of the task force and the need to implement the suggestions that were made. ..Maurice.

Friday, February 23, 2007

Brain Death: Is That Dead Enough?

<b>UPDATE:And now it is June 7 2020 in the midst of a world-wide COVID-19
 pandemic and again what appears
 to be a class of students from the Riverside County California
 have come to this blog thread to read the long, long
 list of pertinent comments regarding brain death. Unfortunately,
in these pandemic days with numerous patients
 requiring ICU and pulmonary respiratory care, there
becomes many, many clinical situations occurring which 
demand a determination of brain death and, if documented to
 clinical satisfaction, termination of ventilatory and
 &quot;life support&quot;. A pandemic with a high lethal outcome
and at times of high patient load presents
 another issue.. who truly deserves that life-necessary
 but not readily available respirator? May I suggest that 
those students and others reading this blog thread in this very unusua
l time of pandemic medical
 &quot;chaos&quot; take time to participate by contributing comments
 on this more pertinent topic.</b> 

Beginning in 1997 and continuing until 2004 when my "Bioethics Discussion Pages" became inactive, I have received numerous comments on this issue of the significance to the public of the term "brain death" and the application of the medical criteria associated with the term to various decisions including organ procurement for transplant. Since "brain death" or currently used term "death by neurologic criteria" is still a not easily accepted concept as compared with death after the heart stops beating, I though I would transplant the subject here to my blog to get some views from my visitors here. Most recent comments from the "Pages" are at the top of the page. ..Maurice

Brain Death: Is That Dead Enough?

It is now considered by the medical profession and supported by legal and some ethical consensus that if a person's entire brain is dead, the person is dead. The reason is that if the entire brain is destroyed, there is absence of spontaneous breathing and expected cessation of heartbeat soon. It is on the basis of this concept that all life support treatments which the patient may have had in place before brain death has been established can be removed because the patient is now dead. It also provides the opportunity to obtain organs from a brain dead patient, who had previously given consent, while the organs are still in good condition for transplantation. Families of a brain dead patient may have to be educated about the physiology. However, some religious groups and even some healthcare workers are uncomfortable with a brain death definition of death since the patient may still have a heart beat and wish to wait until there is persisting absence of heart beat, the classical criterion.
Here is the question:
What do you think about brain death as a criterion for death and how do you look at the implications of such a criterion?


Date: Mon, Apr 19 2004 19:17 AM From: To: DoktorMo
Am I second year nursing student and so far I've been luck not to be involved in a brain death situation. But if a person is on a ventaler then I do believe if they cannot live without this help then I would personally say they are brain dead, if a member of my family where ever in this situation I would have to say the same thing. Helena

Date: Sat. Mar 13, 2004 5:27 PM From: To:
I've been in the medical field for 11 yrs. If a pt. has been confirmed "brain dead" through tests such as EEG, apnea test, etc. The pt. has no chance at surviving without ventilator assistance, multiple meds, and tube feedings. They have no quality of life left. Realizing that it is a very difficult decision for the family members to make regarding discontinuation care, but in the long run many headaches, and sleepness nights will be saved. Not to mention, the family feuds and enormous medical bills that can accrue. Just my thoughts.

Date: Wed, Sep 24, 2003 10:14 AM From: To:
I work as a nurse in an Intensive Care Unit. Over the past two weeks, I have seen three young men with massive head injuries resulting from motorcycle crashes. Although one has made it through so far, the other two are still on life support with a clinical diagnoses of being totally brain dead. I have to perform my job duties to fulfill the wishes of the patient and family. However, if I were ever in this situation as the patient or a family member, I would feel that being totally brain dead would classify as being dead. If a patient with this dx had not been rescued soon enough to be put on a ventilator than nature would have already taken its course and the patient would have ceased all respiratory and cardiac function. They would have still been dead. So to answer the question is brain death dead enough; it is for me. Thanks for allowing me to post my own opinion. Rene

Date: Mon, Sep 1, 2003 4:42 AM From: To:
Our son was determined to be brain dead in 1993. Like most families in this situation, we had only a surface knowledge of brain death. The surgeon explained the process he would use to determine brain death. He said that if our son showed even a slight reaction to any test, he would not be considered brain dead. The worst happened. We donated our son's organs in an attempt to derive something good from a terrible situation. We were told that our son was a perfect candidate for major organ donation. His brain stem had been crushed in an accident but he had no other injuries. He was on a ventilator. As you are probably aware, the patient is kept alive on a ventilator until all of the organs have been removed. This is done in a specific order with the heart being taken last so that the patient's blood continues to flow through all organs until the moment of removal.
A few years later there was a dispute in England among anethesiologists because of the reaction of brain dead patients during the organ retrieval process. Apparently if no anesthetic is used patients react to the pain of incisions by trying to move away from the scaple. At the moment the scalple cuts , the patients blood pressure and heartbeat increase dramatically as well. This is well documented medically but not commonly known by the public. We certainly were never informed of it. Had we been informed we would never have consented to organ retreival and would have let our son die naturally.
I called the organ retrieval team in BC to see if they had used any anesthetic during the procedures on our son. I was told that they do not because the patient would not be considered brain dead if anesthetic were neccessary. The procedure would be considered euthanasia, which is illegal under Canadian Law. They acknowledged the fact that patients do react during the procedure but likened the movement to that of a chicken when it's head has been cut off. You can imagine how this analogy was recieved.
I feel great sympathy for people requiring organ transplants. I can understand the negative effect on the number of organs retrieved, if the above information became common knowlege. As a parent, I feel like I have unwittingly subjected my son to unknown pain. I feel that we were deliberately mislead. The only reason I didn't pursue this legally is because of the devastating effects it would have had on other family members. However that situation will change within the next few years. When it does, I intend to lobby to have this situation corrected.
Deborah Dimitrov,

Date: Sat, Aug 23, 2003 9:21 PM From: To: DoktorMo@aol.comj
When we think of death, we associate a physiological death and a psychological death. If the computers turn unstable, the rest of the warehouse is gone. When a natural brain death occurs, then a bodily death is inevitable, thus resulting in a rooted definition of death.

Date: Sat, Aug 2, 2003 2:40 PM From: To:
The subject question, "Brain Death: Is That Dead enough," says, by the fact that it is asked that brain death is NOT dead enough. At least for those who think the question should be asked, there is doubt, and if there is any doubt, then "that" is not dead enough.
As I read these opinions one seems to thrust itself forward, the one that asserts Philosophy as the best way to find an answer to the question. I agree, and would add that (religion aside) Theology may be of utmost Philosophic value.

Date: Wed, Jun 18, 2003 2:23 AM From: To:
I believe that brain death is not real death because the patient’s heart is still beating and when we touch him or her, we feel his body is warm, which proves they are still alive. Although I don’t consider brain death as a criterion for death, I support the idea that obtaining the organs from a brain dead patient while the organs are still good condition for transplantation. To obtaining the organs from a brain dead patient is to not only help other people but also live in other people as a second life. I have heard that there are many people who can’t live without transplantation. If I was a brain dead patient and my organs were needed, I would be willing to give my organs to those people. I have also leaned that there is a rule that transplantation can’t be held without a brain dead patient’s will and his family’s agreement. So I believe it’s very important for all of us to discuss this brain death matter, whether it should be considered as a criterion for death or not and transplantation. Thank you for your time and attention. Sincerely, Yuka

Date: Tue, Mar 18, 2003 7:33 PM From: To:
Thank you to everyone for interesting, and sometimes heartwrenching, reading. My condolences to those who have learned about brain death through losing a loved one.
I am a neurology professor, so my answer to the question is yes. My reading of the relevant literature is that clinical criteria (supplemented, when appropriate, by diagnostic testing) can accurately identify a situation from which no one has ever recovered. Less scientifically, the concept is so very consistent with my clinical experience. Sometimes, when I’m asked to pronounce a person brain dead, I do, because the many criteria are met, and sometimes I cannot, for various reasons. There is definitely something different missing from someone who is brain dead. I imagine this sounds biased or superstitious, but I would point out that I am not particularly religious. Being at the bedside of an individual who is brain dead does feel like being in the presence of a person who has died by cardiac criteria. Whether one calls it spirit, soul, or something else, whatever it is that makes us human has left.
There was a post asking how careful doctors are in making a pronouncement of brain death. I can’t think of too many things I take more seriously. I have seen the bewilderment in the faces of family members too often not to have a grasp, even if tenuous, of how counterintuitive it must be to have someone there, with a heartbeat on the monitor, yet have doctors say they are dead.
This brings me to my last point. I came across this discussion while doing background work for medical student teaching I'll soon be doing on brain death. I can't begin to say how valuable reading this has been in shaping what I am developing. Part of what I want to convey is what I just alluded to that it is a huge responsibility, and therefore must be taken with seriousness, dignity, and humanity. Your comments have reinforced this, and taught me a great deal more. I am confident it will inform and improve what I teach my students. I am most grateful, and offer my sincere thanks to everyone for sharing their thoughts and feelings.

Date: Mon, Mar 17, 2003 5:56 PM From: To:
Hello. Like most others I agree that brain death makes you dead in all aspects. Your whole body depends on your brain, and it there is no brain body is nothing more then a body. Since soul is more your personality and your mind, your spirit, it can not possibly be contained in the body. Therefore even if you cells are still living but your mind no longer exists - the soul is no longer in the body. Plus this is scientific - it is proven, as in math. You can not drag religion and feelings into something that has a firm ground to stand on. Religion and belief only make the question complex, and allow logical argument, which unfortunately doesn't change the obvious truth. Once the brain no longer functions the person is no longer in this world.

Date: Sun, Nov 10, 2002 1:13 AM From: To:
As an intensive care nurse I am often confronted by severe brain injuires that lead to brain death. Some responses to you, suggest that the body is 'alive' whilst it is on ventilatory support leading to a beating heart. Some years ago, whilst working in a Cardiothoracic unit, an air embolus whilst on 'bypass' led to eventual brain death. For some days this was denied and the patient maintained on the ventilator. In the absence of brain stem function, the heart eventually arrested and a pacemeaker was inserted. The underlying rhythm was asystolic and I eventually met the patient day 5 post surgery. Brain Death testing was performed within the context of Australian Law and the next day Ventilatory support ceased after family counselling. There was no issue of Withdrawal for death had occurred. It is important to separate Withdrawal of Life Support from Brain Death. The difficulty at that time was the crossing over of medical fields, from neuro intensive care to life saving sardiothoracic surgery. The Assistant Director of Nursing for the unit had a problem with brain death, and its meaing, and her concept of spiritual life, and the separation of the spirit, soul, from the body. Such beleifs are not antithetic to brain death. It is possible to still believe that brain death has occurred, and that the spirit is conncected to the body and unable to move on until the body is freed from the ventilator and asystole and no cardiac output allowed to occur. Organ donation is a separate element to brain death, and not all brain death victims become organ donors. It is important to keep the separation morally and ethically, so that people understand the distinct reality of death that has occurred to their loved one. Whilst organ donation is a system of care that has developed through technology that allows people to be mechanically supported and therefore require brain death testing, it is not the origin for brain death testing. Advanced life support, early resuscitation at the time of injury and the ability to prevent the cessation of respiration has caused society to examine the brain. In previous socieies, people died from brain stem death, as respiraion could not occur. Asystole had to follow. Death is not an emotion. It is philosophic as well as physical. Human life requires the connection of the physical body to the spirit and the psyche. They are not independent isolates, each capable of survival without the other. Brain Death accounts and records physical death. It does not prevent respect of the processes that occur in religious beliefs in care of the dead body. It is a process that few people have had to confront or willingly would. I applaud the generations of the present and the future who not only confront brain death but discuss with their loved ones and family the concept of organ donation. It is always important to remember that the right to be an organ donor or refuse to be an organ donor will recieve no indictment from the medical community, and always the respect of the individual life is paramount. Judy.

Date: Sun, Oct 6, 2002 12:23 PM From: To:
I recently became a widow at the age of 32. My husband of 9 years diagnosed as brain dead. I am still awaiting the results of his autopsy to determine the exact cause of his brain death. I have read all of the comments on this topic and must say that some are very disturbing. For a very brief moment a few made me question my decision to let go. Again, this was a very brief moment. I am not in a position to battle anyone elses moral or ethical decions. All I know is that my husband always had expressed his wishes to me, and I can only encourage everyone to discuss these wishes with there loved ones. I know 3 things for sure. 1-My husband would never want to live if he could not have a full quality of life. He told me this over and over again. I know for a fact he did not want to live if the only means were life support. 2-He wanted to be an organ donor. We never could see eye to eye on this subject and he would always make me promise that I would grant this wish. 3- I loved my husband to much to be selfish and allow his body to remain "alive" for my own benefit. Which is exactly what technology allows us to do. Those who argue that the body is alive as long as it has a beating heart and is breathing (only due to a ventilator) need to understand that this is not a natural occurance. There are many many things that are being done to maintain organ function. I unfortunately had the chance to witness this. I saw the bags of meds and IV's that were necessary to honor my husbands wish to be an organ donor. The heart only continues to beat because it is being stimulated by medications and is being given oxygen by means of a ventilator. Don't get me wrong, this was still not an easy choice. I wish everyday I never had to make it. All I know is that knowing my husbands wishes made this decision one that I am able to live with. Even if I was not given the brain death diagnosis which I do believe to be a true diagnosis of death, my husband would not want to be sustained by life support. For those of you that question "brain death" , I offer one suggestion. Don't allow it to be anyones choice but the person who has suffered it. Know you're loved ones wishes.........that is after all, all that should matter.

Date: Tue, Aug 27, 2002 12:22 PM From: To:
What bothers me about most discussions of brain death is that the arguments many people use are based upon what they "feel" is right, upon what medical science can observe about the brain, or upon appeals to "quality of life" or to the necessity of using those organs to help others who need them. These arguments all beg the question: what is death? This can only be answered by a right philosophy, not by science. Science can only portray the physical evidence; it is doctors and ethicists who have made the determination of death based upon that evidence. The medical evidence says nothing except that there is no apparent functioning in the brain; this upon its own does not say whether or not it is death of the person. This is a definition based upon a person's judgement of these facts. Medical ethicists, who admittedly have a vested interest in this, due to the possibility of harvesting organs, have taken over the job of defining death and life. This is not something that should be taken lightly.
To those who argue based upon the fact that they "feel" it is right: one's subjective feelings about something, even though his/her conviction may be very strong, is never a valid basis for truth, unless it is backed up by something objectively right. If there is any question at all, one's feelings may not suffice to provide direction. Especially in matters of life and death, this should NOT be any kind of green light to go ahead.
To those who argue that the benefits of organ harvesting are enough to justify brain death as death of the person: One may not use a relativistic argument that assumes that one person's life is more important than another. Just because you know that a person, because of his medical condition, has little or no chance of living a normal life, and may even die soon, does not make that person's life any less valuable. That person deserves to be nurtured and cared for, until the very end, and the end may not be hastened by well-meaning attempts to help others. Otherwise, human beings play God and decide that this or that person is expendable, because of X,Y, & Z. Where does that end? That's the thinking of Hitler - he disposed of people that he had no use for. Life (ALL life) is precious and sacred, and it must be cherished and respected at every stage, from conception until natural death; otherwise, NO human's life is sacred. The same arguments that are used to justify this situation, as well as many more such current issues in medical ethics, can be used either for or against anyone, according to whoever is making the rules.
What strikes me is that many people, in saying that brain death is "real" death, often contradict themselves by stating that it is cruel to keep someone here on earth indefinitely. The person is either here or not; if dead, the life support machines are not prolonging anything. One thing I hear often when people say brain death is real death, is that the person's soul is no longer there, just the body. While I agree that humans have a spiritual soul, the body and soul are not separate. We are "embodied souls"; the body and soul are intrinsically united. How can the body continue to breathe, the heart beat, and blood flow to the organs, keeping them healthy, if the person is not alive? Machines cannot do all this work: they can pump air into the person and can stimulate the heart to beat, but they cannot cause the exchange of oxygen to happen at the tissue level. Eventually, when the person does die, no machine in the world can keep this process going. Does this not tell us that there is something more to death than mere "brain death"?
I realize that there are still many more questions, and that this does not sufficiently cover all the grounds. But, my point was to at least emphasize that it is CRITICAL what methods we use to justify such an argument. Our culture is so used to using faulty logic to arrive at the conclusions that we do. Only a solid foundation in morality and good philosophical reasoning, based upon objective truth, will suffice to even discuss this question. This question should be considered in the light of these solid foundations, separate from the pressures of organ donation. The pressure of organ donation should not be a factor in determining whether or not brain death is true death; this question has to be fully answered before any questions about organ donation can be answered.

Date: Fri, May 31, 2002 11:53 PM From: To:
In a message dated Wed, May 1, 2002 , Chelsey Risseeuw touched upon the problem I have with brain death, namely, as long as there are known cases of patients who have been misdiagnosed as brain dead who have recovered, there have also undoubtedly been cases where patients have been misdiagnosed "brain dead" who were hustled off to surgery to have their organs harvested for transplantation who were effectively killed as a result. It leaves me wondering what kind of studies were conducted to determine the incidence of errors in diagnosing brain death before its use as a basis for organ donation.

Date: Wed, May 1, 2002 12:57 PM From: To:
My name is Chelsey Risseeuw and I am a senior at Deuel High School and a student of Mrs. Lundberg's Advanced Biology class. We are researching bioethical topics and the topic that I chose was Brain Death. I recently posted a Filamentality Web Quest about that particular topic. At first, I had a preconceived idea that brain death was not the same as actual death and that it was possible for a brain dead person to recover in some miraculous cases. After researching the topic, I realized that this was not the case. Brain dead is in actuality, dead. In some cases, there have been misdiagnosisin which people who were falsely determined brain dead actually recovered. These cases are responsible for the numerous misconceptions about brain death. Through the course of my research, I have also realized that brain death is a highly emotional and difficult situation and it is important that people comprehend all of the facts about brain death before making any kind of decision either way. I also believe that it should be the family's right and decision to make the final say about the welfare of a brain dead person. Thank you for allowing me to share my opinion on Brain Death.
Chelsey Risseeuw

Date: Mon, Apr 29, 2002 7:03 AM From: To:
I fully believe that brain death is death. I worked with many patient declared brain dead and they are gone. The only reason the heart beat remains is because of artifical mechanical ventilation. Once ventilation is removed, they do not breath and their heart stops in minutes. There is so much fear of death in this country and we do so many crazy things to stop what is a natural part of life. I have been a nurse for 13 years and believe in medicine and all it's miracles. However, we can not keep death away forever and when it comes, why prolong it? Unless it is to save another life through organ donation.

Date: Sun, Apr 21, 2002 9:13 PM From: To:
As a family member who suddenly finds herself looking for answers to "What is brain-death?" I feel dissatisfied with the answers out here. Who are any of us to decisively say when life begins and ends? I am waiting for a determination of brain-death for a troubled mother of two young children. I am not as concerned for her physical state as her spiritual one. No one truly knows whether the soul is still in the loved ones who are determined to be in this state of "death". No one can claim to know if sitting and praying with the loved one and sharing our love with him/her is going to comfort or help them in this state. In my case, I have to believe that until they take my loved one off support and her heart stops beating that she is still in there. That in this brain-death her soul will be given a second chance to die and go with God.

Date: Sat, Feb 16, 2001 10:40 PM From: To:
As a Nuclear Medicine student I recently had the experience of assessing the Cerebral Perfusion of a man who had been involved in a motorcycle accident. The basic aim of the study was to assess drain death. Our assessment concluded that the man had no blood going to his brain and was therfore brain dead. The mans life support systems were turned off and his respiration and heart beat ceased almost instantly. I can not see how it could have been considered that this man was 'alive' simply because a machine was making it breath and pump blood. I read the response written by a person saying that it is not a humans responsibility to terminate a life but instead it is gods. I agree with this theory to an extent but I also think has god not shown us enough by taking this persons brain function.In pre-ventilator medicine we did not question if god infact wanted this person to die simply because they maintained respiration and heart beat for a short time after brain death occured. It brings forward the question of quality of life. If there is a heaven do we have the right to keep a man on this earth in a state of relative unrest simply because of human emotion rather than allowing him to transcend to a nother place? If there is not a heaven and we are not at anystage reincarnated then what is the point of sustaining resiration and heart beat in a body that has no idea of what is going on around it and is of relatively no use to us, but is rather taking up a bed where we could treat a person who has a possibility of recovery? This may sound like a rather inpersonal approach but do we not have to take this stance to some degree when dealing with this issue. We are either a being that lives in more than one dimension/time in which case are we not better to alow the spirt to move on (or rather has the spirit moved on and are we holding on to false hope) or we are not. I believe the best approach is to diagnose the status of drain death, in the case where drain death is diagnosed we should cease any mechanical assistance. under the christian approach god will save those he wants saved and under the opposing stance survival of the fittest will be applied.

Date: Sat, Oct 13, 2001 1:06 PM From: To:
As a nursing student I feel that the criteria for a patient to be declared brain dead is extensive enough that if th EEG is flat then that is enough clinical evidence that they are dead . If they are taken off the vent and they can not sustain a heartbeat sponataneously then they should allowed to die. I feel that it is the responsibility of the health care team as a whole to inform tha family of the diagnosis and not to instill a false sense of hope. I feel that the family often do not realise that even if the heart is beating that with out the brain the other body systems will eventually fail . I think that they families often feel that the vent will sustain the brain and it will in time regain function .This as all health professionals know is not true and I feel that it is interfering with the families grieving process.

Date: Wed, Sep 26, 2001 5:49 AM From: To:
I think that brain death is a reliable criterion for death. If the person is on life support systems that is why their heart continues to beat. I have seen this alot of times since I work in an ICU. We have someone on a ventilator and their EEG is flat and we take them off and death is almost instantaneous.
I think we have to consider whether or not their heart would be beating if they were not on the ventilator. If the patient is truelly brain dead as evidenced by the EEG then their heart would not be beating if it were not for the ventilator.
Prolonging death is acceptable if the family is looking at organ donation but just to keep them on until their heart fails is not fair to the family. If the person is young and ventilated then their heart can beat for a long time even after they cease to have any brain activity.
Sandra McCoy, NSU college of nursing

Date: Sun, Aug 5, 2001 12:53 AM From: To:
I think you should wait until the heart stops beating.In my oppinion you are still alive physically until your heart stops beating.Do they take your organs when your heart is still beating but yet you are brain dead? If so this is horrible.

Date: Wed, Jul 25, 2001 9:20 PM From: To:
In light of the recent news about stem cells, I'm curious to know what people think about the possibility of brain resucitation when "brain death" has been diagnosed. Could so-called brain dead individuals be candidates for receiving stem cells? And, if so, what happens to organ donation?
Thanks for listening! Zerobar

Date: Mon, Jul 2, 2001 2:19 PM From: To:
It is the life that remains in dead organ donors that makes their gift worthwhile. If brain death and death were identical and equivalent, there would have been no need to coin the term "brain death". Jell-O and the human brain show similar wave patterns on an EEG. For those who decry "prolonging death," remember that the only thing that prolongs death is life. Removal of life support has never been performed at the request of the patient.

Date: Tue, May 22, 2001 12:24 AM From: To:
If someone has a EEG done and it shows no activity in the upper areas of the brain, does that constituent PERMANENT brain damage/death? Is their ever a state were a brain may have no or activity below the EEG measurement readings? I wonder and im sure many people have wondered. I think that too many doctors assume that, does the brain ever repair itself? Most people may lay on a breathing machine 2-3 months sometimes with no higher level brain activity, but how many people have been left on for years in that state. If the brain is truly dead and is in a state of no being self repairable then maybe the rest of the body catches on and then die. I read something that really made me wonder. Their was a study of about 200+ people who had been classified as brain dead(meaning high order brain function) Most of the people who were taken off ventilators after being "brain dead" for 10 hours showed in autopsy the their brain has massage damage. But the ones who were left on for 120 hours showed statically less damage, and I mean 25-50% less damage, and one group who were on life support for weeks showed a lot less damage then people on for 10-120 hours range. Does this mean the people ever would have improved? Maybe not, but it did raise the question that even after massive damage the brain did seem in most of the cases to be in better (but probably still fatal) shape after being fed oxygen for weeks after the initial damage. I would like to see a further study in this issue. But do to the current pressure placed on most families to harvest the organs we may not have enough cases to further study this.
Thank You...

Date: Sat, Apr 28, 2001 8:38 PM From: To:
As a Christian I believe death is a manifest reality completely different from life. The intrinsic worth of a human being is not in his/her brain or other bodily part but in the whole person, an organism with spiritual and material dimensions united. Death signifies the separation of this unity, which unity is served by the intercooperation of at least three vital systems--the circulatory and respiratory systems, and the entire brain. Therefore, when making a diagnosis of death, it is imperative that no one be determined or declared dead unless and until there is destruction of at least these three basic unifying systems.
Criteria for declaring death are not something to take lightly. As long as "brain death" continues to be accepted and used as a sole diagnosis for death, some patients will be sent to the grave prematurely.
God alone is the Author of a person's life, and He alone may determine when a person's life will end. Since human life is a gift from God, there is a primary moral obligation to show reverence for that life at all times from its beginning until death. Any failure to show reverence for or to safeguard life is an attack on the individual patient, on others involved, on the medical profession, on society, and on God.

Date: Fri, Apr 6, 2001 7:29 AM From: To:
I think that brain dead is to be dead. But I would specify that brain death should mean death of the lower parts of brain, namely "brainstem death". When the conscience is over but the brainstem continues to integrate the cardiopulmonary system the individual is not dead. At this point we don't assume the concept of "neocortical" death but we have to decide policies about euthanasia and organ trasplants. We have to treat a living organism that hasn't biographical life but has still biological life and we can't fulfill our purposes treating the individual as dead.

Date: Sun, Feb 18, 2001 9:05 PM From: To:
I am a nurse and I believe "brain dead" to be dead. Like others have stated, without the machines breathing for the body, the heart would stop beating. I think it's unethical and painful to keep a person on a ventilator if they are "no longer there anymore". I believe a person should be taken off all life-support when there is no longer brain function.

Date: Sun, Jan 21, 2001 4:15 PM From: To:
To answer your question yes I believe when the brain is dead that is enough. As a student I have studied the brain and I believe when it has sustained enough damage there is no return. It is beyond my comprehension why people want to hang on to a loved one by placing them on "life saving" machines there is no life anymore just a body. I speak from experience when I say there is nothing more painful that watching someone you love waist away. God is merciful when death is quick I don't understand why people want to prolong the enviable and watch it take place.

Date: Tue, Nov 28, 2000 8:41 AM From: To:
By definition, brain dead is when the patient can no longer breathe, and would have died from that cause if technology didn't exist to sustain ventilation. So why would someone keep their family member on a machine if they were already dead? We judge death as when a body is no longer breathing. Suppose you saw someone lying in a hospital bed. You knew nothing about them before, but you had to judge them on appearance. This person was not breathing, had no response to stimuli, and reflected no qualities of life at all. You as well as I would consider them dead. But they are not, they are just brain dead. They should not be forced to keep alive by a machine. They should be able to go on to another life without any problems. To answer your question, I think that being brain dead is dead enough. Families who keep their families on machines to keep them "alive" are in my opinion, having trouble coping with the death. They as the loving family need to let the person go. They cannot keep the person alive for their own sake to deny the fact that their family member died. The family should think of the their dead family member's well being first.

Date: Sat, Nov 25, 2000 12:36 PM From: To:
The medical experts assume that the brain is the integrative principle of the body. That is, the brain is the central integrating organ of the human body and its destruction entails loss of bodily integrative unity. People who are brain dead are claimed to be dead for this reason. Defenders of this criterion say that those who are brain-dead cannot be kept alive even by advanced medical means for very long.
Dr. Alan Shewman has documented cases, however, where brain dead people have not only lived beyond two weeks on respirators (some have lived for years), but whose bodies have been able to function as a whole--some of which have even been able to recover from colds and wounds.
If this is so, then I think there is room to question whether or not the brain is in fact the integrating organ of the body. If it is not, then the person in question has not died.

Date: Thu, Oct 12, 2000 1:15 PM From: To:
As a practising neurologist in a large public hospital, my experience with brain death is significant. To answer the posed question- of course it is enough. By its very definition, the patient can no longer breathe, and would have died from that cause if technology didn't exist to sustain ventilation. More often than not, patients who linger to legal life due to the preservation of one or two brain stem reflexes undergo degeneration while still "plugged in." It is this process of apoptosis that leads to other organ systems collapsing after the brain has ceased to function. I feel strongly that if the AAN guidelines of declaring brain death are followed, there is no role for eeg or other adjunctive testing, Electric signals from the ekg leads and even the ventilator can cause false hope when lack of brain stem reflexes after 24-48 hours always bodes poorly.

Date: Thu, Sep 14, 2000 3:37 PM From: To:
I have gone through this just last year. My dad was declared brain dead. His heart was still beating but he could not breathe on his own and had no reflexes. We were going to keep him on the vent for a few days but his heart stopped beating the next day. I believe he was dead because he was not there anymore. It was just his body there. I also believe most vent patients who die on the vent are not ideal organ donors because of the changes to the organs being on the vent causes. But I believe the family should honor their wishes in donating their organs if they still meet the criteria.

Date: Sun, Aug 27, 2000 1:16 PM From: To:
I am an Organ and Tissue Procurement and Transplant Coordinator. On a regular basis, I see the anguish and heartache that accompanies a family's decision to donate the organs of a clinically brain dead loved one. I am a person with strong Christian beliefs. I believe that one's soul departs when the brain no longer functions. I believe very firmly in the current criteria that M.D.'s use in determining brain death. There is nothing quite as depressing and frustrating as working with a family that is misinformed and poorly educated (by medical personnel) concerning the definition of brain death. I could be mistaken, but as far as I know, no one who has met the criteria for brain death (or "irreversible coma") has ever survived for a prolonged period of time. If I am wrong, please let me know. I do know that once brain death has been established, the patient's organ systems quickly begin to "shut down." Usually within 24 to 48 hours, the patient will suffer cardiac and respiratory arrest. Once the heart stops beating, the patient is no longer a candidate for organ transplantation. The lives of as many as 7 people that are waiting on recipient lists miss the opportunity for a "second chance on life." Many people, medical professionals and lay people alike, are uncomfortable with the fact that a person on ventilatory assistance with a beating heart could be considered "dead." Again, I do not know of a single case in which a patient that meets the brain death criteria, is removed from ventilatory assistance, and "survives" for an extended period of time. Look into the eyes of a single organ recipient and you will understand the need for clear education and understanding of brain death. When families are properly informed and knowledgeable about the futility of "hanging on" to a clinically brain dead loved one, they are more receptive to the life saving opportunity of donating the organs of their loved ones. The tragedy of the loss of one life can save as many as 7 people and enhance the lives of as many as 120 others.

Date: Fri, Jul 7, 2000 1:31 AM From: Raoul@sti-. To:
I have not seen an actual confirmation of a brain death, so I don't know the exact meaning of it. However, may I ask the experts how long it takes for the rest of the body to detect that brain function is gone, and so begin to deteriorate? My feeling is that when all the other bodily systems have stopped functioning, that would be death. Any one system still showing signs of work, then death has not set in yet. You can't lop off a foot or take out an organ to donate. This might seem weird but there is wisdom in the way the old folks prepare chicken for the table. The killed chicken is set aside for a time for that one final gasp. Sometimes the gasp would be barely perceptible but they always knew when it can already be prepared for dressing. Just chopping off the head does not mean straight to the cauldron. All bodily function should stop first. IMHO.

Date: Sat, Jun 24, 2000 6:30 AM From: To:
I have read the comments on brain death. As a professional in the healthcare field, I believe that the only way to establish death is by a flat line EEG or the absence of functioning of the higher levels of the brain. I have watched patients die on the ventilator whose families did not want to turn loose and believe that patient was gone. It is very difficult to watch a family member die during a prolonged natural death, and I am sure the families of those on a ventilator suffer immensely while struggling to make a decision to "pull the plug". In my opinion, we as healthcare professionals should give the families emotional support and all the information possible about the meaning of brain death. In the past, I also was confused about the true meaning of "death". However, now I feel confident that the flat line of the EEG means the end of the person's life as we knew that person. The soul and everything we loved about that person is gone. I will donate my organs if possible. My husband is a candidate for a heart transplant and we struggled with making the decision to accept a heart, from a spiritual standpoint. Our physician who was a Christian also gave us good advice, he encouraged us by telling us he would do it if he were in our situation.

Date: Tue, May 2, 2000 8:26 AM From: To:
If the heart is still pumping , your still alive

Date: Sat, Mar 25, 2000 4:18 PM From: To:
I think we should concentrate on Higher brain death rather than whole brain death. Organs are still alive and viable for transpantation, and thusly giving the gift of life from ones death. The debate of bodily death v. brain death is long over...our tecnological means has made it possiible for us to superceed body death. One could argue that does "might make right? How far away are we from nontechnologic means to perevent even brain death? In the face of our evolving society we need to someday recogize when enough is enough.

Date: Wed, Feb 16, 2000 6:08 PM From: To:
As a critical care nurse, I have had the opportunity to deal with patients who are determined to be brain dead. I have seen flat line EEGs and cerebral arteriograms that demonstrated no blood flow at all to either side of the cerebral hemispheres. How can anyone argue that brain dead is not death? These patients have no ability to feel, breathe, any of the basic functions of the brain that sustain life. I agree with the comment that eventually the body realizes that the brain is dead and begins to deteriorate. But, in the case of brain death, I think life support should be removed after the patient's family has come to terms with the fact that their loved one is gone, and if that takes disconnecting the ventilator so that they can see that their loved one does not breathe, then so be it. The only situation in which I advocate continuance of life support in the brain dead individual is in the case of organ donation.

Date: Wed, Jan 5. 2000 11:39 AM From: To:
If an individual experiences cardiac arrest followed by resuscitation, that individual is not considered to have been brought back from the dead by anyone with a minimal understanding of human physiology. However, those who should have a greater understanding (in my experience, physicians) still shy away from stating death by neurologic criteria as death. Rather, they say essentially dead or brain dead, as though that were something other than the cessation of life. A better question may be, "How do we educate those that should know the difference about death and it's finality regardless of it's origin?" Electromechanical function of the heart organ does not imply life just as cessation of the same does not imply death. And yet ventilator dependent patients are allowed to succumb to the effects of a non-intact neurological system rather than removing them from the machines that assist organ function.

Date: Fri, Dec 24, 1999 9:42 AM From: To:
A person that is "brain-dead" could in the very near future transplant more than just his or her internal organs. They can provide hands, feet, and even their entire body. Now if current medicine could keep his body healthy than maybe the brain dead person could have a "body dead" person (i.e., someone with a perfectly good brain with a failing body) attached to it? Interesting notion. As far as current laws that exist in Wisconsin, a person in a persistent vegetative state may be taken off of life sustaining measures (i.e., feeding tube or other technological or remedial supports). In this case the equipment was delaying imminent natural death of the body. If the person had an advance directive or power of attorney for health care instrument the matter would be easy to solve -- regarding what should be done in such a circumstance. The best solution is that the person chose what is to be done with his body. In this case the individual's right to chose what course is to be taken, considering his options (i.e., cost of health care, emotional and physical drain on family members, etc.). If a person does not have an "just in case" kind of "end of life instrument" the person's making the decision to continue or stop support measures must act in "the best interests" of our brain dead person. We know that if I, as a guardian of such a person, decide to continue care because of my own religious beliefs-knowing that my good "brain dead" friend is a long-standing Christian Scientist, than I am not acting in that person interests. The "best interest imperative requires that I act as that person would have acted, as I and others have known that person to act in the past. It would require that I act consistent with the values and beliefs the brain dead person. In this case our brain dead friend wanted to have his organs donated. This can only be done while it is viable. If his organs are at risk than the decision should be to no longer delay the death of his body. The person wanted it that way. With respect to health care workers attitudes, values, and opinions are not relevant and as professionals they should respect the wishes and desires of their patients. They should feel comfort in the fact that they have the right to determine what happens to their own body and not have it dictated by another. Because we live in a society, with an individualistic constitutional democracy that is the way it goes.

Date: Tue, Dec 7, 1999 6:56 PM From: To:
Although I have the highest respect for life in all of its forms I do not feel that there is a need to keep a brain dead patient alive. The body exists seperate from the soul. The body is a complex machine made of millions upon millions of microscopic parts, but what good is any machine without someone to run it? Even the most complex of computers cannot perform a task without being told to. In the same way, what good is a body without a mind? What possible function could it provide other than the prolonged anguish of those who loved the mind that once inhabited the body. A person cannot be defined as a body, but only as a soul. In a worldly existence this soul exists within the mind. For all purposes other than those on a higher plane the brain dead person is already dead.

Date: Sun, Oct 10, 1999 12:06 AM From: To:
I am an organ recovery coordinator, and have seen many brain dead patients. I truly believe with all my being that a person is truly dead when brain function in the entire brain and brain stem have ceased to function. This is irreversible and even if a brain dead person is maintained on a ventilator, the body eventually realizes that the captain is gone and will also cease to function, regardless of ventilatory support.

W. Drucker, RN CPTC
Date: Wed, Apr 28, 1999 6:59 PM From: To:
The term "brain death" is a misnomer and should be deleted from our medical useage. Death is death is death is death. Just because science has discovered means to keep tissues functioning after death does not change the diagnosis. In the coming decades, I have no doubt that methodologies will be discovered to keep almost every human tissue functioning outside of the body. Does this mean that you your pancreas is "alive" after you die? I do not believe so. Let us avoid the laziness of speaking of "brain death" which only disorients families and speak of "death due to brain failure" or similar terminology.
Hans G. Engel, M.D.

Date: Mon, Apr 12, 1999 5:14 PM From: To:
I am only seventeen and am not a medical professional but i beleive i have a valid opinion. As i understand brain death it is final and without cure and I don't beleive that by using addititional life support after brain death you are prolonging death because the victim is already dead. I beleive that you are just prolonging burial. When my family was told that my mother was brain dead all we could do is beleive them so I truly hope that all doctors have ethics and are sure of their decisions. I think they realize the responsibility placed on them and take it seriously. I also watched the light on the respirator that lit up when my mother breathed on her own and after waiting long enough for it to light up you have no doubts that there is no one left to hold onto in that bed. I won't ever say that was easy but I also know that she was gone and that the only people that benefited were her organ recipients who she saved.
I guess the only question that iI ever wonder is, How careful are doctors?

Date: Tue, Oct 27, 1998 3:59 PM From: To:
In my opinion I think once a person is pronounced brain dead then they are dead. And so it is a criterion for death. The term Òbrain deathÓ has been confessed its an inception. The real definition includes the total and irreversible cessation of the brain function and activity in both the cerebrum and brain stream. In my terms it is just saying that the body as a whole cannot function. Doctors have been trying to decide for years on what it really means. The doctor may decide if the person is really brain dead. Doctor had found out that the brain required much more energy then other organs and, if its needs were not met, it would cease to function, while other parts of the body (requiring less energy) might remain viable and even regain their activity. The result would be a dead brain in a viable body. Then the doctor has to find out if this says the brain is dead or not; and to do so they have to detect a coma and find out what caused it. In brain death there are two parts. First, the heart would eventually stop. Second, was of the cardiac prognosis an individual with a dead brain stream was already dead (because they are unconscious). In these facts I can say that if a person is considered brain dead then they are dead. They can not think for themselves, feel, move and so anything the brain controls everything if it is dead then the body is also dead. Perhaps the problem with their loved ones is that they feel that the person may come out of it and be back in there life. The loved ones feel grief, denial and simply each day they see the person the same way as the day they were pronounced brain dead and it is hard to let go of a person. But I think it is better for them to let go and let the person go on to a better life. Furthermore I believe if the brain is absent then that the brain is dead and the person can not do anything then why should they stay alive. I hate to say this but, with all the evidence gathered here you should just pull the plug and let the person die. It is a criterion for death because it is a standred rule when the brain is dead the life of the person is also gone.

From : Aarti Patel
Date: Tue, Oct 13, 1998 7:32 AM From: To:
I think there is no need to have a whole brain death. It is enough to have cortical and thalamus death. It's not easy to say always these things happened. But sometimes we can say, based on medical evidence that those things happened beyond any reasonable doubt. So, if you can not have any sort of conscious relationship you are not anymore a person. And that establishes you are not alive. Because not being is equivalent to death.

Date: Fri, Oct 2, 1998 11:09 AM From: To:
I belive that brain death is same as complete (somatic death) and there is nothing really to discuss about?

Date: Tue, Jun 23, 1998 3:39 PM From: To:
I agree with the argument made on your website. I believe that a person is dead when they are brain dead. Even though they may be breathing and have a heartbeat, if their brain is not functioning, how can they be determined to be alive? The brain is the control organ of the body that tells all the other organs how to function via the nervous system. I do not believe in "life suppport" systems unless they are supporting an organ donor.
Amy Costner, Nursing Student

Date: Sat, Jun 20, 1998 1:38 PM From: To:
I think that if a person is medically determined to be brain dead then let the person go. Being kept alive is only causing possible pain and suffering to this person and the family. Let the grieving process begin...............

Date: Fri, May 22, 1998 4:33 PM From: sheilac@kalama.doe.Hawaii.Edu To:
A person that is brain dead isnt really dead he/she just cant respond to anything a person say's to mthem or does. technology has gone only so far why not just let the person suffer, for all we know they cant feel any of the paine we think that they are feeling?All in all, it doesent matter if they end the persons life or not , it just matters if in the end they will be able to save some of these peoples lifes one day.
Sheila Cyboron, J. B. Castle High School, 45-386 Kaneohe Bay Dr., Kaneohe, HI 96744

Date: Wed, May 20, 1998 4:39 PM From: To:
The actual diagnosis of brain death, as defined, includes the total and irreversable cesation of brain function and activity in both the cerebrum and brain stem. As written in many states, that diagnosis is determined by the doctor that is in charge of the patients care. It is my given opinion that if all of the brain is destroyed, by whatever mechanism, the body will not be able to live on its own without continued life support, and then for only a short period of time. In talking with many religious persons, the soul of the individual is contained in the upper portion of the brain, the area that controlls emotion, thought and intelligence. If this area is destroyed to a point that no blood, "the life" of the body cannot reach this portion for an extended period of time, then the metabolism is shut down and all electrical and biochemical responses are stopped thus terminating the function of the soul. When diagnosing brain death it is important to determine that no blood is reaching the upper portion of the brain, this should be done by confirmatory testing, and can only be accomplished by cereberal blood flow. At present this test is not required by law, but for myself, I would encourage all individual to request this test. I justify my decision in that clinical exam, no matter how skilled the doctor is, has a very minimal chance for error. I do believe that if all reflexes from the brain are absent then that brain is dead, as long as no paralytics,cold body temps,hypovolemia etc are present. But as for myself, I need to see that all blood flow is stopped, not just speculate due to abscence of reflexes.

Date: Fri, Mar 20, 1998 10:18 AM From: To:
It is really hard to believe that a person labeled as "braindead" could make any recovery at all. It would be a tough decision, but I believe that it would be easier to pull the plug than to sit back and watch (a family member, or whoever) waste away motionless and non responsive. Hopefully in the future we will have the technology to repair major brain injuries or even brain death, but until we do, their will always be a strong debate over this issue.

Date: Wed, Mar 18, 1998 4:23 PM From: To:
I think that once a person has been declared brain dead, then the person is dead. There is no hope for a normal life after brain death has been declared. The person should be allowed to die, not forced to linger on life supports.

Date: Tue, Mar 17, 1998 5:38 PM From: To:
I believe that if one is found brain dead, then they are officially dead. Number 1 they are unable to think, talk or anything else. They are costing their families money for nothing. If there is no hope then keeping them alive is only painful. I am open for any thoughts or comments.

Date: Thu, Jan 29, 1998 6:31 PM From: To:
I just read your comments and would like to add some outlook. I also have some questions of people who are reading this and are in medical profession. What is the exact scientific definition of Death? If it happens to be either the stopping of the brain or the stopping of the heart either one of them can be replaced. Would a brain transplant change the whole personality of a person? Has it ever been tried before by doctors in experiments? Maybe in future people use the process of cloning to use cloned ones as scape goats to grow organs and replace those organs in actual humans. Can one of you explain me what is the scientific definition of death? And if it is the death of the brain or death of heart I don't think it is a valid reason to loose a loved one if you could replace those with donated organs to save other people.
Question is that is it that simple. And if so then why donot doctors do it??

Date: Fri, Nov 21, 1997 1:42 AM From: To:
The problem with PVS is that the time scale used at least in the U.K. to determine the persistancy of the state is not fixed and will change from the diagnosis of one consultant to another. 6 mnths is typical for those consultants keen on an early organ harvest ( or on proving the point that no one recovers after that time - of course they won't if you kill them ). The main criteria in such cases is often the absence of improvement during a given time period, although the likeklyhood of any degree of improvement decreases accordingly, there are many documented cases of patients achieving marked degrees of recovery and functioning after having been diagnosed as being in a progressive vegetative state. The doctors concerned are in the awfull position of having to make a probabistic diagnoses that may be wrong and may deprive someone of the chance of recovery. If they don't make the decision those waiting for organs may die. Wot do ya do???

Date: Sat, Nov 8, 1997 3:14 AM From: To:
The best standard to use for determining when death occurs is the traditional one: cessation of heartbeat and breathing.
No artificial means should ever be used in the attempt to stave off death. All artificial means can only be use when and if the person is, well, already dead. That's why they need CPR or a respirator; they're dead. Once the traditional standard is rejected, we open the door to technology, and technology has no ethics per se. Our technological abilities will increase and we will keep people alive by any means necessary. Whatever can be done will be done and no one, NO ONE, will be permitted to draw any ethical limits. Why should they?
This is our problem, having rejected the traditional standard, we have opened the door to technology and it has become impossible to determine now when death occurs. It occurs now when our abilities to keep dead people alive through machines fails (or fails to bring them back from the dead). But our technological expertise will only increase, and push that limit ever farther.
Alex Mac Donald, Little Rock, AR

Date: Mon, Oct 13, 1997 7:55PM From: To:
My neice was in a car wreck a year and a half ago. She was labeled brain dead and we "pulled the plug" two hours later. If a person is considered brain dead there just doesn't seem to be any hope for a fruitful life should recovery occur. It was a difficult decision.

Date: Sep 18, 1997 4:55 PM From: To:
I feel that if the person who was braindead was going to die anyway and had signed all the forms than his/her organs should be given to people whose lives they might save

Date: Sat, Jul 26, 1997 8:09 AM From: (William H. Reading, MD) To:
Brain death as a criterion for death is fine in deciding on a fairly acute basis when to disconnect artificial life support mechanisms in an intensive care unit or hospital situation. This definition has served us well in that regard. The obvious implication of using this definition is that there are many transplantation opportunities which are missed with this definition when a person must be dead in order to harvest critical tissues. It seems to me that the best way to avoid this implication would be change the circumstances in which harvesting is allowed rather than to change the definition of death. In an earlier poll conducted by Dr. Bernstein, the term "permanent vegetative state" was defined. The poll showed that a majority of the respondents did not accept this definition as meaning death. I do not believe that this will be accepted as death by any other group. A more useful designation to allow for more harvesting would be something like "acutely dying without chance of recovery". A definition would include elements suggesting that there is no appreciable chance of survival and a short time limit until death is assuredly expected eg. 12 to 48 hours. Studies could be made to determine the "LD100" and the time limits until death. Organs could then be harvested with the consent of the individual if the individual is conscious or by the family if the individual is not expected to ever have a period of consciousness before death. This change in law would allow for the definition of death not to interfere with harvesting opportunities. Of course, the people in a permanent vegetative state (those without cortical functioning) are not included in this definition.

Date: Sat, May 24, 1997 7:01 PM From: To:
Yes, I was wondering if someone would give me a statement or an argument from a respected source dealing with the fact that, brain death is used for patients who do not have the possibility of recovery, it was a safegaurd for those who did have that possibility. However, anencephalic babies have no possibility of recovery and therefore should not need the requirements of brain death, so as to use their organs for transplantation. If any information or statements could be found on this topic, I would appreciate it if some one would contact me. Thank you.

Date: Wed, May 7, 1997 8:11 AM From: (Trisha Taylor) To:
As a student nurse and a mother it is my hope to never have to make the decision of death for a patient or my child. However, when the loss of one life, that will never really be a life, can save one or more other lives, it is my opinion to preserve the life of the one who will actually have life. As a health care worker it is my responsibility to not only provide the best quality care for a person, but to do so in a manner that will perserve dignity. Death with dignity is a right that all patients have, to keep a person in a constant vegitative state when there is no hope for life is neither quality care or perserving dignity.
This is my opinion at this time. As I face new situations in my career, I am sure that my opinion will change. That is one of the greatest things about health care it is always changing.
Trisha Taylor OU College of Nursing

Sunday, February 18, 2007

Anatomy for a 10 Year Old:"What is a Scrotum?"

The ethical issue for today is whether it is fair and just for school librarians and teachers around the U.S. banning and refusing to purchase and stock a book “The Higher Power of Lucky” by Susan Patron, to be read by 9 to 12 year olds and which was this year's winner of the Newberry Medal, the most prestigious award in children’s literature, simply because the anatomic term “scrotum” was used once in the entire book According to the article in today’s New York Times by Julie Bosman: The book’s heroine, a scrappy 10-year-old orphan named Lucky Trimble, hears the word through a hole in a wall when another character says he saw a rattlesnake bite his dog, Roy, on the scrotum.
“Scrotum sounded to Lucky like something green that comes up when you have the flu and cough too much,” the book continues. “It sounded medical and secret, but also important.”

The issue involves the use of a proper anatomic term in a context that is a straightforward description of an anatomic location and not used in any prurient or pornographic sense. One may argue that if the author did not include a description in the text or a footnote explaining the word scrotum, then the child reader may not be really further educated by the isolated used of the word. However, if not explained by the teachers certainly a child’s question about “what is a scrotum?” should be explained by the parents. Ahh! That may be the reason for pulling the book. Proper anatomic terms are OK to be bantered back and forth by adults to each other but there is a resistance to talk to children due to the uncertainty of how to answer this question and any further questions the child may then ask. Perhaps also there is embarrassment by the parent since the word to the parent may have emotional meaning beyond an anatomy book definition.

As a physician I think anatomy is anatomy and learning anatomical words is part of growing up and is not the prize possession of the medical profession. I would be most interested in reading from my visitors at what age they learned anatomic terms or at what age they are explaining them to their own children. And should an entire book be banned by the single use of a single word? ..Maurice.

Friday, February 16, 2007

“You Have to be a Surgeon with Testicles”

The issue I want to present here is whether there is something special in the orientation and behavior of surgeons that separate them from all the other specialties in medicine or from folks in entirely different occupations. Does it have something to do with their ego, a greater attention to themselves and perhaps their manliness? Or is this simply a reflection of the surgeon’s self-confidence (??or lack of self-confidence??) Or is it, if present, a consequence of the immediate and personal responsibility to preserve their patient's life while the surgeon has hands inside the patient's body. Has anyone found that women surgeons display any similar egotistical behavior.

Read the excerpts below which were written by medical students in the
Medscape Medical Student Blog
Let me know what you think about surgeons and whether this analysis of them is really fair and realistic. If so, is it a surprise? ..Maurice.

Nasstasjia, actually a year and a half out of medical school and awaiting a surgical residency, wrote her comment on Feb 1, 2007. While performing a hernia operation, the supervising surgeon told her "You have the skills but if you want to remain a woman in a man's world, you have to be a surgeon with testicles!!!! Or don't be a surgeon at all.!!!"

Bob wrote on Feb 2, 2007:
I work in cardiothoracic surgery w/ a surgeon who is excellent at his job. Having said that he can also be one of the most immature individuals I have ever met! I have never seen a grown man actually 'pout' when he doesn't get what he wants. On one hand you respect him then on the other you just want to yell "GROW UP!!"
There are alot of great surgeons out there but the best are the ones that treat everyone like a human being. One heck of a concept huh? If you are a doc reading this take notes.

imamedicalstudentgetmeoutofhere wrote on Feb 2, 2007:
One neurosurgeon who recently taught us actually introduced himself as god, and he wasn't taking the piss! I love surgery and hope one day that I’ll make it through the ranks myself. Will I develop an ego? Probably.

Tuesday, February 13, 2007

"Why Can't I Be a Doctor?"

From Loma Linda University SCOPE, Autumn, 2004, in a nursing school graduation speech , T. Richard Rice, PhD concluded about for whom medicine is practiced:

In one of Charles Schultz’ cartoon strips, two of Peanuts characters have a spirited exchange. Linus has declared his intention to be a doctor, and his big sister, Lucy, does what big sisters often do. She cuts him down to size, deflates his fantasy with a healthy does of reality. Says Linus “I want to be a doctor.” Lucy:“You’ll never be a doctor.” Linus: “Why can’t I be a doctor?” Lucy: “Because you don’t love mankind, that’s why”
“But I do love mankind,” Linus insists, “I do love mankind. It’s people I can’t stand!”

I am sure that there are many of my visitors who truly care for their fellow people and, whatever their current occupations, may have had thoughts either in the past or even in recent times to change their role in life and become a physician. It would be most interesting to read about those who had hoped to be a doctor once or who still have that feeling. Could it be that the profession of medicine and the role of the physician, despite all the bad stories of doctors and medical practice, still has qualities that would lead some folks to thinking that would be just the right job for me and then seriously asking themselves “Why can’t I be a doctor?" Maybe you would like to write about your yearnings in this regard and why you might want to take on being a doctor. ..Maurice.

Friday, February 09, 2007

“Not My Cup of Tea But Should I Offer It to My Patient?”

I have posted on this blog a number of times the issue of how healthcare providers including pharmacists should react to patients who request services or medications against which the professionals have strong moral or ethical feelings. Examples of such requests would be abortion, emergency contraception, contraception to minors without parental permission, termination of nutrition and hydration, terminal sedation and others. In the public discussion within the media, the public and even ethicists have taken both sides on the issue of whether a doctor’s conscience about providing legal services or medications should play any part in the delivery of modern medical care. What hasn’t been researched well is what is the opinion of physicians themselves on this issue.

It was therefore rewarding for me to read an article in the current Februrary 8, 2007 issue of the New England Journal of Medicine by Farr A. Curlin, M.D. and others who presented the results of their study of 1820 physicians in an article titled “Religion, Conscience and Controversial Clinical Practices”. They found that 63% of the doctors that participated in the survey expressed the opinion that it was ethically permissible for doctors to explain their moral objections to the patients. Eighty percent said that physicians are obligated to present all options to the patient and 71% agreed with the concept of referring the patient to another physician who did not object to the requested procedure. Reviewing the demographics of the participants disclosed that “physicians who were male, those who were religious and those who had personal objections to morally controversial clinical practices were less likely to report that doctors must disclose information about or refer patients for medical procedures to which the physician objected on moral grounds.”

Although, the study revealed only what physicians said about the issue and not whether they actually practiced what they said. Nevertheless "if the physician's ideas translate into their practices, the 14% of patients--more than 40 million Americans--may be cared for by physicians who do not feel they are obligated to disclose medically available information they consider objectionable. In addition, 29% of patients--nearly 100 million Americans--may be cared for by physicians who do not believe they have an obligation to refer the patient to another provider for such treatments." The authors concluded that "patients who want information about and access to such procedures may need to inquire proactively to determine whether their physician would accommodate such requests.” This means, I think, that it certainly would be wise, before selecting a physician, to ask them about how they would respond to these requests by a patient. If the patient was unsatisfied with the physician’s response, another physician should be sought.

Have any of my visitors interviewed a physician with regard to their moral opinions and practices before selecting that physician as ones personal doctor? ..Maurice.

Monday, February 05, 2007

Professional vs Personal in Decision Making:Twist on Quiz #2

Before you read any further, if you haven’t already been there, go to Ethics Quiz #2 and read the scenario and the Comments. Then come back here.

On this posting I am going to present another made-up but realistic scenario in which there is a conflict between the physician’s professional duties and his personal responsibilities.

Mrs. J. came to Dr. W. office at 4pm with a cough and fever of 1 days duration. She had not eaten nor drunk fluids well for the previous week because of some abdominal pain. Dr. W. took her history, examined her, got a blood count and chest X-ray. It was now 4:45pm. He made a diagnosis of right middle lobe pneumonia and dehydration. The cause of her abdominal pain was uncertain. He felt she should go now to enter the hospital but that would mean he would miss his son’s football game that started at 5:30pm. He had promised for several weeks now to attend. Dr. W. decided to arrange hospital admission for Mrs. J. for the morning and send her home on oral antibiotic.

How is this scenario in the personal vs professional aspects of decision making different than the previous one? And was Dr. W.’s decision ethical and professional? If not, what should have been better alternatives? ..Maurice.

Sunday, February 04, 2007

Now It’s Time to Take Ethics Quiz 2

Back in June 2005, I posted “Now It’s Time to Take Ethics Quiz 1.”
I thought it was about time now for my visitors to take ethics quiz number 2.

Here is a made-up scenario but someone in the pharmaceutical research profession tells me that this is not an unrealistic scenario.

Dr. R. has a patient with epilepsy who is not adequately controlled on any of the current anti-seizure drugs. Dr. R. is aware of a formal clinical study being performed in the clinic of Dr. S. with a new experimental anti-seizure drug that is being tested in hopes of benefit for intractable epilepsy patients. Dr. R. does not inform his patient about this study as an alternative option because of fear of losing the patient to the other clinic.

Here is the question: Is there anything unethical or unprofessional about Dr. R.’s decision not to inform the patient? Now,here is one way of looking at the issue. Dr. R. knows that a new drug is studied in a research experiment because any beneficial effect on human patients is unknown or that the beneficial effect as compared to the best present treatment is unknown. He is aware that in a randomized study his patient might be getting the new drug with unknown benefit or the other drug to which his patient has not responded, then wouldn’t Dr.R.’s decision be ethically reasonable? Why? Because there is no proof at present that whatever drug was given to the patient in the experiment would be of any medical benefit.
When considering this rationale, wouldn’t the possible loss of a patient to another clinic trump any act of informing the patient about the research project? I am eager to read what my visitors think about the behavior of Dr. R. ..Maurice.

Viewing the World Through a Microscope

Doesn't anyone on this blog feel as I do on the topic of exotic and energetic debate? What do I mean by that kind of debate? Look at this week's Time magazine (Feb.12, 2007 ,p59)and the description of what is going on in the courts and by activists on one side or another on the subject of when rape starts, how many seconds (or less) after the woman says "no". As the descriptive sub-title states "When a woman says yes and then changes her mind, how fast must a man stop before it is a crime?"

And then of course there is the issue of when an embryo (or even earlier!) becomes a person. Why is it that people get so energized and upset by such issues? I worry that we worry too much about trivialities in our world and really ignore the important. It's like folks like to use a microscope rather than a wide angle lens to look at what is going on around us. Why is that? ..Maurice.