Family wants to keep life support for girl brain dead after tonsil surgery #1

[BeginnersLuck]

Older commentary "Treating the Brain Dead for the Benefit of the Family"

I thought there was some good ethical discussion in this article.

http://web.utk.edu/~jhardwig/BrainDead.pdf

eta: Just jumping off my post and those that work in the medical field can correct me if I'm wrong in my thinking. The primary responsibility is treating the patient and doing what is best for the patient. Performing procedures on a dead person has no benefit for that person. Since the hospitals responsibility is to the patient then they are not obligated to the family, other than providing counseling. In fact there may be legal ramifications that may arise, if the hospital were to continue to treat the dead and perform additional procedures. Therefore, the hospital must take the stand that they are with the family and in court. By the court ruling against the hospital to keep Jahi on the ventilator, it removes any additional legal responsibility that the hospital could potentially be subjected to, while she is in their care. (more or less) It is also necessary, from a legal and ethical standpoint, for the hospital to be firm in their stance that they will not approve of transport of Jahi to another facility or perform the necessary procedures in their facility for her to be approved for admission in the other facility, unless a court order requires them to do so.

 

[K_Z]

Can I just say how much I appreciate all the verified medical professionals who are participating in this thread? It has helped me so much to understand exactly what is happening with Jahi and has solidified my opinion that this poor child is dead and her body needs to be treated with the dignity we allot to the deceased and left alone.

BBM, and snipped.



I'd like to add that I personally don't believe meanmaryjean is mean at all. JMO. FWIW.

 

[CHERIE.T]

Been reading about this story from the beginning. It is sad... any time a child dies it is tragic. I just don't quite understand why the parents can't accept that brain death is not reversible. Praying for them.

 

[K_Z]

Understandably hospital doesn't want to perform any surgeries on what they consider a dead body. And the new facility isn't equipped to carry out surgeries.
So what is the family going to do next?
Appeal to the higher court?

The request to surgically insert a tracheostomy and feeding tube in a patient declared dead by 5-6 separate examinations over 2+ weeks, and declared dead in a court of law, is tremendously troublesome on just so many levels-- morally, ethically, legally, physically, physiologically, socially, financially, etc.

There isn't even a preoperative anesthetic physical status category for this-- the highest is ASA 6, brain dead donor for organ procurement. Her body does not meet the criteria for ASA 5.

ASA physical status classification system - Wikipedia, the free encyclopedia

What exactly is the medical and anesthetic standard of care for a brain dead patient undergoing elective surgery?

Do we give this child's body blood products if there is excessive bleeding? Do we treat blood pressure, heart rhythm disturbances, etc? Do we monitor intracranial pressure, since there isn't anything we can do to treat it? Do we insert an arterial line? Do we put in a PA catheter to monitor heart pressures? Do we attempt to resuscitate her heart if it has malignant rhythms? Do we use electricity to shock the heart? Do we do CPR? Do we crack the chest and do internal cardiac massage? Do we crash her body onto a cardiopulmonary bypass machine if her heart arrests and we aren't having success restarting it? Do we have a bypass team and machine standing by just in case? Do we "save" her ICU bed and deny another child an ICU bed while her body is in surgery and recovery?

Is it possible to be charged with negligence/ malpractice for actions in surgery and anesthesia and the recovery room while performing elective surgery on a person declared brain dead? What if certain staff members decline to participate? Will the hospital subject them to discipline?

Does my malpractice insurance cover me while performing elective procedures on a patient 5 times declared dead?

Which surgical specialty should perform these procedures? ENT? General Surgery? Should a medical examiner be the one to place the tubes?

There are dozens and dozens of issues involved in this seemingly "simple" request to place a trach and PEG in this legally dead child's body in preparation for transport somewhere else. An ethics committee needs to be convened asap at CHO. And the hospital should file papers with the court requesting that they be allowed to legally decline to comply with this request, because the family is signaling that they will ask the hospital to be compelled to do it.

 

[BeginnersLuck]

I added to my post above. I didn't mean to edit and add to it but that's what I did. I mean't to create a new post. Time for a break....

 

[craftybatchy]

An example of neuroimaging of brain perfusion (no intracranial blood flow) in brain death with a beating heart.

"A picture is worth a thousand words."

http://www.mypacs.net/cases/BRAIN-DEATH-7751102.html

Are any fluids making it into her brain ? She is receiving IV fluids, correct ?

I would surmise that in the absence of blood and flow of fluids, the brain itself would begin to decay, leading to a life threatening infection.

 

[seattlechiquita]

The request to surgically insert a tracheostomy and feeding tube in a patient declared dead by 5-6 separate examinations over 2+ weeks, and declared dead in a court of law, is tremendously troublesome on just so many levels-- morally, ethically, legally, physically, physiologically, socially, financially, etc.


There are dozens and dozens of issues involved in this seemingly "simple" request to place a trach and PEG in this legally dead child's body in preparation for transport somewhere else. An ethics committee needs to be convened asap at CHO. And the hospital should file papers with the court requesting that they be allowed to legally decline to comply with this request, because the family is signaling that they will ask the hospital to be compelled to do it.

Respectfully snipped by me.

BRAVO on your post. This whole ordeal has me so upset. It feels like this child's dead body is being violated. this is NOT in her best interest, but serves the only purpose to make parents feel better about themselves. This sweet child has passed, if only those who should love her the most could allow her to rest in peace with dignity.

 

[LinasK]

By Matthias Gafni Contra Costa Times
Posted: 12/26/2013 05:52:46 PM PST | Updated: 47 min. ago
RODEO -- Two years before Jahi McMath's tonsillectomy went tragically awry, another Bay Area girl went to Children's Hospital Oakland for tonsil surgery to treat her sleep apnea and left with catastrophic brain damage.
Rebecca Jimenez, of Rodeo, once a smart and vivacious elementary school student, can no longer walk, talk or communicate with her family following her Sept. 6, 2011, elective tonsillectomy and adenoidectomy, the most common surgery with general anesthesia for kids in America.

Different doctors were involved in each girl's surgeries, although both girls began showing signs of distress in the hospital's pediatric intensive care unit.<snip>
Rebecca's attorney, Richard Schoenberger, said he has reached out to Jahi's family to offer assistance any way possible. "It is eerily and sadly reminiscent -- startlingly so -- to what happened to Rebecca."
The twin tragedies have raised further questions about the use of tonsillectomies to treat sleep apnea, as well as the level of care at the highly respected East Bay hospital. Should pediatric tonsillectomy patients have second thoughts about Children's Hospital Oakland?


more at link: http://www.contracostatimes.com/news/ci_24799118/jahi-mcmath-2-years-ago-girl-wound-up

 

[Minette]

I can't imagine why any medical professional, facility, or insurance company would volunteer to get involved with this situation given the multiple physicians stating she is brain dead, the litigious family, the organized marches on the hospital, etc. I think there are a lot of people--including the family--who STILL don't get that brain death is not the same thing as being in a coma or even a persistent vegetative state.

It's so sad. And one of the worst things about it is if they do succeed in prolonging this by getting someone to perform the procedures they want and getting Jahi moved to another facility the issue of exactly what went wrong with her surgery will become even more clouded. So if the hospital/surgeon was in any way liable that will become extremely difficult to prove AND whatever may have been learned that could help the next child will be lost.

 

[seattlechiquita]

I can't imagine why any medical professional, facility, or insurance company would volunteer to get involved with this situation given the multiple physicians stating she is brain dead, the litigious family, the organized marches on the hospital, etc. I think there are a lot of people--including the family--who STILL don't get that brain death is not the same thing as being in a coma or even a persistent vegetative state.

It's so sad. And one of the worst things about it is if they do succeed in prolonging this by getting someone to perform the procedures they want and getting Jahi moved to another facility the issue of exactly what went wrong with her surgery will become even more clouded. So if the hospital/surgeon was in any way liable that will become extremely difficult to prove AND whatever may have been learned that could help the next child will be lost.

It is not only sad, I find it violent.

 

[K_Z]

Are any fluids making it into her brain ? She is receiving IV fluids, correct ?

I would surmise that in the absence of blood and flow of fluids, the brain itself would begin to decay, leading to a life threatening infection.

No blood flow is the same as no perfusion. No, there are no fluids perfusing her brain. Her brain has been without perfusion for more than 2 weeks. Absolutely it is deteriorating and decomposing.

Autopsy reports will document the extent of brain decomposition.

(Warning-- graphic description.)

I read an autopsy report on a child not too long ago, who had a diagnosis of global hypoxic encephalopathy. The tonsillar pillars (bottom of the brain that herniates thru the foramen magnum) were described as friable and crumbling on autopsy. Portions of that child's brain were described as softening and liquefying. The child had been gravely injured only about 3 days earlier than the autopsy.

Normal brain tissue is like the consistency of a firm jello. During open cranial procedures, the surgeon will ask to "bring the brain up a bit" "or bring the brain down a bit" as they operate. You can see the brain tissue change in response to ventilation and hand-bagging-- lower the CO2 by increasing the respiratory rate and the brain "goes down", etc. Hypoventilate and the CO2 and the brain tissue "goes up". (This is a vastly simplified explanation, but it gets the point across.) However, non-perfused brains, as in brain death, are not responsive to measures to increase or decrease the intracranial volume and pressure.

 

[shana]

Lawyer charts legal moves in brain-dead girl case

Christopher Dolan told The Associated Press that he is drafting a civil rights lawsuit alleging that Children's Hospital Oakland's refusal to perform the procedures that would allow 13-year-old Jahi McMath to be transferred to a long-term care facility violates her family's religious, due process rights and privacy rights.

...

If Winkfield decides to take the case to federal court, Dolan said he would also seek a temporary restraining order to prevent the hospital from disconnecting the girl from the ventilator...

 

[Nana46]

I am not ready to put on paper what my feelings are on parts of this....perhaps because I know the heartache of losing a child and what would I do if I had a chance and believed he could still be here......

On the other hand, I worked for a general surgeon for many years....at one point he continued to do Tonsillectomies...and then later decided not to and referring all to an ENT.....the reason being as it is a very bloody surgery and the surgical field is especially small in a child's mouth....I can remember him saying over and over it is NOT a routine surgery...NOT......too many times following these procedures, I saw an ENT rush back to surgery to take a child back in that broke loose bleeding...no surgery should ever in my opinion, be called routine...the risk is there no matter the cause.

I also have a dear friend who is in a well known hospital following a back surgery that went awry when the surgeon nicked her aorta....we should all remember all surgery is a risk..........never routine, IMO.

 

[Donjeta]

Lawyer charts legal moves in brain-dead girl case

Christopher Dolan told The Associated Press that he is drafting a civil rights lawsuit alleging that Children's Hospital Oakland's refusal to perform the procedures that would allow 13-year-old Jahi McMath to be transferred to a long-term care facility violates her family's religious, due process rights and privacy rights.

...

If Winkfield decides to take the case to federal court, Dolan said he would also seek a temporary restraining order to prevent the hospital from disconnecting the girl from the ventilator...

"The hospital seems to feel that only it can make decisions and in that sense, you have, I have and everyone has the right to privacy over our health care," Dolan said. "It touches on some very significant issues, namely, who controls the decisions when you are dead or alive."

I never thought that privacy rights mean that patients or their families have the right to force the hospitals to perform procedures that are not medically indicated. Can a prescription drug addict file a court complaint that his privacy rights were violated because the doctor refused to prescribe him pain killers that he doesn't need for any medical diagnosis?

 

[wendiesan]

From your link is this quote from the lawyer ""They told us there is a bed; they care for children like her all the time," Dolan said. "They believe they can provide her with care and support and treat her as if she's a living person."

So is he actually admitting that is not really a living person? Because he is saying they will treat her AS IF she were a living person, which I take to mean that they know she is NOT but they will do it anyway. Interesting way for him to phrase it.

I read it that way too, sort of a Freudian slip on the part of Dolan. It could be because he it painting a particularly negative view of the hospital, implying that the staff has been callous towards Jahi and her family. He is definitely making a comparison to the potential treatment of the new facility saying that they will treat Jahi "as if she's a living person" inferring that the hospital has been disrespectfully treating her as a corpse.
http://www.latimes.com/local/lanow/...cility-20131227,0,7596501.story#axzz2ohnmNMov
I think Donan's comment was intended to portray the medical staff as heartless and focused on denying Jahi the treatments she needs to live. He said "It appears this hospital is hell-bent on this girl going out in a box." He then accused the doctors of wanting "to block every opportunity for Jahi to leave".
http://www.contracostatimes.com/news/ci_24799648/jahi-mcmath-family-ready-move-brain-dead-girl
Donan's claimed that the family had been rushed by CHO. "The hospital has been pushing, pushing, pushing from the word go, and these folks never really had time to process it in a way that would be the normal way." IMO, that isn't the case, but, IMO, Donan is just using hyperbole to make his point to the press.

Donan seems to be taking this case to the court of public opinion in the hopes of bullying the hospital into doing whatever the family wants--to insert the feeding tube, the trach tube--despite what the court has ordered and what CHO policies are in effect. Sadly, no matter how vitriolic the language Donan uses to advocate for them, the family will never get what they want--a happy, healthy Jahi.

 

[rob]

The only way ANY thing surgerical should be done on this child is if it is court ordered. Then the hospital and any dr or nurse should be able to say, I don't want to be involved.
This could only get worse. I can't imagine fighting this fight. In this amount of time, what is real should be sinking in. Unless the family is so caught up in the fight, that is where there mind is now. Winning the fight.

Please, please, please, think of your daughter. Pray, people, talk to your minister. Talk to the grandmother nurse.
Death is not easy, but it is a fact of life. If God is going to heal her, he doesn't need a vent or a feeding tube. He called Lazerath out of the grave after 3 days.
All the above is my opinion, based on my personal experience.

 

[shana]

Family, Oakland hospital dispute next move for Jahi McMath

Jahi's uncle Omari Sealey arrived at the hospital late Friday morning and spoke with reporters. We've learned that they say it is not necessary that Children's Hospital perform the procedure in order for them to move Jahi to a care facility.

...

"We have a few things in place right now, my attorney is working on, I can't disclose that just yet," Sealey said. "We'll probably have some updates later this afternoon. But we're working on multiple facilities now that are willing to help her. We're going to try to do it without the procedure if possible."

When asked about the ventilator and tracheotomy, he added, "Yeah that was just one facility that was requesting that. There are other facilities that are not requesting that."

 

[wendiesan]

Just some info on hospice that I was unaware of.


Hospice firms draining billions from Medicare

http://www.washingtonpost.com/busin...f75bbe-68c9-11e3-ae56-22de072140a2_story.html

But over the past decade, the number of “hospice survivors” in the United States has risen dramatically, in part because hospice companies earn more by recruiting patients who aren’t actually dying, a Washington Post investigation has found.

But the survival rates at AseraCare are emblematic of a problem facing Medicare, which has created a financial incentive for hospice companies to find patients well before death.

Jim Barger, a lawyer in Birmingham, Ala., who has filed several of the suits, said the root of the problem is that a company profits when it admits patients who aren’t dying, and it is the hospice itself that helps determine whether a patient is dying.

Cui bono indeed!!

I'd suspected it, it's not surprising, but spelled out in black and white it's a shock. Thanks so much for doing this research.

After reading that Jahi's uncle has been approached by many facilities who do not need the operations done, and are eager to take her, it makes me wonder just how this poor little girl's body will be treated, and for how long. If the illusion of life only comes from mechanical and pharmaceutical aids, will she be attached to machines until profound breakdowns occur that the family will be unable to deny?

If her body has been "healing", won't it be difficult to determine what caused her death? If it was a nick to her throat, or the suctioning of well-meaning family members, or something unforeseen? Isn't an autopsy necessary? Will the new facility be in charge of arranging it or will that fall on the hospital? How will this proceed to a malpractice suit (I'm assuming that's where it's heading) if a cause of death cannot be supplied? Will they just go with injury and pretend she's in a vegatative state?

 

[Donjeta]

But the attorney for Jahi's family argues that Jahi is not dead.

"Whose definition of death are we taking? The court made a determination about a technical definition of brain death. I have spent time with Jahi. She is breathing with the assistance of this tube," said Chris Dolan, the family's attorney. He says they'll go back to court to get the procedure done.

http://abclocal.go.com/kgo/story?section=news/local/east_bay&id=9373813


JMO but since death has some rather important juridical consequences it could lead to a number of strange situations if hospitals defined death differently for different patients according to whatever is convenient for the family.

(Hey, can you sign a death certificate for my grandpa?
-But he's not dead yet.
-According to our religion he is, and you have to take our definition or I'll sue you. I need the life insurance money now to buy a house.
-Well, I guess y'all have your privacy rights...Here you go, a death certificate signed to order.
-Thank you very much. Hey, late grandpa, let's get you a coffin and go home now.)

What if the next of kin differ on whether their relative should be dead or not?

 

[LinasK]

Cui bono indeed!!

I'd suspected it, it's not surprising, but spelled out in black and white it's a shock. Thanks so much for doing this research.

After reading that Jahi's uncle has been approached by many facilities who do not need the operations done, and are eager to take her, it makes me wonder just how this poor little girl's body will be treated, and for how long. If the illusion of life only comes from mechanical and pharmaceutical aids, will she be attached to machines until profound breakdowns occur that the family will be unable to deny?

If her body has been "healing", won't it be difficult to determine what caused her death? If it was a nick to her throat, or the suctioning of well-meaning family members, or something unforeseen? Isn't an autopsy necessary? Will the new facility be in charge of arranging it or will that fall on the hospital? How will this proceed to a malpractice suit (I'm assuming that's where it's heading) if a cause of death cannot be supplied? Will they just go with injury and pretend she's in a vegatative state?

It's not necessary for her to be dead for them to proceed with a malpractice suit. Read the other article I just posted about the other tonsillectomy Children's also screwed up two years ago. The girl survived with major brain damage.