Researching Law Volume 30, Number 2 - Flipbook - Page 9
R ESEA RC HI N G L AW
just coming here for stents for his
liver. Now he’s on pressors and Levo
[life-supportive medications].
CRITICAL CARE ATTENDING:
We’ll have to consult with our ethics
committee to make sure that we’re
doing the right thing—that we’re
following his wishes.
DAUGHTER-IN-LAW: Yes, we
understand.
CRITICAL CARE ATTENDING:
We’ll talk to Ethics and the nurses
who were here as soon as possible
to get their thoughts. Unfortunately,
during the night, things sometimes
are complicated because the primary
team and the family aren’t around.
The critical care team then consulted
the chair of the hospital ethics
committee to determine whether
the patient’s wife was permitted to
reverse the patient’s decision made
just hours earlier. The physicians
and nurses who had cared for the
patient overnight and had secured
his consent to be intubated were
consulted as well. Physicians also
reviewed instructions in the patient’s
power-of-attorney document. At 10:30
A.M. the critical care team removed
life support and initiated comfort
measures. The patient died around
midnight.
It is unusual to hear the expression
“pull the plug” in a hospital, let alone
observe loved ones demand so
quickly and decisively that physicians
do so. More often families beg
physicians to do everything possible,
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even when all hope is gone. The
family of a second ICU patient shows
the lengths to which loved ones may
go to ensure that the plug remains
securely in place. The immediate
and unequivocal insistence of the
first family to remove life support is
matched by the unrelenting and fierce
resistance to doing so by this second
family. And the justifications for their
decision look entirely different from
those articulated by members of the
first family, who stood in the patient’s
shoes and reprised his instructions
and conversations.
neurosurgeon on the case explained
to the patient’s family that the results
were consistent with brain death.
The second patient is a fifty-fiveyear-old Middle Eastern man from
a Christian denomination who
immigrated to the United States in his
late teens. He works in real estate.
While doing pushups at home, he
collapsed and had a seizure. He
was taken to a small neighborhood
hospital, which found that an
aneurysm (a weak bulging in the
wall of an artery that supplies blood
to the brain) had ruptured. Initially
talking and moving, the patient
suffered another seizure and lost
consciousness. He was airlifted to a
second hospital, which administered
life support and other interventions,
but an exam suggested possible
brain death. The patient’s family
transferred him to a third hospital,
seeking a second opinion and a
lifesaving intervention. Arriving at
1 A.M., the neurosurgeon on call
explained to family members that
an intervention was not appropriate
and that another brain-death exam
would be administered in the
morning. The next morning the senior
NEUROSURGERY ATTENDING
PHYSICIAN: It cannot come back. It
is destroyed. There is no blood going
into the brain… If there was a one in a
million chance, I would do something.
…Twenty to fifty percent of people
with aneurysms do not survive. I
do aneurysms, hemorrhages, brain
trauma. This is what I do. If there is
anything I could do, I would do it. If
there was a one in a billion chance, I
would do something.
NEUROSURGERY ATTENDING
PHYSICIAN: The doctors have done
an exam and I have reviewed all the
scans. His brain is dead. His heart is
only beating because we are giving it
medication. He cannot think, cannot
talk, cannot see, cannot hear.
SISTER: Give it more time to see if it
comes back.
WIFE: I believe in miracles.
NEUROSURGERY ATTENDING
PHYSICIAN: I believe in miracles
too. But I deal in facts. His brain is
completely dead.
WIFE: They said something about
a nuclear flow study [a scan that
measures the amount of blood flow in
the brain].
NEUROSURGERY ATTENDING
PHYSICIAN: If you want that, we
can do that.
WIFE: If there is even minimal ow,
there is still hope. I was a doctor for
four years. I know that things can
happen. You don’t always know what
will happen.
About a half hour after the meeting
ended, a senior neurologist arrived
to perform a different kind of braindeath exam in the presence of the
family. As he performed each step, he
told the witnesses what he was doing.
He shined a ashlight in the patient’s
eye and explained that he didn’t see
any reaction to light. He asked for
permission to turn the patient’s head
to see if his eyes move. He explained
that they didn’t. He said that he will
pinch the patient’s ngers to see if
he responds to pain. He noted that
the patient didn’t. He explained that
he will put some cold water in the
patient’s ear to see if his eyes move.
The neurologist inserted the water
and said that it can take as long as
a minute. Everyone in the room was
riveted, staring at the patient’s eyes,
but they don’t move. The patient’s
mother began shaking her head no.
The neurologist put cold water in the
other ear, again with no response. He
then sat down beside the patient’s
wife and explained that, once again,
the exam indicates brain death.
As they await the results from the
nuclear ow study, fteen family
members begin ling in and out of
the patient’s room. Many are in tears.
Others are screaming at the patient
to wake up and commanding, “Don’t
do this to us!” As the hours tick
away, visitors continue to implore the
patient to wake up and open his eyes.
“C’mon, it’s time to wake up!”
The results from the ow study nally
come back. The critical care attending
physician escorts the family to a
conference room. He hands a copy
of the report to the patient’s sister,
who passes it to her brother and
then to the patient’s wife. They each
slowly read the report. The physician
explains that the report is absolutely
clear; you can see it for yourself.
“The scan shows that there is no ow
to the brain. It is unequivocal. This
conrms what we have known all day
from the various tests that we have
done—that he is brain-dead. Brain
dead means that we can no longer
treat him.” Family members begin
to protest that they need more time,
and the patient’s brother explains
that they believe everything the
physician said, but they need to be
sure. They need to know that they
have done everything that they can
for him. As the resistance continues,
the neurosurgery attending enters
the room and declares, “I have
just reviewed the last set of scans.
The brain is entirely dead and the
blood vessels in the brain are all
empty.” As the family les out of
the room, the critical care attending
tries negotiating with the patient’s
wife: the team will continue to treat
the patient, but there will be no
escalation of treatment, including
resuscitating the patient if his heart
should stop. The wife agrees.
The next morning the patient’s
sister arrives to rescind the do-notresuscitate agreement, request that
physicians give the patient Ambien
(a sleeping pill touted on the Internet
to reverse brain damage), ask for
the name of the hospital’s lawyer,
and explain that the family hopes to
transfer the patient to another facility
and a better neurosurgeon. The nurse
manager of the ICU responds that he
will arrange a family meeting.
SISTER: We did that yesterday and
we weren’t happy with it.
NURSE: The patient is brain-dead.
That means he is dead. Because he is
dead. We cannot in good conscience
send a dead patient to another
facility. He is dead. He has passed.
There is no blood ow to the brain.
AUNT: We don’t believe it.
SISTER: People come back.
NURSE: But he has no blood ow to
the brain.
SISTER: We know of another
situation exactly. No blood ow and
the guy comes back.
Some family members tell the
hospital chaplain that the patient’s
fate is in God’s hands and that they
wish to give God every opportunity
to restore the patient to health. God
will decide. Others continue to argue
with various members of the health
care team that they do not believe
the diagnosis. They cite anecdotal
stories of individuals written off as
brain-dead who are now alive and
fully functional. Their goal is to keep
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