Paul A. Byrne, M.D.
Execution in a New York hospital
By Paul A. Byrne, M.D.
Michael, 60 years old, had just finished eating. Michael and his family were watching television when Michael suddenly slumped and fell to the floor. His family called 911. The emergency medical team resuscitated Michael. On the way to the hospital, a pulse was detected. Medications to support blood pressure were used during the resuscitation.
A diagnosis of mental illness was made many years earlier. Michael had no known physical illness prior to his collapse. Michael lived with his mother and sisters. They were Catholic and lived in accord with the teachings of the Catholic Church. Michael did not use tobacco or drink alcohol. Michael took 2 medications for his mental illness. Both affect the brain; one of them "increases risk of death."
On admission to hospital, Michael was breathing, but unresponsive. He was anemic (Hemoglobin 8) and his white blood cells showed many young forms (occurs with infection). On admission, his temperature was normal, but the next morning was elevated to 103 degrees (occurs with infection).
One consultant wrote, "There has apparently been some discussion back-and-forth between the hospitalist team, the intensivist, and the organ donor people as to how to properly manage him." In less than 24 hours after admission to hospital the neurology consultant wrote, "Limited neurological examination. The patient is unresponsive. Pupils are fixed. Absent corneal reflex bilaterally. Absent doll's eyes. No purposeful movements of the extremities noted. No movements of extremities to noxious stimuli. Reflexes are absent throughout. Toes are mute. IMPRESSION:... clinically, the patient is brain-dead status post cardiac arrest, likely with severe anoxic damage to the brain. May consider, do not resuscitate."
EEG showed "intermittently fast background activity of very low amplitude. Anteriorly also record consist of an irregular fast activity of small amplitude. No focal slowing or frank epileptiform features noted throughout the recording."
Sodium was abnormally elevated to 157 mEq/L; repeat was 162. Two days after admission he was determined to be "brain dead" per neurology. During an apnea test, no breathing was observed.
No blood levels of drugs that were prescribed or any other drugs were obtained. No cause of collapse of Michael was overtly considered other than statements that Michael had suffered from lack of oxygen and that Michael was "brain dead." It didn't matter that there was brain wave activity and that his heart was beating 100,000 times per day and that circulation and respiration were occurring with support from the ventilator.
Michael's relatives were assured that the determination of "brain death" was done in accordance with the hospital policy of certification of death by neurological criteria, which is patterned after, and consistent with, the New York State Department of Health and New York State Task Force on Life & the Law, "Guidelines for Determining Brain Death," published November 2011. In this document "brain death" is defined as "irreversible loss of all function of the brain. The three essential findings are coma, absence of brainstem reflexes and apnea." It was determined by a neurologist, an intensivist, and a hospitalist that there were no "confounding clinical circumstances." Under New York State law, Michael was determined to be "brain-dead" and was legally dead.
A Catholic priest who is Chairman of the Ethics Committee at the hospital volunteered that the hospital operated in accordance with the Ethical and Religious Directives of the Catholic Bishops. This man was legally "brain dead" and ventilator support of the vital activity of respiration would be stopped at a precise hour and Do Not Resuscitate (DNR), which was already in place over the objection of the relatives, would be carried out. The ventilator was then taken away at the precise hour, even though Michael's relatives strongly objected. Prior to removal of the ventilator Michael's heart was beating; blood pressure was normal. Michael had respiration supported by a ventilator that pushed air in. Michael had to push the air out before the ventilator could push the air in again. A ventilator can push air into a cadaver, also known as a corpse, but quickly after death, the air will not and cannot come out of a cadaver.
Michael was judged to be "brain dead" shortly after arrival at the hospital, which Michael's relatives and the general public expect to be a healing center. In the hospital Michael was sentenced without a trial to true death. How was true death imposed on Michael? The Uniform Determination of Death Act (UDDA) includes "irreversible cessation of all functions of the entire brain." Note that the word "functions" is plural.
The statute in New York includes "total and irreversible cessation of brain function." Thus, the statute has reduced the plural "functions" to the singular "function." The brain has many functions; absence of any function as determined by the three doctors in the New York Hospital meant absence of "all function." Thus, the statute and Rules do not protect the life of the patient.
The Rules and Regulation call for providing "reasonable accommodation of a Surrogate Decision-maker's religious or moral objections to use of the brain death standard to determine death." Michael's mother and sisters pleaded with the administrator of the hospital not to take away the ventilator, but the judgment had been made; nothing could be done to stop the removal of the ventilator. It was the hospital's decision that they had provided "reasonable accommodation" to Michael's family's religious and moral objections to the "brain death" criteria used by the hospital. They had a Catholic priest, the Ethics Committee, and it was stated that they were operating in accordance with the Ethical and Religious Directives of the Catholic Bishops. It was also stated that they had a judge who agreed with what they were doing and they would give no more time to Michael, not even one more hour or one more day!
Prior to 1968, ventilators were in use but there was no controversy. Patients died on ventilators. So how did all these issues that involve taking organs and stopping ventilators come about? The goal of medical practice used to be that a living person would not be declared dead. Until the advent of mechanical ventilators and other complex life supporting therapies, the mistake of judging a dead person as alive was practically impossible. Prior to these developments and the desire to do vital organ transplantation, medicine made every effort to judge the moment of death in the direction of preserving human life from a death-dealing mistake.
"Brain death" did not originate or develop by way of application of the scientific method. "Brain death" began with the appointment of the Harvard Committee to consider the issues. The results of their work were in the "Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death." [1] The first words of this report are as follows: "Our primary purpose is to define irreversible coma as a new criterion for death." Only persons who are alive can be in a coma, whether reversible or not. Was this the hubris of a few academicians or was it simply a surrender to fear of legal chastisement regarding perceived economic and utilitarian needs in 1968, especially the desire to get healthy living vital organs for transplantation? It seems that a predetermined agenda existed from the onset. There were no patient data and no references to basic scientific studies. In fact, there was only one reference, which was to Pope Pius XII. [2] While there was a reference to and a quotation from this Allocution of Pope Pius XII, they neglected to include the following: "But considerations of a general nature allow us to believe that human life continues for as long as its vital functions – distinguished from the simple life of organs – manifest themselves spontaneously or even with the help of artificial processes."
The primary purpose of the Committee was not to determine IF irreversible coma was an appropriate criterion for death but to see to it that IT WAS established as a "new criterion for death." With an agenda like that at the outset, the data could be made to fit the already arrived at conclusions. There was a serious lack of scientific method in the origination and development of "brain death."This has continued to the present time where there is no consensus as to which of the myriad of sets of criteria to use and criteria for "brain death" are not evidence based.
"Brain death" is not true death. Rather it is observing cessation of functioning of the brain, which is then translated into "brain death." The primary reason for the origination and propagation of "brain death" was and is the desire to obtain vital organs for transplantation. It can now be ascertained that a validly applied scientific method, sound reasoning, and available medical technology were not utilized in developing the new way of determination of death called "brain death" for the simple reason that death is the absence of life. Life and true death cannot and do not exist at the same time in the same person.
When a person has a head injury or, as in this case, sudden collapse, explainable or not, quickly the possibility of getting organs for transplantation is entertained. In Michael's case no attempt was made to get his organs. Why not? No reason was apparent to indicate that Michael's organs would not be suitable for transplantation. Was it related to mental illness? "Discussion with the organ donor people did occur." Quickly it was determined that Michael was "brain dead" and Do Not Resuscitate (DNR) was considered and later carried out over the objection of Michael's relatives.
Michael's mother and sisters wanted Michael to be treated. Why wouldn't they? They took care of Michael during his entire life. When Michael collapsed, they called 911 expecting to get help for Michael. Paramedics responded. During transport the pulse returned. At the hospital Michael was said to be "brain dead" based on absence of brain stem reflexes and no visual observation of breathing. The fact that Michael had electrical activity in his cerebral cortex, the largest part of his brain, meant nothing to the doctors who said all they needed was absence of the brain stem reflexes that they had tested and a positive apnea test (positive meaning that he did not show breathing efforts at that time sufficient for observers to see). I add that for these doctors at this New York hospital, they had all they needed to discontinue care! Yet, these doctors, quick to evaluate for "brain death," did not do basic diagnostic tests to rule out infection, identify causes of the metabolic derangements of his electrolytes nor did they test for the presence of obvious drugs or toxins as the reason for his sudden collapse. They did not provide basic supportive care more than 48 hours. Once they determined that he was not an organ donor, they seemed not only to want a "do not resuscitate order" in the event of another collapse, they were intent on withdrawing life-sustaining ventilator support making another collapse, anoxic events and death almost inevitable. They refused family wishes to continue to treat the patient and even denied them time to make transfer arrangements so that their loved one might have a chance at life at a different institution with different doctors. Michael, an innocent person, was effectively executed without trial in a New York hospital.
See: www.lifeguardianfoundation.org for information on how to protect and preserve your life.
NOTES:
© Paul A. Byrne, M.D.
October 29, 2013
Michael, 60 years old, had just finished eating. Michael and his family were watching television when Michael suddenly slumped and fell to the floor. His family called 911. The emergency medical team resuscitated Michael. On the way to the hospital, a pulse was detected. Medications to support blood pressure were used during the resuscitation.
A diagnosis of mental illness was made many years earlier. Michael had no known physical illness prior to his collapse. Michael lived with his mother and sisters. They were Catholic and lived in accord with the teachings of the Catholic Church. Michael did not use tobacco or drink alcohol. Michael took 2 medications for his mental illness. Both affect the brain; one of them "increases risk of death."
On admission to hospital, Michael was breathing, but unresponsive. He was anemic (Hemoglobin 8) and his white blood cells showed many young forms (occurs with infection). On admission, his temperature was normal, but the next morning was elevated to 103 degrees (occurs with infection).
One consultant wrote, "There has apparently been some discussion back-and-forth between the hospitalist team, the intensivist, and the organ donor people as to how to properly manage him." In less than 24 hours after admission to hospital the neurology consultant wrote, "Limited neurological examination. The patient is unresponsive. Pupils are fixed. Absent corneal reflex bilaterally. Absent doll's eyes. No purposeful movements of the extremities noted. No movements of extremities to noxious stimuli. Reflexes are absent throughout. Toes are mute. IMPRESSION:... clinically, the patient is brain-dead status post cardiac arrest, likely with severe anoxic damage to the brain. May consider, do not resuscitate."
EEG showed "intermittently fast background activity of very low amplitude. Anteriorly also record consist of an irregular fast activity of small amplitude. No focal slowing or frank epileptiform features noted throughout the recording."
Sodium was abnormally elevated to 157 mEq/L; repeat was 162. Two days after admission he was determined to be "brain dead" per neurology. During an apnea test, no breathing was observed.
No blood levels of drugs that were prescribed or any other drugs were obtained. No cause of collapse of Michael was overtly considered other than statements that Michael had suffered from lack of oxygen and that Michael was "brain dead." It didn't matter that there was brain wave activity and that his heart was beating 100,000 times per day and that circulation and respiration were occurring with support from the ventilator.
Michael's relatives were assured that the determination of "brain death" was done in accordance with the hospital policy of certification of death by neurological criteria, which is patterned after, and consistent with, the New York State Department of Health and New York State Task Force on Life & the Law, "Guidelines for Determining Brain Death," published November 2011. In this document "brain death" is defined as "irreversible loss of all function of the brain. The three essential findings are coma, absence of brainstem reflexes and apnea." It was determined by a neurologist, an intensivist, and a hospitalist that there were no "confounding clinical circumstances." Under New York State law, Michael was determined to be "brain-dead" and was legally dead.
A Catholic priest who is Chairman of the Ethics Committee at the hospital volunteered that the hospital operated in accordance with the Ethical and Religious Directives of the Catholic Bishops. This man was legally "brain dead" and ventilator support of the vital activity of respiration would be stopped at a precise hour and Do Not Resuscitate (DNR), which was already in place over the objection of the relatives, would be carried out. The ventilator was then taken away at the precise hour, even though Michael's relatives strongly objected. Prior to removal of the ventilator Michael's heart was beating; blood pressure was normal. Michael had respiration supported by a ventilator that pushed air in. Michael had to push the air out before the ventilator could push the air in again. A ventilator can push air into a cadaver, also known as a corpse, but quickly after death, the air will not and cannot come out of a cadaver.
Michael was judged to be "brain dead" shortly after arrival at the hospital, which Michael's relatives and the general public expect to be a healing center. In the hospital Michael was sentenced without a trial to true death. How was true death imposed on Michael? The Uniform Determination of Death Act (UDDA) includes "irreversible cessation of all functions of the entire brain." Note that the word "functions" is plural.
The statute in New York includes "total and irreversible cessation of brain function." Thus, the statute has reduced the plural "functions" to the singular "function." The brain has many functions; absence of any function as determined by the three doctors in the New York Hospital meant absence of "all function." Thus, the statute and Rules do not protect the life of the patient.
The Rules and Regulation call for providing "reasonable accommodation of a Surrogate Decision-maker's religious or moral objections to use of the brain death standard to determine death." Michael's mother and sisters pleaded with the administrator of the hospital not to take away the ventilator, but the judgment had been made; nothing could be done to stop the removal of the ventilator. It was the hospital's decision that they had provided "reasonable accommodation" to Michael's family's religious and moral objections to the "brain death" criteria used by the hospital. They had a Catholic priest, the Ethics Committee, and it was stated that they were operating in accordance with the Ethical and Religious Directives of the Catholic Bishops. It was also stated that they had a judge who agreed with what they were doing and they would give no more time to Michael, not even one more hour or one more day!
Prior to 1968, ventilators were in use but there was no controversy. Patients died on ventilators. So how did all these issues that involve taking organs and stopping ventilators come about? The goal of medical practice used to be that a living person would not be declared dead. Until the advent of mechanical ventilators and other complex life supporting therapies, the mistake of judging a dead person as alive was practically impossible. Prior to these developments and the desire to do vital organ transplantation, medicine made every effort to judge the moment of death in the direction of preserving human life from a death-dealing mistake.
"Brain death" did not originate or develop by way of application of the scientific method. "Brain death" began with the appointment of the Harvard Committee to consider the issues. The results of their work were in the "Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death." [1] The first words of this report are as follows: "Our primary purpose is to define irreversible coma as a new criterion for death." Only persons who are alive can be in a coma, whether reversible or not. Was this the hubris of a few academicians or was it simply a surrender to fear of legal chastisement regarding perceived economic and utilitarian needs in 1968, especially the desire to get healthy living vital organs for transplantation? It seems that a predetermined agenda existed from the onset. There were no patient data and no references to basic scientific studies. In fact, there was only one reference, which was to Pope Pius XII. [2] While there was a reference to and a quotation from this Allocution of Pope Pius XII, they neglected to include the following: "But considerations of a general nature allow us to believe that human life continues for as long as its vital functions – distinguished from the simple life of organs – manifest themselves spontaneously or even with the help of artificial processes."
The primary purpose of the Committee was not to determine IF irreversible coma was an appropriate criterion for death but to see to it that IT WAS established as a "new criterion for death." With an agenda like that at the outset, the data could be made to fit the already arrived at conclusions. There was a serious lack of scientific method in the origination and development of "brain death."This has continued to the present time where there is no consensus as to which of the myriad of sets of criteria to use and criteria for "brain death" are not evidence based.
"Brain death" is not true death. Rather it is observing cessation of functioning of the brain, which is then translated into "brain death." The primary reason for the origination and propagation of "brain death" was and is the desire to obtain vital organs for transplantation. It can now be ascertained that a validly applied scientific method, sound reasoning, and available medical technology were not utilized in developing the new way of determination of death called "brain death" for the simple reason that death is the absence of life. Life and true death cannot and do not exist at the same time in the same person.
When a person has a head injury or, as in this case, sudden collapse, explainable or not, quickly the possibility of getting organs for transplantation is entertained. In Michael's case no attempt was made to get his organs. Why not? No reason was apparent to indicate that Michael's organs would not be suitable for transplantation. Was it related to mental illness? "Discussion with the organ donor people did occur." Quickly it was determined that Michael was "brain dead" and Do Not Resuscitate (DNR) was considered and later carried out over the objection of Michael's relatives.
Michael's mother and sisters wanted Michael to be treated. Why wouldn't they? They took care of Michael during his entire life. When Michael collapsed, they called 911 expecting to get help for Michael. Paramedics responded. During transport the pulse returned. At the hospital Michael was said to be "brain dead" based on absence of brain stem reflexes and no visual observation of breathing. The fact that Michael had electrical activity in his cerebral cortex, the largest part of his brain, meant nothing to the doctors who said all they needed was absence of the brain stem reflexes that they had tested and a positive apnea test (positive meaning that he did not show breathing efforts at that time sufficient for observers to see). I add that for these doctors at this New York hospital, they had all they needed to discontinue care! Yet, these doctors, quick to evaluate for "brain death," did not do basic diagnostic tests to rule out infection, identify causes of the metabolic derangements of his electrolytes nor did they test for the presence of obvious drugs or toxins as the reason for his sudden collapse. They did not provide basic supportive care more than 48 hours. Once they determined that he was not an organ donor, they seemed not only to want a "do not resuscitate order" in the event of another collapse, they were intent on withdrawing life-sustaining ventilator support making another collapse, anoxic events and death almost inevitable. They refused family wishes to continue to treat the patient and even denied them time to make transfer arrangements so that their loved one might have a chance at life at a different institution with different doctors. Michael, an innocent person, was effectively executed without trial in a New York hospital.
See: www.lifeguardianfoundation.org for information on how to protect and preserve your life.
NOTES:
[1] Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. Special Communication. JAMA 1968;205(6):85-88.
[2] Pius XII. To an International Congress of Anesthesiologists, Nov. 24, 1957, The Pope Speaks, Vol. 4, No. 4 (Spring 1958), 393–398.
© Paul A. Byrne, M.D.
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