The cases of Marlise Munoz in Texas and Jahi McMath in California raise anew questions of how we respect the end of life
What does "life support" mean when the body connected to machines has been dead for a month? What do "best interests" mean, and whose are being served? The meanings can be quite different to a family than to a critical care nurse. And meaning is everything in the ongoing "care" of Marlise Munoz , a 33-year-old brain-dead, pregnant woman in Fort Worth, Texas, and Jahi McMath , a 13-year-old whose death certificate was signed on Sunday by a coroner in Northern California before she was released to her family for treatment at an undisclosed location.
So we are in a time in America when the medically and legally dead are being checked out of one hospital to pursue further treatment elsewhere, and a dead woman is kept functioning mechanically to serve the interests of a not-yet-viable fetus.
This is not some episode on a cable TV channel. Check that. It is, actually. On Fox News over the weekend, Mike Huckabee, the onetime and possibly future presidential candidate, interviewed Terri Schiavo's brother and a country singer, and they were in agreement that comatose and brain dead are pretty much the same thing. There was no neurologist on the show to say otherwise. And no critical care nurse.
Now that 31% of America believes doctors should "do everything in all circumstances" to keep someone alive, according to Pew Research, we desperately need more light than heat on this subject. So best step away from the TV clicker.
Social networks, too, are full of inflamed, poorly informed dialogue about both cases. No surprise there. But they also are the sources of invaluable information, and informed dialogue involving the public and crucial to improved end-of-life care and decision-making.
Before writing this story, I reread a document (pdf) that I discovered via Twitter from the US District Court in Northern California. It is a pediatric critical care specialist's description of Jahi McMath's irreversible "post-mortem bodily deterioration".
And it is a look at what happens to a newly dead body from the medical perspective – a process slowed but not reversed by ventilators and feeding tubes. The description is not easy to read, but what makes it difficult reading also makes it crucial to understanding such conflict. You will discover what "the inability of (a brain-dead body) to regulate life-sustaining functions" really means.
That "her body is sloughing her gut" is one important medical reason why inserting a gastrointestinal tube was not in McMath's best interest – she is dead.
When alive, a person coughs to clear the airways. This is initiated by the brainstem. But as the brainstem no longer functions among the brain dead, this clearing does not occur unless performed by a nurse, most likely.
Dr Heidi R Flori writes:
Although we are applying inhaled therapy twice daily to improve the body's 'pulmonary toilet' (its clearance of pulmonary respiratory secretions), its secretions are continuing to change adversely with time. They are now more malodorous, changed in color (sometimes tan, creamy or bloody) and thicker in consistency.
It's not my goal here to offend. I wouldn't include Flori's written testimony at all but for a recent conversation I had with an longtime ICU nurse at a medical ethics conference. I had just participated on a panel concerning community perspectives about intractable disputes in futile care of the dying, and the nurse was angry. Not at me, but at the nature of the problem. The nurse was tired of having his integrity questioned.
I hope he doesn't quit before I need him. Maybe part of the problem is hidden in this section of Flori's testimony. While McMath's body is breaking down internally, Flori writes, "the medical team has done an excellent job of maintaining the body's external appearance (the hair is done, nails manicured, etc)".
What a hopeful family sees is not what an ICU nurse sees, and what the nurse sees is captured unforgettably in Flori's testimony.
When Marlise Munoz collapsed on her kitchen floor, she was 14 weeks pregnant. She is now about 20 weeks pregnant. But it is not her life that is being supported. Her life is over. Her father, his grief on hold, says his daughter feels like a mannequin. Now she is a vehicle for the state of Texas to support the life of her unborn child, against the wishes of her husband and family, and against Marlise's own wishes.
Texas is not unique in this. About half the states in the US prohibit withholding or withdrawing life support when the woman is pregnant, though it is unclear if that was meant to include the brain dead.
But nowhere in the US are the extremes of end-of-life care in higher relief than in Texas, where the Texas Advance Directives Act gives hospitals legal authority to cease all measures determined to be non-therapeutic regardless of what the family wants. And now Texas is keeping a dead woman functioning mechanically regardless of what the family wants.
Is this right? I'd like to hear from Marlise Munoz's nurse.
Allowing the dead to be dead is in their best interest. AMedical professionals are better positioned to determine this than the rest of us. Families need recourse, but it can't be to demand that medical professionals disregard their own integrity. Reported by guardian.co.uk 21 hours ago.
What does "life support" mean when the body connected to machines has been dead for a month? What do "best interests" mean, and whose are being served? The meanings can be quite different to a family than to a critical care nurse. And meaning is everything in the ongoing "care" of Marlise Munoz , a 33-year-old brain-dead, pregnant woman in Fort Worth, Texas, and Jahi McMath , a 13-year-old whose death certificate was signed on Sunday by a coroner in Northern California before she was released to her family for treatment at an undisclosed location.
So we are in a time in America when the medically and legally dead are being checked out of one hospital to pursue further treatment elsewhere, and a dead woman is kept functioning mechanically to serve the interests of a not-yet-viable fetus.
This is not some episode on a cable TV channel. Check that. It is, actually. On Fox News over the weekend, Mike Huckabee, the onetime and possibly future presidential candidate, interviewed Terri Schiavo's brother and a country singer, and they were in agreement that comatose and brain dead are pretty much the same thing. There was no neurologist on the show to say otherwise. And no critical care nurse.
Now that 31% of America believes doctors should "do everything in all circumstances" to keep someone alive, according to Pew Research, we desperately need more light than heat on this subject. So best step away from the TV clicker.
Social networks, too, are full of inflamed, poorly informed dialogue about both cases. No surprise there. But they also are the sources of invaluable information, and informed dialogue involving the public and crucial to improved end-of-life care and decision-making.
Before writing this story, I reread a document (pdf) that I discovered via Twitter from the US District Court in Northern California. It is a pediatric critical care specialist's description of Jahi McMath's irreversible "post-mortem bodily deterioration".
And it is a look at what happens to a newly dead body from the medical perspective – a process slowed but not reversed by ventilators and feeding tubes. The description is not easy to read, but what makes it difficult reading also makes it crucial to understanding such conflict. You will discover what "the inability of (a brain-dead body) to regulate life-sustaining functions" really means.
That "her body is sloughing her gut" is one important medical reason why inserting a gastrointestinal tube was not in McMath's best interest – she is dead.
When alive, a person coughs to clear the airways. This is initiated by the brainstem. But as the brainstem no longer functions among the brain dead, this clearing does not occur unless performed by a nurse, most likely.
Dr Heidi R Flori writes:
Although we are applying inhaled therapy twice daily to improve the body's 'pulmonary toilet' (its clearance of pulmonary respiratory secretions), its secretions are continuing to change adversely with time. They are now more malodorous, changed in color (sometimes tan, creamy or bloody) and thicker in consistency.
It's not my goal here to offend. I wouldn't include Flori's written testimony at all but for a recent conversation I had with an longtime ICU nurse at a medical ethics conference. I had just participated on a panel concerning community perspectives about intractable disputes in futile care of the dying, and the nurse was angry. Not at me, but at the nature of the problem. The nurse was tired of having his integrity questioned.
I hope he doesn't quit before I need him. Maybe part of the problem is hidden in this section of Flori's testimony. While McMath's body is breaking down internally, Flori writes, "the medical team has done an excellent job of maintaining the body's external appearance (the hair is done, nails manicured, etc)".
What a hopeful family sees is not what an ICU nurse sees, and what the nurse sees is captured unforgettably in Flori's testimony.
When Marlise Munoz collapsed on her kitchen floor, she was 14 weeks pregnant. She is now about 20 weeks pregnant. But it is not her life that is being supported. Her life is over. Her father, his grief on hold, says his daughter feels like a mannequin. Now she is a vehicle for the state of Texas to support the life of her unborn child, against the wishes of her husband and family, and against Marlise's own wishes.
Texas is not unique in this. About half the states in the US prohibit withholding or withdrawing life support when the woman is pregnant, though it is unclear if that was meant to include the brain dead.
But nowhere in the US are the extremes of end-of-life care in higher relief than in Texas, where the Texas Advance Directives Act gives hospitals legal authority to cease all measures determined to be non-therapeutic regardless of what the family wants. And now Texas is keeping a dead woman functioning mechanically regardless of what the family wants.
Is this right? I'd like to hear from Marlise Munoz's nurse.
Allowing the dead to be dead is in their best interest. AMedical professionals are better positioned to determine this than the rest of us. Families need recourse, but it can't be to demand that medical professionals disregard their own integrity. Reported by guardian.co.uk 21 hours ago.