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Dead Still(2014)

Death seems one of life's few certainties, but the cases of a girl and a young woman who are being kept on life support even though they are legally dead show how difficult it still can be to agree on the end of life.

Dead Still(2014)

The husband and parents of 33-year-old Marlise Munoz in Fort Worth, Texas, were ready to accept their loss when doctors declared her brain dead after a suspected brain embolism. But Munoz was 14 weeks pregnant when she was afflicted. Because of that, the hospital has refused to remove her from a ventilator, despite her loved ones' wishes.

Both cases run counter to a definition of death that has been used for decades, with rare exceptions. If a person experiences the "irreversible cessation of all functions of the brain," he or she is considered legally dead.

Nailah Winkfield, mother of 13-year-old Jahi McMath, at a court hearing on Dec. 20, 2013, in Oakland, Calif. The family opposed hospital efforts to disconnect Jahi from life support, even though she was declared brain dead. Ben Margot/AP hide caption

Doctors use a slew of different tests to determine if a person is brain dead. They test reflexes and see if the patient tries to breathe when carbon dioxide levels in the blood increase. If the patient shows no signs of brain function throughout these tests, they are officially brain dead.

A brain-dead person can never recover, Bernat says. The best doctors can do at that point is to offer compassion. That might mean keeping the patient on a ventilator until the family says its goodbyes.

Media coverage of brain death can cloud public understanding, Caplan says. "I've seen headlines that have said 'Little girl brain dead, now pronounced dead,' " he says. "That gives the suggestion that maybe brain death isn't death."

"The fight over what it means to be dead is essentially a philosophical or religious fight," says Robert Veatch, a professor of medical ethics at Georgetown University's Kennedy Institute of Ethics. "In many ways," he says, "it's the abortion question at the other end of life."

"At least in New Jersey there can be living people with dead brains," Veatch tells Shots. A coroner can choose to hold off on declaring that a brain-dead person is dead if the family objects to that definition of death for religious reasons.

There are three main schools of thought on death, Veatch says. There's the commonly accepted view that a person is dead when all brain functions cease. But there's also the view that a person is only dead after their heart stops beating. That's the view held by many Orthodox Jews and Native Americans, as well as some Catholics and fundamental Protestants, Veatch says.

And there's a third variation. While most definitions of brain death mean that all parts of a person's brain are out of commission, Veatch and some others believe that a person can be brain dead even if certain minor functions of the brain remain. For example, if a patient shows a gag reflex, but no other signs of life, they should be considered brain dead.

Once brainstem function is lost, breathing stops first and the heart soon thereafter. If in the acute phase the patient can be intubated, placed on a mechanical ventilator, sufficiently oxygenated, fluid resuscitated, and vasopressors and vasopressin added, this agonal sequence can potentially be prevented. Once an untreatable catastrophic neurologic structural injury has been proven while in this supported state, recovery does not occur and there is no known effective medical or surgical intervention. Irreversibility is determined by absent motor responses, loss of all brainstem reflexes, and apnea after a CO2 challenge and not by further waiting. After this state is reached, blood pressure is unstable and often relentlessly declining despite efforts to stabilize it. Cardiac arrhythmias appear and typically multisystem injury as a result of a widespread inflammatory response and intravascular coagulation occurs. Support measures are complex, often fail, and the ability to maintain a brain dead body is virtually impossible. There is no disagreement that brain death is a distinct clinical neurologic state and different from all other manifestations of acute or prolonged coma. For example, the clinical findings in brain death are different from those of comatose patients, where patients eventually may be able to breathe on their own and when some or all brainstem reflexes are preserved. In the medical judgment of practicing neurointensivists, neurosurgeons, and all neurologic and neurosurgical societies and academies throughout the world, brain death constitutes death of the person.

Hours before the December 30 deadline, Judge Grillo issued another restraining order again stopping the hospital from removing support and giving the family until January 7, 2014, to make arrangements for her transfer. As a stipulation for transfer, the hospital lawyer and administrators required clearance from the county coroner that a dead body could be removed and transferred from their hospital. Although the hospital refused to allow either their surgical staff or outside medical staff to perform a tracheostomy and feeding tube placement necessary for her transfer to a long-term care facility, to our knowledge the hospital did not place restrictions on the family's access to the body, which remained in a monitored hospital bed throughout this time.

To our knowledge, no clinical guidelines have been developed for the purpose of determining how much time should be afforded to families for the purpose of grieving at the bedside following a declaration of death in the hospital. This likely reflects the great diversity of needs that grieving families have in such circumstances, as well as differing clinical settings in which death may occur (e.g., intensive care units, hospital nursing floors, hospital-based hospice units). When patients die in intensive care units, it is reasonable to expect that their bodies will be removed from those bed spaces within a few hours due to the need for other patients to receive the heavily monitored care available in those units. On rare occasions, it may be permissible for hospitals to depart from this general practice in order to balance competing moral imperatives. For example, appeals to beneficence or social justice may support short-term extensions of care following a declaration of death by neurologic criteria as a way to support grieving families or facilitate grieving rituals that are responsive to the cultural or religious needs of some families. In remarkable situations where a family member is in transit from a distant location or is otherwise unavailable for a short time, for example, a hospital facility may elect to continue providing limited care to an individual who has been declared dead.

We are not familiar with situations in which new medical interventions have been provided to deceased patients for an extended period of time such as was requested by Jahi's family.18 This is appropriate, as intentionally providing medical care to a deceased person may compromise the professional integrity of physicians. Doing so also may foster misconceptions about the deceased patient's status as dead, detract from the care of living patients, and create significant moral distress for medical professionals. Hospitals that accommodate a family's request to extend the provision of care to a deceased person must weigh these risks against their commitment to supporting the moral integrity of their physicians, with each unique case being evaluated individually to determine what is ethically permissible.

Now, St. John has died, according to his attorney Mark Geragos and the Los Angles Police Department. Reports from TMZ and CBS2 added that St. John, who played Neil Winters on the daytime drama for nearly 30 years, was found dead Sunday afternoon in his Woodland Hills home, with the cause suspected to be alcohol poisoning.

Early enteral nutrition (EN) is consistently recommended as first-line nutrition therapy in critically ill patients since it favorably alters outcome, providing both nutrition and nonnutrition benefits. However, critically ill patients receiving mechanical ventilation are at risk for regurgitation, pulmonary aspiration, and eventually ventilator-associated pneumonia (VAP). EN may increase these risks when gastrointestinal (GI) dysfunction is present. Gastric residual volume (GRV) is considered a surrogate parameter of GI dysfunction during the progression of enteral feeding in the early phase of critical illness and beyond. By monitoring GRV, clinicians may detect patients with delayed gastric emptying earlier and intervene with strategies that minimize or prevent VAP as one of the major risks of EN. The value of periodic GRV measurements with regard to risk reduction of VAP incidence has frequently been questioned in the past years. Increasing the GRV threshold before interrupting gastric feeding results in marginal increases in EN delivery. More recently, a large randomized clinical trial revealed that abandoning GRV monitoring did not negatively affect clinical outcomes (including VAP) in mechanically ventilated patients. The results have revived the discussion on the role of GRV monitoring in critically ill, mechanically ventilated patients receiving early EN. This review summarizes the most recent clinical evidence on the use of GRV monitoring in critically ill patients. Based on the clinical evidence, it discusses the pros and cons and further addresses whether GRV is a dead marker or still alive for the nutrition management of critically ill patients.

Wilson was born dead in the American Midwest in 1930. He was blue and not breathing at birth from the anesthesia administered to his mother. A pediatrician happened on him before he was placed in a casket and held him under cold water until he revived. It seems as if he has spent a lifetime embodying this moment as metaphor in his dark, shocking, and ultimately life-affirming art. 041b061a72


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