Hospitals have always served as a lifeline to survival. Whether from pneumonia, heart attack, stroke, or trauma, they have been a community safeguard between life and death.
Today, cost of care has been added to the patient treatment discussion forcing medical decision-making to look closely at expense. Financial considerations have come to the forefront as preservation of resources will be important to national healthcare. This can be a threat to hospitalized patients teetering on the edge of life where the gray-zone of technology does not provide all answers, especially regarding brain death. There are adverse and often tragic results of uncertainty in this diagnosis.
A two year old is swiftly removed from life-support by a hospital before the family can appeal a court order. A son has Power of Attorney to make decisions for his recently stroked mother and requests a feeding tube, but is denied by the hospital. A family sees their father declared “brain dead” by two doctors, both employed by the hospital, and the ventilator is disconnected.
Can we assure a hospital is making decisions solely on behalf of the patient they serve, as opposed to maximizing profits that personally benefit administrators in salaries, bonuses, and retirement packages?
How do we protect the medical and legal rights of a hospitalized gravely-ill patient from potential abuse?
Declaring someone dead in the past was not complicated. No breathing or pulse = dead. With technology though, patients can survive on life support — ventilator for breathing; artificial pacemaker to sustain pulse; medication to maintain blood pressure; and feeding tube for nutrition.
This might preserve the body, but here is the fundamental question: Is the brain viable and will the patient be able to return to a normal life? No one has this answer. But because the legal criteria and implementation for “Brain Death” is loose and inconsistent, some hospitals and their lawyers have exploited this ambiguity forcing termination of care.
To be declared brain dead, certain medical criteria must be met. Some are achieved at bedside by doctor physical exam, and others defined by testing evolved through scientific technology (EEG – brain wave studies; blood flow exams; or apnea test). Because of extreme variation of physician education and testing interpretation, application of criteria is not consistent and therefore could be subject to manipulation.
To protect patients from potential abuse, doctors and the public must be better educated on brain death criteria. Loopholes must be shored up and criteria standardized. With ever-changing science, new testing (like fMRI – a video of brain function) should be harnessed. And finally, utilizing the hospital Ethics Committee, or having available legal advice through patient advocating ombudsmen can serve as a guide.
We must be aware of the threat profit and greed play in healthcare. Through education and vigilance, protecting the vulnerable against those who exploit a deficient and susceptible system might safeguard against adverse and tragic results.
Gene Uzawa Dorio, M.D.
Thank you Dr. Dorio for this article. I want to make comments from a mental health/neuroscience POV. Head injury has not been specialty because it has been pretty much controlled by the medical field. My interest comes from my study of neuroscience and biofeedback therapies and my practice of biofeedback and neurofeedback in Santa Clarita for the last 30 years. most of my neurofeedback practice has been to treat people with Attention Deficit Disorder, 1st by getting a quantitative EEG brain map where the brain is compared to a database of normals to see which parts are over or under aroused and which parts over or under communicating to other parts (to give a simple description). Once we see the which parts of the brain are more than 2 standards of deviation, we know where to place electrodes and which frequencies to train. In the 1980s I started reporting on the working of Margaret Ayers, a neuropsychologist in Beverly Hills who was pulling people out of coma, by examining the EEG and then feeding back brainwave signals. She would hold the patient’s eye lids open and tell them to try and make the wiggle on the computer screen to get larger. If the person was locked in with some degree of consciousness, they would exercise their brain and kick in increased brainwave activity and many pulled out of coma.. There have been more professional studies published in peer reviewed journals since then on the efficacy of neurofeedback for head trauma and the military is using neurofeedback in many clinics to help soldiers who have sustained head injury. Though I have taken this discourse to a side bar I am happy to answer any questions on this specialized work if your readers want to contact me
May I refer you to “Brain Death: Tread Lightly, Treat Vigorously,” CLINICAL ELECTROENCEPHALOGRAPHY (CLINICAL EEG), 1984 (VOL. 15, No. 1) by the undersigned? This editorial was inspired or triggered by a zealous transplant team from another hospital that appeared suddenly, like uninvited guests, while the patient was undergoing EEG. They were uninvited just as quickly — Robert Weinmann, MD, San Jose, then editor, CLINICAL EEG
I agree that the definition and diagnosis of “brain dead” needs standardization. However, I think you may be pointing your finger at the wrong entity. Insurance companies pay so little that many hospitals have closed in the past. I received a $96k bill recently for an accident that caused my hospitalization. The insurance paid pennies on the dollar. If hospitals or us as individuals had to bear the financial burden for patient care, we would all be bankrupt. Sometimes the answer isn’t so easy and cost had to be weighed into the decision as sad as it is.
I would argue for having doctors making this decision be free of financial influence by any party other than the patient: I would exclude the employees of the hospital.
H. E. Butler III M.D., FACS
HButler@post.Harvard.edu