Wednesday, December 22, 2010

Brain Dead?

Sam was late and Ella was furious. "Now why isn't that man back by now? He knows it's time to leave for church."

The hours began to pass and Ella became frightened. Sam had gone out for his usual two mile run and had simply disappeared. Ella called friends and neighbors but no one had seen him. Panic began to set in so Ella called 911 who connected her to the police, "No mam, we've had no reports or contact with anyone by that name."

Finally in desperation, Ella began to check with hospitals which also had no knowledge of Sam. In checking John's dresser in the bedroom, Ella found his wallet, car keys, and cell phone. She was stunned, "Of course they didn't know anyone by that name. He had no ID with him."

With persistence she got through to the administrator of the 911 crew. That morning at 10:03AM they had received a call from a metro bus driver that a man was down and not moving on the sidewalk. The Medics found him not breathing, with no pulse, and the heart in ventricular fibrillation. CPR and shocks revived him to the point that his circulation was reestablished. He was admitted to the trauma center as a "John Doe" and kept on life support. When Ella arrived at the hospital and found her husband, she was overwhelmed by the sight of her husband. A tube protruded out of his mouth, another tube was in his nose, and a heart monitor quietly beeping plus IV's in his arms. "Is this really happening? Have I lost him?", she thought to herself while trying to be brave for her children.

It was determined that Sam had had a severe heart attack while jogging bringing his heart rhythm to a standstill. The heart, lungs, and kidney were all working once again but how about the brain?

The testing over the next few days was extensive. Sam had no significant brain activity with an EEG. Perhaps even more discouraging was the complete absence of blood flow to the higher centers of the brain. The hope for Sam to return to his prior life was nil.

I came into the picture when Sam was transferred to my hospital's ICU for "on going care". As a treating physician my obligation is first to the patient and then to the family. Sometimes this is easy, but sometimes loaded with conflict. Fortunately Sam and Ella had a strong family structure with two beautiful teenagers (Adella and Isaiah).

When I went into the ICU that afternoon, I listened to their pastor coincidentally reading from the Bible in the book of Isaiah, "For as the rain comes down, and the snow from heaven, and returns not thither, but waters the earth, and makes it bring forth and bud, that it may give seed to the sower, and bread to the eater. So shall my word be that goes forth out of my mouth: it shall not return unto me void, but it shall accomplish that which I please, and it shall prosper in the thing whereto I sent it. For ye shall go out with joy, and be led forth with peace: the mountains and the hills shall break forth before you into singing, and all the trees of the field shall clap their hands."

They were celebrating Sam's life. The pastor explained, "The soul is present but the body too damaged to further clothe the soul. The real Sam will live on." We discussed the hopeless situation of Sam's brain and the options of continuing ventilator support (a better term here than life support) along with a feeding tube. The Neurologist had met with them and explained the complete absence of meaningful brain function. The family and pastor further met with the hospital social worker. They felt clearly that Sam would want to removed from the ventilator and allow to die naturally and peacefully.

They were taken aback though when a transplant coordinator wanted to meet with them. Per protocol, the ICU staff had notified the regional transplant center about the potential of an organ donor. The transplant center confirmed that Sam was a registered donor (per his driver's license election). Ethically, I needed to keep a distance from the transplant team and remain focused on Sam my patient. However Ella and the children and pastor agreed to meet with the transplant coordinator to discuss how Sam could benefit many people, even more than a dozen as a donor. His organs could live on being useful and life saving to a recipient.

Initially Ella was queasy, "Isn't this somehow disrespectful to the deceased? How can I allow my husband to be cut open when he's barely dead?" Ella said she prayed over this overnight asking God what to do. Somehow, she found the greatest peace by carrying out Sam's wishes to be a donor. They were reassured that the transplant team would treat Sam's body with great respect and that his organs could benefit many people. The children appeared bewildered but were accepting. The tears flowed.

Comment: I'm not sure how many organs were harvested from Sam. I did hear that the transplant team followed protocol. The heart was allowed to stop for 120 seconds (no heart will spontaneously restart after that) to ensure that death had occurred. This is a precaution so that organs are not removed from the living, but the need to wait these two minutes in a brain dead person has been questioned. A recent Scientific American issue entitled "The End" has an excellent review of the ethical debate involved.

Out of the blue, eight years after Sam's death, I received a call from Ella, "Hi Dr. deMaine, do you remember me." Some patients really stand out, so I immediately recalled the trials of Sam's death. Ella said she wanted again to thank me for my care, but she was really calling to let me know that the children had both graduated from college. Then she shyly added, "And you know, for the first time since Sam's passing, I've started a relationship - and am so happy!" We agreed that although the pain of the past doesn't really disappear, life (and love) does go on.

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