Resuscitation theater ("slow codes"), and Medical Aid in Dying

 Here's an article pointing out that "slow codes" often constitute resuscitation theater, i.e. they are a way to follow bureaucratic directives requiring attempted resuscitation after cardiac arrest in hospitals, when the physicians don't think that would be in the patient's best interest, i.e. when resuscitation would only prolong dying and suffering.  I think this should be part of the discussion of the kinds of "covert" medical aid in dying that takes place even in jurisdictions that don't legally authorize physicians to help shorten the dying process.

McLennan S, Bak M, Knochel K. Slow Codes are symptomatic of ethically and legally inappropriate CPR policies. Bioethics. 2025 May;39(4):327-336. doi: 10.1111/bioe.13396.

Abstract: Although cardiopulmonary resuscitation (CPR) was initially used very selectively at the discretion of clinicians, the use of CPR rapidly expanded to the point that it was required to be performed on all patients having in‐hospital cardiac arrests, regardless of the underlying condition. This created problems with CPR being clearly inadvisable for many patients. Do Not Resuscitate (DNR) orders emerged as a means of providing a transparent process for making decisions in advance regarding resuscitation, initially by patients and later also by clinicians. Under hospital policies in many countries, however, CPR remains the default position for all patients having cardiac arrest in the hospital if there is no DNR order in place, regardless of whether CPR is medically indicated or in the patient's best interests. “Slow Codes” are the delayed or token efforts to provide CPR when clinicians feel CPR is futile or inappropriate. After giving a historical overview of the development and the changing use of CPR, we argue that more attention needs to be given to the cause of slow codes, namely, policies requiring CPR to be performed as the default action while simultaneously lacking implementing interventions such as advance care planning as a routine policy. This is ethically and legally inappropriate, and hospital policies should be modified to allow clinicians to consider whether CPR is appropriate at the time of arrest. Such a change requires a stronger emphasis on early recognition of patients for whom CPR is not in their best interests and to improve hospital emergency planning.

" Proponents of the ‘slow code’ find that intentionally delaying CPR might, in some cases, be a more compassionate alternative to aggressive and potentially futile interventions.

...

"Cardiopulmonary resuscitation is indicated for the patient who, at the time of cardiopulmonary arrest, is not in the terminal stage of an incurable disease. Resuscitative measures on terminal patients will, at best, return them to the dying state. The physician should concentrate on resuscitating patients who were in good health preceding the arrest, and who are likely to resume a normal existence"

Jewish cemetery and Pinkas synagogue in Prague

 During our visit to Prague in May we visited the Old Jewish Cemetery, crowded with the dead from the historic Jewish Ghetto.

 We also visited the Pinkas synagogue, whose walls are covered with the names of those murdered in the Shoah, with their birth dates and death dates.  The birth dates reveal a vibrant community, from small children to senior citizens.  The dates of death are all from 1942 to 1944.

 

New York State senate passes medical aid in dying bill

 Yesterday the NY State Senate took the next step in making medical aid in dying legal in NY.  Now the bill goes to the governor...

The NYT has the story:

New York Moves to Allow Terminally Ill People to Die on Their Own Terms
A bill permitting so-called medical aid in dying passed the State Legislature and will now head to Gov. Kathy Hochul for her signature. by Grace Ashford

"Eleven states and the District of Columbia have passed laws permitting so-called medical aid in dying. The practice is also available in several European countries and in Canada, which recently broadened its criteria to extend the option to people with incurable chronic illnesses and disabilities.

The bill in New York is written more narrowly and would apply only to people who have an incurable and irreversible illness, with six months or less to live. Proponents say that distinction is key.

“It isn’t about ending a person’s life, but shortening their death,” said State Senator Brad Hoylman-Sigal, a Manhattan Democrat and one of the sponsors of the bill. It passed on Monday night by a vote of 35 to 27, mostly along partisan lines.

...

"The bill was first introduced a decade ago by Assemblywoman Amy Paulin, a Westchester Democrat who leads the body’s Health Committee, at a time when few states were considering such measures.

...

"The bill has earned the support of a range of powerful interest and advocacy groups, including the New York State Bar Association, the New York State Psychiatric Association, the Medical Society of the State of New York and the New York Civil Liberties Union.

"While it was also backed by some religious groups, including Congregation B’nai Yisrael, a Westchester synagogue, and Catholics Vote Common Good, it was staunchly opposed by the New York State Catholic Conference."

Disturbing NYT report about an Organ Procurement Organization in Kentucky

 Deceased donation of organs mostly occurs after potential donors suffer brain death, which, roughly speaking, means the loss of all organized brain activity, including the automatic activities that control breathing and heartbeat.  If the deceased died while on a ventilator, their organs continue to get oxygen, and may be able to save other lives through organ donation.

But sometimes the patient appears to be dead, but there's still enough brain activity to potentially support breathing and heartbeat.  If the decision is made to remove the patient from the ventilator, breathing and heartbeat may cease very quickly, and the patient dies (including brain death which follows the loss of blood  circulation).  In some cases the patient can be reconnected to the ventilator and become a potential organ donor. This is called Donation after Circulatory Death (DCD).  But sometimes the patient doesn't die right after being removed from the ventilator, and might remain alive, for some time,  and even posssibly recover.

Today's NYT reports cases in Kentucky in which the Organ Procurement Organization (OPO) apparently tried to press physicians to declare death prematurely,.

Doctors Were Preparing to Remove Their Organs. Then They Woke Up.   A federal investigation found a Kentucky nonprofit pushed hospital workers toward surgery despite signs of revival in patients.   By Brian M. Rosenthal  June 6, 2025,

"[A federal] investigation examined about 350 cases in Kentucky over the past four years in which plans to remove organs were ultimately canceled. It found that in 73 instances, officials should have considered stopping sooner because the patients had high or improving levels of consciousness. 

...

"Most of the patients eventually died, hours or days later. But some recovered enough to leave the hospital, according to an investigation by the federal Health Resources and Services Administration, whose findings were shared with The New York Times.

"The investigation centered on an increasingly common practice called “donation after circulatory death.” Unlike most organ donors, who are brain-dead, patients in these cases have some brain function but are on life support and not expected to recover. Often, they are in a coma.

"If family members agree to donation, employees of a nonprofit called an organ procurement organization begin testing the patient’s organs and lining up transplant surgeons and recipients. Every state has at least one procurement organization, and they often station staff in hospitals to help manage donations.

"Typically, the patient is taken to an operating room where hospital workers withdraw life support and wait. The organs are considered viable for donation only if the patient dies within an hour or two. If that happens, the procurement organization’s team waits five more minutes and then begins removing organs. Strict rules are supposed to ensure that no retrieval begins before death or causes it."

Medical aid in dying in Canada doesn't require a terminal diagnosis--should it?

 Repugnance to medical aid in dying is sharpest when death isn't otherwise imminent.  Canada allows patients with irremediable pain to qualify for MAID (qualifying in this way is called Track 2).  Here's a thoughtful article in the NYT about some of the issues.

Do Patients Without a Terminal Illness Have the Right to Die?
Paula Ritchie wasn’t dying, but under Canada’s new rules, she qualified for a medically assisted death. Was that kindness or cruelty?   By Katie Engelhart 

"While a Track 1 patient could technically apply for and receive MAID within a day, the process for Track 2 was slower; there had to be at least 90 days from the start of the assessment to the patient’s death. Each patient was assessed by two independent clinicians, and if neither of the assessing clinicians had expertise in the patient’s medical condition, they had to consult with a clinician who did. The patient requesting assisted death also had to be informed of “the reasonable and available means” to relieve the suffering — and to give “serious consideration” to those means.

"By law, a MAID patient had to be suffering in some way. The suffering could come either directly from the medical condition or indirectly from the condition’s follow-on effects. It could be either physical or psychological, as long as it was “enduring.” The law did not define exactly what it meant to suffer, or exactly how a medical professional was meant to evaluate the suffering. It was up to individual clinicians to figure out, in conversation with their patients. In a “Model Practice Standard” published by Health Canada, the country’s federal health regulator, MAID assessors were instructed to “respect the subjectivity of suffering.”

"For other clinicians, the concern about Track 2 was more philosophical. Dr. Madeline Li, a cancer psychiatrist who developed the MAID program for Toronto’s University Health Network and who has personally overseen hundreds of Track 1 patients, told me that she was hesitant to involve herself in Track 2 because it didn’t fit with her larger understanding of medicine and its purpose. “If you want to allow people to end their lives when they want to, then put suicide kits in hardware stores, right?” Li told me. It was not “assistance in dying” if the patient was not actually dying.

...

"The most organized critique of Canada’s law came from disability rights advocates. In September 2024, two people with disabilities and several nonprofit organizations announced a legal challenge to Bill C-7. Their case argues that, by definition, all Track 2 MAID patients are disabled — people with medical conditions that limit daily functioning — and thus, that the law is discriminatory. If a nondisabled person is suffering and wants to die, her desire will be understood as pathological, and she will be offered suicide prevention. If a disabled person is suffering and wants to die, her doctor will hand her the proverbial gun.

...

“I’m certainly not going to argue that the system is in good shape,” Wonnacott said. He tended to receive criticism of MAID with equanimity. Of course the system was broken. Of course people ended up on the wrong side of it. And of course the government should work urgently to improve it. But then again, it was the system. There was no other system on offer. “And to force people to continue suffering as we wait an indefinite amount of time to fix it is unfair.” Sure, in any given MAID assessment, Wonnacott could allow himself to get caught up in the past conditional of what should have been done, what could have been. But there was the suffering patient sitting in front of him, here and now, wanting an answer.

"Wonnacott also disagreed with the solution that the critics offered: to shut it all down. Fundamentally, he didn’t think the best way to protect poor and marginalized patients was to force them to stay alive, because in some counterfactual version of events, in which the world was a better and more just place, they might have chosen differently. That wasn’t how anything in medicine worked; a doctor always treated the patient as she was. How could it be otherwise? If only those who were rich or well connected were recognized to have autonomy and allowed to choose?

...

"The critics seemed to imply that a few hundred Track 2 deaths each year were, together, taking the pressure off government officials to improve the system. And that, inversely, if enough people who wanted to die were instead forced to live, their suffering would create the moral imperative for a wide-reaching social-welfare revolution. Wonnacott and his colleagues thought this seemed unlikely. As it was, Canada had more publicly funded health care than many other countries."

Palliative care involves hard conversations

 JAMA has a viewpoint by several palliative care physicians reflecting on why they are sometimes "fired" by their patients, i.e. why patients with (potentially) terminal illnesses may stop talking to them.  The reasons range from not necessarily agreeing that their illness is terminal (their other physicians may be conveying more optimistic messages), to finding that the patient's thoughts  about ending their lives are documented in their medical record.

Why Good Palliative Care Clinicians Get Fired  by Abby R. Rosenberg, MD, MS, MA1,2; Elliot Rabinowitz, MD1,2; Robert M. Arnold, MD  JAMA. Published online April 14, 2025. doi:10.1001/jama.2025.4353

 
"Even the most seasoned palliative care clinician gets fired. In the past year, one of us was fired after asking whether a patient endorsing suicidal ideation had access to a gun; the patient requested not to see the palliative care team because we asked intrusive questions and documented the encounter. One of us was fired after supporting a family’s decision to discontinue life-sustaining therapies for their loved one with multisystem organ failure; the primary intensivist suggested palliative care overstepped in discussing options for which the family (and clinical teams) was not ready. And one of us was fired after sharing the impression that a patient with cancer was dying; the family suggested they preferred the oncologist’s version of a more hopeful future.

Although many health care clinicians have been fired by a patient or family, palliative care clinicians may be at increased risk for dismissal.1,2 We invite difficult conversations, confront people with news they prefer to avoid, and encourage otherwise taboo topics such as human frailty and death. Our focus on what may go wrong differs from other clinicians’ optimism and may be unwelcome to patients and health care teams alike. We acknowledge emotional vulnerability, explore uncertainty, uncover fears, and describe a future in which patients make difficult choices about how they live and how they die."

Hospice care and its limitations

 I've recently posted about Medical Aid in Dying (MAID), which is quite controversial.  An alternative model of end of life care is a hospice, which offers palliative care to patients with terminal diagnoses.  But it turns out that Medicare only covers very limited hospice care, so that most patients who qualify medically have to be cared for by relatives at home.

Slate has the story, by a hospice doctor.

“But They Are Dying.”  Hospice physicians like me can’t usually offer patients the care they need.
By Charlotte Grinberg 

"A patient qualifies for hospice when they have a terminal illness with a prognosis of six months or less based on the natural progression of their disease. Hospice does not usually provide 24/7 private care or the physical place of residence for the dying; typically, people with a terminal diagnosis who opt against further medical interventions die at home, and with significant caregiving duties provided by someone in their family or hired privately. The only place where people receive 24/7 care by hospice-trained professionals are inpatient hospice facilities.

...

"I also work with patients who are under routine care at home or in an assisted living or a nursing facility. To me it’s clear that continuous attention provides a better experience, for patients and their loved ones. But most hospice patients will never be able to access inpatient hospice care. In fact, most hospices across America don’t even have inpatient hospice facilities because they are expensive to build, staff, and maintain, and ultimately depend heavily on philanthropy to both build and cover ongoing operations. Instead, dying patients only see a hospice nurse approximately once per week and are able to call a hospice triage nurse 24/7. They rarely—or never—see a hospice physician.

"The average cost of routine hospice at an inpatient hospice facility is $350 a day. Medicare will only cover inpatient hospice care under very specific circumstances. Families can request “respite care” for five days at a time to get temporary relief from serving as caregivers. Patients can also meet a General Inpatient Hospice level of care. The GIP level of care is intended to cover the time it takes to stabilize a crisis of acute symptoms that cannot be managed in any care setting other than a Medicare-certified inpatient hospice facility (or a contracted hospital or nursing facility). Once a patient’s symptoms are stabilized, the payment for room and board ceases, and the patient is considered to be in a routine level of care.

GIP is only approved when there is a crisis of physical symptoms such as pain, vomiting, seizures, or difficulty breathing. In 2021, only about 1 percent of all hospice days in the United States qualified for the GIP level. Medicare specifies that GIP is not appropriate for situations where a patient’s caregiver support has simply broken down. Complete caregiver breakdown would also not qualify someone for respite care, because respite care is specifically designed to be temporary relief. The primary burden still falls on the patient’s support system, if they have one, to simply figure out how to manage."

“Schrödinger’s persons". The indeterminate legal status of embryos.

 Courts are increasingly called on to decide who should get custody of frozen embryos. Their decisions will touch on both abortion and IVF.

This NYT oped discusses some of the issues.

Are Embryos Property? Human Life? Neither?  By Anna Louie Sussman

 "For over a century, courts generally did not grant personhood or independent rights to embryos or fetuses in utero. An 1884 decision by Oliver Wendell Holmes, at the time a Massachusetts Supreme Court justice, held that when a pregnant woman slipped and fell on a road, resulting in the loss of the fetus, no claim could be pursued on behalf of the fetus against the town; he voiced skepticism about “whether an infant dying before it was able to live separated from its mother could be said to have become a person recognized by the law.”

"Once embryos began appearing ex utero, however, courts and legislatures were forced to reckon with their legal status in novel scenarios — notably in divorce cases in which the parties disagreed on how to deal with frozen embryos created during the marriage. The answers courts have come up with for how to view embryos have been all over the map, ranging from seeing them as property to declaring them, in the Alabama decision, “unborn children.”

...

"Embryo custody cases, as they’re sometimes termed, were typically resolved along similar lines — that parenthood should not be forced on a person who does not want it, with a few exceptions, said Ellen Trachman, a Denver-based lawyer specializing in assisted-reproduction-related cases. That principle was challenged in 2018, when the Arizona State Legislature passed a law requiring judges to award disputed embryos “to the spouse who intends to allow the in vitro human embryos to develop to birth,” regardless of any contracts signed by both parties 

...

"The murkiness of embryos’ status has sent courts on strange detours in their legal reasoning. In a 2023 Virginia case a judge was tasked with deciding whether two frozen embryos should be awarded to Honeyhline Heidemann, who wanted to implant them, or kept frozen, per the wishes of her ex-husband, Jason Heidemann. Ms. Heidemann asked that the embryos be considered property, so they could be assigned to her like any other salable item. Mr. Heidemann said each was unique and nonfungible and thus could not be treated as personal property.

"The case, as Leah Libresco Sargeant wrote, turned embryos into “Schrödinger’s persons,” resulting in “one parent bizarrely needing the embryos to be considered persons in order to prevent them from being born and the other parent needing to argue the children were property in order to let them be born.”

##########

Earlier:

Tuesday, February 20, 2024 Frozen embryos are children: Alabama Supreme Court ruling

 

 

 

Abortion bans have increased both births and infant mortality (JAMA)

 Not unexpectedly:

US Abortion Bans and Infant Mortality, by Alison Gemmill, PhD1; Alexander M. Franks, PhD2; Selena Anjur-Dietrich, PhD1; et alAmy Ozinsky, BS1; David Arbou r, PhD3; Elizabeth A. Stuart, PhD4; Eli Ben-Michael, PhD5; Avi Feller, PhD6; Suzanne O. Bell, PhD1  JAMA. Published online February 13, 2025. doi:10.1001/jama.2024.28517

"Findings  This analysis of US national vital statistics data from 2012 through 2023 found higher than expected infant mortality in states after adoption of abortion bans (observed vs expected, 6.26 vs 5.93 per 1000 live births; relative increase, 5.60%). Estimated increases were relatively larger among infants who were Black, had congenital anomalies, or were born in southern states.

Meaning  Abortion bans were associated with increases in infant mortality. These increases were larger for populations that already experienced higher than average rates of infant mortality." 

########

There's also an accompanying editorial:

Abortion May Be Controversial—Supporting Children and Families Need Not Be  by Alyssa Bilinski  JAMA. Published online February 13, 2025. doi:10.1001/jama.2025.0854
 

"In this issue of JAMA, 2 articles characterize the impact of recent state abortion restrictions.1,2 Applying observational causal inference methods, the authors estimate a 1.7% increase in birth rates from abortion restrictions in affected states (corresponding to about 22 000 excess births) and a 6% increase in infant mortality (about 500 excess deaths) from 2021 to 2023.1,2 Excess births occurred disproportionately among racially and ethnically minoritized, low-income, and unmarried individuals.1 Among births linked to abortion bans, infant mortality rates were about 4 times higher than rates in the general population.2 The authors note that this likely resulted both as a consequence of abortion bans requiring pregnant individuals to carry fetuses with lethal abnormalities to term and from excess births occurring disproportionately among individuals at high risk for complications. "

Britain moves towards legalizing medical aid in dying

 The Guardian has the story:

MPs vote for bill to legalise assisted dying in England and Wales
Terminally ill adults with less than six months to live will be given right to die under proposed legislation, by Jessica Elgot, Eleni Courea and Rowena Mason 

"MPs have taken a historic step toward legalising assisted dying in England and Wales after backing a bill that would give some terminally ill people the right to end their lives.

"The Commons backed the bill by 330 votes in favour to 275 against, a majority of 55. Keir Starmer and Rachel Reeves both voted in favour, Labour MPs told the Guardian.

"The private member’s bill, brought by the Labour MP Kim Leadbeater, gives terminally ill adults with less than six months to live the right to die once the request has been signed off by two doctors and a high court judge.

"The change is unlikely to occur for three years as the bill must pass several more hurdles in parliament and will not be brought before MPs again until April. The government is likely to assign a minister to help work on the bill, without formally giving its support.

...

" Peter Prinsley, a Labour MP and surgeon, said he had changed his mind over his years in medicine after witnessing the “terrifying loss of dignity and control in the last days of life”.

“When I was a young doctor I thought it unconscionable. But now I’m an old doctor and I feel sure it’s the right change. I have seen uncontrollable pain, choking, and I’m sorry to say the frightful sight of a man bleeding to death whilst conscious as a cancer has eaten away at a carotid artery.”

"Opponents of the bill said it would fundamentally change the relationship between the state and its citizens, and between doctors and patients. They argued the bill was rushed and the safeguards for vulnerable people were insufficient."

##########

Earlier:

October 15, 2024 Medical aid in dying comes up for a vote in England

A medically aided death in New Jersey: Pat Koch Thaler

 Following a full life, a peaceful end.

Pat Koch Thaler, Sister to a Famed Mayor, Chose to Die on a Saturday
Ms. Thaler, a former dean at N.Y.U., used her last interview to reminisce about her brother, Ed, and to publicize the alternatives to prolonging pain and suffering. By Sam Roberts

"After 22 years of fending off cancer, Ms. Thaler had run out of miracles. Twice the disease had gone into remission, only to return. One kidney had been removed. She had been bombarded by radiation, chemotherapy and ablation. Finally, the tumors had been declared inoperable.

“My mother died in agony,” Ms. Thaler recalled. Her mother was 62, misdiagnosed and undergoing an operation to remove her gall bladder when surgeons found her body was riddled with cancer.

"Of her own experience, Ms. Thaler said she had been offered a drug that “would slow things down, but would have some serious side effects.”

“And I decided, I’m 92 and a half years old, I have lived a very, very rich life, a very happy life, and I didn’t want to torture myself anymore,” she said. “I did what I could, and knowing that the law is on my side, I decided to take advantage.”

"A New Jersey law that took effect in 2019 allows a mentally alert adult — whose prognosis of having less than six months to live has been certified by two doctors — to self-administer a lethal prescription. The powdery medication is mixed with three ounces of juice, must be consumed within two minutes, immediately induces sleep and, within hours, causes death.

...

"Ms. Thaler spent her last few days paying bills, disposing of her furniture, distributing her artwork to her children and grandchildren, and confirming the funeral arrangements

...

"She chose Saturday, she said, because her children worked, and she wanted a time that would be most convenient. Wearing a white long-sleeved shirt and loose black pants in her apartment, surrounded by her family, she took the powdered medication mixed in apple juice under a doctor’s supervision at 11 a.m.

"At 4:58 p.m., she was pronounced dead."

Medical aid in dying comes up for a vote in England

 The upcoming vote on legalizing medical aid in dying in England and Wales has attracted controversy along lines that will be familiar to readers of this blog, concerning both fundamental values and slippery slopes.  But a comment by British Cardinal Vincent Nichols introduces an argument that I hadn't heard stated so clearly before, about the religious significance of suffering.  But first, here's the background, from the BMJ.

MPs set for historic vote on bill to legalise assisted dying in England and Wales,  by Clare Dyer, 07 October 2024  BMJ 2024;387:q2191

"A bill to legalise assisted dying for terminally ill people in England and Wales is expected to be introduced in the House of Commons on 16 October.

...

"Hundreds of terminally ill people from the UK have travelled to the Swiss clinic Dignitas to end their lives. But friends and relatives who help them are at risk of prosecution for assisting a suicide, which carries a maximum prison sentence of 14 years.

...

"Surveys of public opinion show that about two thirds of the public support allowing assisted dying. The BMA dropped its opposition in 2021 to take a neutral position on a change in the law."

##########

And here is a story about objections from a religious point of view, from the senior Catholic official in England.

UK’s top Catholic bishop urges faithful to lobby MPs to oppose assisted dying  by Hayden Vernon Sat 12 Oct 2024 

"The archbishop of Westminster continued: “The suffering of a human being is not meaningless. It does not destroy that dignity. It is an intrinsic part of our human journey, a journey embraced by the eternal word of God, Christ Jesus himself. He brings our humanity to its full glory precisely through the gateway of suffering and death.”

#############

Earlier:

Friday, March 1, 2024

Medical aid in dying--the ongoing debate in Britain

Leading Causes of Death in the US, 2019-2023.

 Covid has dropped out of the top 10.

Leading Causes of Death in the US, 2019-2023. by Farida B. Ahmad, MPH1; Jodi A. Cisewski, MPH1; Robert N. Anderson, PhD1, JAMA.  August 8, 2024. doi:10.1001/jama.2024.15563

Main causes of death around the world, 1990-2021

 Here's a recent article from the Lancet that traces leading causes of death around the world, in more than a thousand countries and subnational locations.  Kidney disease went from #18 in 1990 to #9 in 2019, to #11 in 2021 (when Covid entered the list at #2)  So it looks like the rest of the world is catching up to the developed world in chronic disease as compared to infectious disease.

Naghavi, Mohsen, Kanyin Liane Ong, Amirali Aali, Hazim S. Ababneh, Yohannes Habtegiorgis Abate, Cristiana Abbafati, Rouzbeh Abbasgholizadeh et al. "Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021." The Lancet (2024).

Most diseases are causing less premature death, but Diabetes and Chronic Kidney Disease (CKD) are among the few that are causing more premature death, along with Malaria, AIDS, Covid and Other Pandemic Related Mortality (OPRM). (War is not included in the study.)

Dr. Guy Alexandre (1934-2024), gave birth to brain death in deceased organ transplantation

 The father of brain death has died.

Here's the NYT obit.

Guy Alexandre, Transplant Surgeon Who Redefined Death, Dies at 89. His willingness to remove kidneys from brain-dead patients increased the organs’ viability while challenging the line between living and dead.  By Clay Risen

"Guy Alexandre, a Belgian transplant surgeon who in the 1960s risked professional censure by removing kidneys from brain-dead patients whose hearts were still beating — a procedure that greatly improved organ viability while challenging the medical definition of death itself — died on Feb. 14 at his home in Brussels. He was 89.

...

"Dr. Alexandre was just 29 and fresh off a yearlong fellowship at Harvard Medical School when, in June 1963, a young patient was wheeled into the hospital where he worked in Louvain, Belgium. She had sustained a traumatic head injury in a traffic accident, and despite extensive neurosurgery, doctors pronounced her brain dead, though her heart continued to beat.

"He knew that in another part of the hospital, a patient was suffering from renal failure. He had assisted on kidney transplants at Harvard, and he understood that the organs began to lose viability soon after the heart stops beating.

"Dr. Alexandre pulled the chief surgeon, Jean Morelle, aside and made his case. Brain death, he said, is death. Machines can keep a heart beating for a long time with no hope of reviving a patient. His argument went against centuries of assumptions about the line between life and death, but Dr. Morelle was persuaded.

...

"Over the next two years, Dr. Alexandre and Dr. Morelle quietly performed several more kidney transplants using the same procedure. Finally, at a medical conference in London in 1965, Dr. Alexandre announced what he had been doing.

...

"In 1968, the Harvard Ad Hoc Committee, a group of medical experts, largely adopted Dr. Alexandre’s criteria when it declared that an irreversible coma should be understood as the equivalent of death, whether the heart continues to beat or not.

"Today, Dr. Alexandre’s perspective is widely shared in the medical community, and removing organs from brain-dead patients has become an accepted practice.

“The greatness of Alexandre’s insight was that he was able to see the insignificance of the beating heart,” Robert Berman, an organ-donation activist and journalist, wrote in Tablet magazine in 2019.

###########

And here's the story from Tablet magazine, interesting in a number of respects:

The Man Who Remade Death. Guy Alexandre was the first surgeon to remove organs from a patient with a beating heart. His colleagues thought him a murderer; Alexandre disagreed and revolutionized our understanding of death.  BY ROBBY BERMAN, Feb 4, 2019

"I met Alexandre a few months ago in his home in an upscale suburb of Brussels. The octogenarian is charming, affable and avuncular but he does not mince words: The physicians who accused him of murder “were hypocrites. They viewed their brain dead patients as alive yet they had no qualms about turning off the ventilator to get the heart to stop beating before they removed kidneys. In addition to ‘killing’ the patient, they were giving the recipients damaged kidneys that suffered ischemia … oxygen deprivation. The kidneys did not work well; they did not last long.”

"Given that brain death was not well known by the public in 1963, I asked Alexandre how he succeeded in getting consent from families to donate the organs. “It was simple. I didn’t ask. I told the families the situation was grim and I removed the organs in the middle of the night. When the family returned the next morning I told them their loved one had died during the night.”

"In 1961, Alexandre was in his third year of surgical training. He left Brussels for Boston to attend Harvard Medical School where he studied under professor Joseph Murray, the surgeon famous for performing the first successful kidney transplant between twins in 1954. After Alexandre successfully executed a number of kidney transplants between dogs in the laboratory, he was invited by Murray to join him in the operating room to operate on humans. It was there that Alexandre noticed a curious phenomenon.

"Murray turned off the ventilator in order to cause the heart to stop beating and only then did he extract the organs. Alexandre felt there was no need to damage the kidneys by depriving them of oxygen. He believed when looking at a human body with a dead brain that he was looking at a corpse that was suffering from a bizarre medical condition: a beating heart. In other words, the organism was dead but the organs remained alive."

#########

Earlier:

Friday, January 18, 2019

Fifty years of "brain death"

Frozen embryos are children: Alabama Supreme Court ruling

 The Washington Post has the story, which emphasizes the implications this ruling could have on in-vitro fertilization (IVF).  That would also impact surrogacy, and possibly deceased donor transplantation (depending on how it impacts the definitions of who is alive and who isn't...) 

Frozen embryos are children, Ala. high court says in unprecedented ruling. By Dan Rosenzweig-Ziff, February 19, 2024 

"The Alabama Supreme Court ruled Friday that frozen embryos are people and someone can be held liable for destroying them, a decision that reproductive rights advocates say could imperil in vitro fertilization (IVF) and affect the hundreds of thousands of patients who depend on treatments like it each year.

"The first-of-its-kind ruling comes as at least 11 states have broadly defined personhood as beginning at fertilization in their state laws, according to reproductive rights group Pregnancy Justice, and states nationwide mull additional abortion and reproductive restrictions, elevating the issue ahead of the 2024 elections. Federally, the U.S. Supreme Court will decide this term whether to limit access to an abortion drug, the first time the high court will rule on the subject since it overturned Roe v. Wade in 2022.

"The Alabama case focused on whether a patient who mistakenly dropped and destroyed other couples’ frozen embryos could be held liable in a wrongful-death lawsuit. The court ruled the patient could, writing that it had long held that “unborn children are ‘children’” and that that was also true for frozen embryos, affording the fertilized eggs the same protection as babies under the Wrongful Death of a Minor Act.

...

"The push for defining personhood has even affected tax law: Georgia now recognizes an “unborn child” as a dependent after six weeks of pregnancy.

Brain death for organ donation, and its relation to controversy about abortion

 Here's a summary of the current discussion of brain death (and its possible connection to the debate on whether a fetus is a living person), in JAMA. Maybe it will reach some resolution this year...

Truog, Robert D., and David C.  Magnus. The Unsuccessful Effort to Revise the Uniform Determination of Death Act. JAMA. 2023;330(24):2335–2336. doi:10.1001/jama.2023.24475

"In 1968, a Harvard committee proposed a new approach for determining death, one based on the irreversible loss of neurological functions.1 This concept was instantiated into law in 1980 when the Uniform Law Commission endorsed The Uniform Determination of Death Act.2 The act, which a large majority of states have adopted in whole or with some variations, says, in part, that an individual is dead if the individual has sustained (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem. A determination of death must be made in accordance with accepted medical standards.

"In 2020, the commission was asked to consider updating the act, based in part on concerns that the act does not fully align with current medical practice.3 A draft of its revision was presented and discussed at the commission’s annual meeting on July 26, 2023.4 Herein, we summarize the major issues that led to the decision to draft a revision, the alternatives that were considered, why there was failure to reach consensus, and what this means for the future.

"The Uniform Determination of Death Act defines neurological death, commonly known as brain death, as the complete absence of all functions of the entire brain. The current diagnostic criteria, however, test for only a subset of brain functions, and most notably do not include testing for neurosecretory hypothalamic functions, which are retained by many patients who have been diagnosed as brain dead.5 In addition, the law requires the “irreversible” cessation of biological functions, whereas in practice the standard has been “permanence,” with the distinction being that irreversible implies that the function cannot be restored, whereas permanence means that the function will not be restored because no attempt will be made to do so.

...

"n order for medical practice to be in compliance with the law, the commissioners considered either changing the guidelines to conform with the law, or changing the law to conform with the guidelines. Under the first approach, the guidelines would require physicians to diagnose the irreversible cessation of all brain functions, not just selected functions. This would be challenging, given the difficulty of detecting and measuring all of the brain’s many functions. Alternatively, the law could be revised to be coherent with current practice guidelines. At the annual meeting of the Uniform Law Commission, the committee considered the following draft alternative to the existing Uniform Determination of Death Act4: “An individual is dead if the individual has sustained: (1) permanent cessation of circulatory and respiratory functions; or (2) permanent (A) coma, (B) cessation of spontaneous respiratory functions, and (C) loss of brainstem reflexes.”

"This proposal would harmonize the law with the practice guidelines. Instead of requiring the absence of all brain functions, this revision would have required only the absence of specific brain functions, namely the capacity for consciousness and spontaneous respiration.

"The proposed revision also would have replaced the requirement for irreversible cessation with permanent cessation, thereby anticipating the trajectory of new developments in resuscitation research, including work demonstrating the potential for restoration of neuronal function in brains, even many hours after the loss of brain perfusion.6 Using the permanence standard, death can be determined in these patients on the grounds that function will not be restored rather than the requirement that it cannot be restored.

"Finally, the proposed revision also included a section that would have required hospitals to respect the refusal of patients or their surrogates to having death determined by neurological criteria. This position was supported by various constituencies, including the Catholic Medical Association, as well as several of the Uniform Law Commission commissioners, who saw it as a way to respect the diversity of opinions surrounding the determination of death while still supporting the concept of brain death. At the same time, this approach was strongly condemned by most mainstream physician and transplant organizations, given the burden that it would place on hospitals and intensive care units and its potential negative impact on organ procurement.

...

"in an email on September 22, 2023, the committee leadership announced that they had decided to pause the process, saying that “although we will continue to hope mid-level principles will become apparent, no further drafting committee meetings will be scheduled at this time.”

"Perhaps this outcome could have been predicted from the beginning, given the polarization that has evolved in the US around issues at the beginning and end of life. Commissioner James Bopp emphasized these connections in asserting that the controversies around brain death and abortion are an “identical debate, just in a different context.”7

###########

Earlier:

Wednesday, October 18, 2023

Peter Singer on brain death

Medical aid in dying considered in Britain, and evolving in Canada

The Guardian has the story about England and Wales, and the NYT has a story on Canada.

Here's the Guardian:

Two former health secretaries join calls for new law on assisted dying

Senior Conservative and Labour figures said they would back changes to legislation on the issue in England and Wales.  by Michael Savage

"Two former health secretaries on Saturday night became the latest senior figures to join the growing demands for a new attempt to legalise assisted dying, as a prominent Tory said he is willing to champion the legislation in parliament.

"With both former Conservative minister Stephen Dorrell and Labour’s Alan Milburn stating they back changing the law in England and Wales, the Observer understands that a Labour government would make time and expert advice available for an assisted dying bill should MPs back it in a free House of Commons vote.

"The news comes as campaigners hope to hold a new vote on the issue early in the next parliament, almost 10 years after the last attempt to alter the law. Kit Malthouse, a former cabinet minister, said he was “absolutely” prepared to front a new private member’s bill on the matter.

...

"Doing nothing is not a passive choice. Leaving the law as it is will consign many thousands of people who may want a different end to a horrible death.”

...

"Milburn, who served as health secretary under Tony Blair, said: “When people today expect to have control over so many aspects of their lives, it feels paradoxical that we are denied the same about how we want to die. It’s perhaps the most important decision any of us can make. To deny that choice feels increasingly anachronistic. The time has come for a free vote in parliament on the issue.”

...

"However, other senior figures such as Michael Gove have expressed doubts about any change.

"Critics of an assisted dying law have also warned about the difficulties in defining who is eligible, the danger of people being pressured into a decision and subsequent attempts to widen the law.

"Alistair Thompson, a spokesperson for Care Not Killing, a group that opposes assisted dying, pointed to polling that suggested public support for assisted dying may have actually fallen since the mid-1990s.

"He also raised questions about the effects of the drugs used for the process in Oregon and said the law would be widened. “As we saw in the Netherlands and Belgium, limits on who qualifies for an assisted death have been swept away,” he said.

“At a time when we have seen how fragile our healthcare system is, how underfunding puts pressure on services, when up to one in four Britons who would benefit from palliative care aren’t receiving it, and when our nation’s hospices are facing a massive shortfall in their income, I would suggest this should be the focus of attention, rather than discussing again this dangerous and ideological policy.”

#########

And here's the NYT on the controversy in Canada:

Death by Doctor May Soon Be Available for the Mentally Ill in Canada. The country is divided over a law that would allow patients suffering from mental health illnesses to apply for assisted death.  By Vjosa Isai  Dec. 27, 2023

"Canada already has one of the most liberal assisted death laws in the world, offering the practice to terminally and chronically ill Canadians.

"But under a law scheduled to take effect in March assisted dying would also become accessible to people whose only medical condition is mental illness, making Canada one of about half a dozen countries to permit the procedure for that category of people.

...

"There is still uncertainty and debate over whether assisted death will become available to the mentally ill early next year as scheduled. Amid concerns over how to implement it, Parliament has delayed putting it into place for the past three years and could delay it again."

Peter Singer on brain death

 Here's Peter Singer's op-ed in the Washington Post on the debate over brain death, presently used to decide when deceased donor organs can be used for transplantation:

What is the line between life and death? Here’s my answer.  By Peter Singer  October 17, 2023 

"When it is justifiable to end a human life?

"Here’s my answer: When consciousness has gone, never to return. Other bioethicists have different views. No surprise there. But on this we should all agree: These differences need to be hammered out in public, not behind closed doors by a body that few people have heard of.

"The last effort to define death in the United States was in 1980, and at that time there was remarkable consensus on a decision so consequential. Then, the commission proposed a new Uniform Determination of Death Act establishing that in addition to the traditional determination of death by the heart ceasing to beat, a person is dead when their whole brain has irreversibly ceased to function. All 50 states and D.C. adopted the act’s central proposition — which is staggering, really, given today’s battles over when life begins."

############

Earlier:

Sunday, October 8, 2023

Dead or alive? Debates about defining brain death and circulatory death in the medical literature

Sunday, May 21, 2023

Defining death for deceased organ donation

Thursday, April 13, 2023

Brain Death

Friday, August 21, 2020

Brain death (death by neurological criteria)

Fentanyl

 The NY Times has the story:

Some Key Facts About Fentanyl. It’s lowering American life expectancy and influencing the nation’s politics. By Josh Katz, Margot Sanger-Katz and Eileen Sullivan

"Overdose deaths have been increasing in the United States for decades, but the introduction of fentanyls has led to a staggering rise, accounting for the vast majority of overdose deaths in recent years.

"Around 77,000 Americans died from overdoses involving synthetic opioids like fentanyl in the 12-month period ending in April of this year, according to provisional estimates from the Centers for Disease Control and Prevention. In 2022, the most recent year with complete data, this number was around 74,000. Those three wars  [Vietnam, Iraq and Afghanistan] killed a little over 65,000 Americans combined.

"For comparison, around 55,000 Americans died in 1972 from car crashes, the year with the most such deaths. Around 49,000 died from guns in 2021 (including suicide), the year with the most such deaths.

"Fentanyl alone has become a leading cause of U.S. deaths. It was responsible for a third of deaths among Americans 25 to 34 in 2022, according to a New York Times analysis of C.D.C. mortality data.

...

"Most of the fentanyl sold in the United States is coming from Mexico, where drug cartels synthesize the drugs from precursor chemicals believed to come from factories in China. Some fentanyls are also shipped directly from China into the United States."