Sunday, August 30, 2015

Kevorkian "Coma" [EOL in Art 111]

In "Coma" Jack Kevorkian depicts an unconscious patient being slowly pulled into the mouth of a macabre death mask. Helpless. The death's head resembles the opening of a CAT scan machine, a symbol of modern medical technology.

New Futility Case: Siner v. Kindred Hospital Indianapolis

The Court of Appeals of Indiana issued a decision that allows a family to proceed with its medical malpractice action alleging that a hospital's unilateral DNR order caused the patient's death. 

"October 26, 2007, eighty-six-year old Geraldine Siner became a patient at Kindred Hospital. Geraldine suffered from advanced dementia caused by Alzheimer’s disease and as a result could no longer care for herself. Geraldine’s son, John Siner, was designated as her health care representative and had power of attorney."

"Upon Geraldine’s admission to Kindred, and several times thereafter, John informed . . . Geraldine’s attending physician, that Geraldine was to be a ‘full code’ patient. On November 16, 2007, Kindred’s Ethics Committee decided to make Geraldine a No Code/Do Not Resuscitate (“DNR”) patient, meaning that Kindred staff would not attempt to resuscitate her in the event that she went into respiratory or cardiac arrest (otherwise known as “coding”)."

"The Ethics Committee did not receive approval from John or any other family member to change Geraldine’s status in this manner. Geraldine’s health continued to decline over the following two weeks and Kindred declined to keep Geraldine on ‘full code’ status despite her family’s protests."

Expert Testimony
Plaintiff's expert Timothy Pohlman opined both that the hospital was negligent and that this negligence caused Siner's death.

"Kindred’s Ethics Committee recommended over-riding the wishes of the family and instructions of the patient’s medical representative for full treatment, and instituted Do Not Resuscitate (DNR) order, which ruled out such alternative treatments."

"Gerri Siner was also suffering from over-whelming infection, and septic shock at the time of intake. There is no documentation produced for me that indicate SCCM Surviving Sepsis Guidelines, . . . were followed . . . . These guidelines were not followed apparently because the patient was under a DNR order."

"Full damages and suffering that more likely than not resulted from re-prioritization of treatment modalities for Gerri Siner based on her existing ‘DNR’ order that was left in place without full agreement and consent of her Surrogate decision makers . . . ."

Appellate Ruling
The trial court granted summary judgment n favor of Kindred Hospital, finding the family had failed to introduce any evidence on causation.  The appellate court reversed, because Pohlman's testimony does create a disputed fact as to causation

Saturday, August 29, 2015

Kevorkian "Very Still Life" [EOL in Art 110]

In "Very Still Life," Jack Kevorkian's message, "though somewhat capricious, nebulous and indefinable, is clearly underscored by intense feeling. Brilliant colors highlight the melancholoy age-old balance between the warmth of life and the iciness of death, spiced with the sardonic humor of irony."

"The disquieting mood portends inescapable doom for the frail symbol of individual life and seemingly callous extinction of its evanescent aura. The age-old balance is certainly skewed."

Supreme Court of Nevada Asked to Determine Brain Death Standards

Earlier this month, the Supreme Court of Nevada ordered a hospital to continue physiological support for a dead woman pending briefing, argument, and adjudication.  (I summarize the lower court proceedings here.)

Today, the family filed its opening brief.  Basically, they make two arguments.

First:  "The District Court incorrectly interpreted Nevada's Uniform Determination of Death Act (NRS 451.007(1)(b). The plain language of the Act specifically requires that if there is any functions of a person's brain, including his or her brain stem, then there is no 'death.'"

Second:  "The District Court failed to apply and construe the Act in a manner that makes Nevada's criteria uniform among the states which have enacted the law regarding the determination of death. NRS 451.007(3). For what appears to be the first time, a District Court has concluded that the medical standards and protocols to determine ''brain death" are set by the American Academy of Neurology. Indeed, Nevada will be the first state to make a determination of death when the person was first determined to be alive, as confirmed by an electroencephalogram (EEG), without confirmatory evidence of a subsequent flat EEG."

This is not the most eloquent or comprehensive brief.  But the core argument is not crazy.  The UDDA articulates a standard:  "irreversible cessation of all functions of the entire brain."  But it is deliberately silent on the specific criteria used to measure "cessation of all functions."  

In shot, the law punts the question to the medical profession.  But there is significant variability in medical practice across the country in terms of the criteria used to ascertain brain death.  

Friday, August 28, 2015

Minnesota Board of Medical Practice at Hamline

Join the Minnesota Board of Medical Practice at Hamline on September 12 for some educational sessions on health law.

The Changing Definition of What Is ‘Brain Dead’

Healthline News has just posted a nice new review of the debate over brain death.  It is not 100% accurate.  But it is a lucid, comprehensive, lay presentation of the issues.  

I love this quote from the distinguished critical care specialist and ethicist John Luce: " The brain dead people are not as dead as we once thought they were, in the overall biological sense."

The article also notes that Calixto Machado is working on a paper, to be published before the end of the year, which will propose a new category of consciousness to describe Jahi McMath’s as-yet-unseen circumstances.

Medicine Holding Back Death [EOL in Art 109]

The buff man of medicine holding back death itself at Fulton County Health Services in Atlanta.  Are we still so confident?

Thursday, August 27, 2015

Is ICU Treatment Inappropriate? Clinicians Now Have Guidelines

Medical Ethics Advisor has just posted an article on the new "Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units." 

There are comments from me, Gabe Bosslet, Larry Schneiderman, and Nancy Jecker.