It’s The Ventilator’s Fault

It’s The Ventilator’s Fault

Posted on Saturday, January 11th, 2014 at 9:41 am by lifemediamatters

Respiratory therapist examining a mechanically ventilated patient. Courtesy WikiMedia Commons.

Respiratory therapist examining a mechanically ventilated patient. Courtesy WikiMedia Commons.

If you were from a foreign nation looking at the United States news, you might think that this was a nation that has declared war on death. Or perhaps, this country has denied death entirely. 

In California, teenaged Jahi McMath,who has been medically and legally dead for nearly a month (death certificate was issued December 12), has been moved to an unnamed facility and given surgical procedures to introduce air, water and food more easily. Meanwhile, her body continues to degrade and decay.

In Texas, Marlise Munoz, a woman who may be brain dead or may be in a persistent vegetative state, is being maintained due to the hospital’s interpretation of a state law. This way, Munoz may be used as an incubator to keep her 14-week old fetus growing- despite the wishes of her family that she be disconnected from her ventilator.

In California, a mother is facing criticism for exercising her autonomy beyond reason to define death in her own terms. In Texas, a family’s autonomy to make surrogate health care decisions is being denied. Both McMath and Munoz have become objects and tools of various groups.

In California, McMath is now an object of unrealistic hope and political factions. In Texas, Munoz is being made into an object and tool to gestate a fetus that may never be born and may not be viable after oxygen deprivation. Not only has her family expressed their wishes, but Munoz herself had deliberate conversations with loved ones about not wanting to be maintained with the use of artificial support. Lest we forget, the human incubator is now also being used as a political tool for elected officials in attempts to further careers and standing with certain political, religious and social factions.

Erick and Marlise Munoz, Family Photo

Erick and Marlise Munoz, Family Photo

Ethicists, politicians, physicians and attorneys have taken strong stands and shared opinions on these two cases. There are questions about family decision making autonomy, surrogate decision making, the limits of law, the protection of the unborn, the respect for personal beliefs, the financing the maintenance of the bodies, a state’s interest in unborn life, the poor state of science education, the lack of public education on death and if these situations are some odd confluence of events or precedent-setting.

Some blame McMath’s mother for refusing to accept the reality of her daughter’s death. Others blame a right-leaning state government. There are some placing blame upon a hospital for refusing to acquiesce to a grieving family’s wishes. Still others blame a family that will not give a fetus every chance at being born.

However, I take a different approach as to whom or what is at fault. I blame the ventilator.

If ventilators did not exist, then McMath’s heart would have stopped a month ago, and her mother would have been forced to face her daughter’s death. Without a ventilator, there would be no way to use Munoz as an incubator.

As technologies are created, there is often debate about how we should put them to use. But history has shown that new technologies are usually adopted and used in ways no one could conceive. I suggest it is time we rethink the vent.

Ventilation machines date to the 1800s as negative pressure devices. In 1928, the Drinker respirator was introduced. More refinements came in 1931. These early machines were widely used for polio patients. In 1949, J. H. Emerson designed a vent to be used in anesthesia and in intensive care, predominantly for polio patients and those undergoing surgery. In 1971, a more powerful, smaller and more effective ventilator was introduced. The vent could be used on a wider variety of patients and for longer periods of time.

Sometimes, the ventilator is used to preserve organs for transplant. Since the 1970s, it has been used to keep alive those individuals who lack consciousness—those in a coma or persistent vegetative state.

Apparently in 2014, ventilators are now used to keep the dead functioning as incubators and as vessels of misguided hope. From its early use as a tool to keep those with functioning brains alive, the vent exists now for the purpose of perfusing air into dead bodies.

My suggestion is that we limit the use of the vent, since its use seems to be the problem in these cases. Vents should only be used on those individuals whom can consent. If a patient has consented to organ donation, then that patient has given advance consent to the use of a ventilator. If a patient has a disease that destroys the ability to breathe, that patient can consent. But if a someone starts to bleed and suffers a heart attack that deprives the brain of oxygen to the point of death, that patient cannot consent.

In every other medical aspect, patient consent is required before a doctor so much as touches him or her (with exceptions for emergencies). Why is the opposite true in the case of the ventilator? “Vent now, ask questions later” has become a medical rule.

For example, if one’s kidneys are failing, we do not wait for that person to become unconscious to reflexively put them onto dialysis- requiring consent to remove the treatment or look for documentation stating that this support should removed. In most cases, a person must consent to dialysis before its initiation. This is, of course, an imperfect comparison- waiting ten or 30 minutes to begin dialysis would most likely not be fatal- and waiting that amount of time to ventilate someone not breathing certainly would be.

In present circumstances, if a patient does not want a vent, then an advance directive is required. Why should we accept that we must consent to not being treated, when in most other areas of medicine- the reverse is true?

We should adopt a notion of presumed refusal of ventilators. If a person wants one, then he or she must provide advance consent. Rather than being a first reaction, the vent should only be used when medically appropriate and requested by a patient (or the patient’s legal surrogate or advance directive).

There is likely to be resistance to such a change, as the ventilator is a long accepted part of medicine and has been popularized in the media. It seems that no medical drama would be complete without a ventilated patient. This notion may not have prevented McMath’s mother from consenting to her child’s dead body being kept warm; but moving in this direction would change our expectations that miracle machines- ones that bring people “back from death”- are the norm. Therefore, they should not be expected.

I blame the frequent, automatic use of ventilators for many of these issues and unrealistic expectations. If we change the law, the standard of care and the media’s treatment of these circumstances, then perhaps the tragedies that these two cases represent can be avoided.


Some Suffering Needed At The End Of Life

Posted on Friday, May 31st, 2013 at 1:09 pm by Life Matters Media

One physician looks to medieval era for guidance

Image: WikiMedia Commons

Image: WikiMedia Commons

When hospice and palliative care aims to eliminate all suffering at the end of life, it circumvents the art of dying well, said physician Farr Curlin, co-director of the University of Chicago’s Program on Medicine at Religion at its 2nd annual conference Wednesday.

Citing the Ars Moriendi, “The Art of Dying,” two 15th century Latin texts offering advice on the protocols of a good death, Curlin underscored the role of consciousness in the dying process- a mental state which end of life care increasingly prohibits with its widespread use of sedation.

“Everyone wants a good death, one with dignity, but both have been reduced to one where one is free from unwanted suffering,” Curlin said, explaining the belief among most modern medical professionals that all suffering calls for immediate treatment.

While shortness of breath, vomiting and delirium surely make the task of dying very difficult, reducing all symptoms of the end of life reduces ones’ ability for reflection and meditation on the reality of the process that is underway.

Image: University of Chicago

Image: University of Chicago

“In hospice and palliative medicine, we are increasingly aiming to end the condition of health that makes suffering possible, namely consciousness,” Curlin said; however, he continued: “Consciousness for many is itself a form of suffering which many find unbearable.”

The intentionality involved in the Ars Moriendi of the medieval era required an active decision to contemplate one’s past, the present reality, and the patient’s belief in whatever may, or may not, come after death. That contemplation, Curlin argued, is essential to “dying well.”

True palliative medicine, he said, will recognize that, and not seek sedation at the end of life for comfort measures at the expense of consciousness. “Palliative medicine aids in restoring a measure of health, the sort of measure we need to take part in the task of dying.”


What Is A Life Worth?

Posted on Thursday, May 30th, 2013 at 2:38 pm by Life Matters Media

Geriatrician argues against bias against the aged and ill

Spirituality

Physicians caring for the elderly and for those nearing the end of life cannot be effective patient advocates until they confront their own deep and widespread prejudices, said geriatrician James Wright at the University of Chicago’s Conference on Medicine and Religion Wednesday.

Wright’s presentation, “The Courage to be a Geriatrician,” examined the bias held by many towards those lacking in independence, particularly those residents of nursing homes.  “Most of us share the same prejudice, that life is of less value when lived in dependency,” Wright explained. “We are in a tradition that cultivates freedom, independence and productivity, and that is what we give value.”

“We live in an era of meaningless- now that we no longer fear the sword, plague, even hell, we fear meaningless,” Wright said.

This prejudice thus serves as a blockade to administering comprehensive care to some of society’s most vulnerable- the oldest and most infirm. Medical professionals, those in geriatrics especially, must experience a shift in mindset from valuing life based on independence and instead towards seeing innate human value. The oldest and sickest are long divorced by age and ability from past functions, Wright said, but their lives remain valuable. That value does not stem from any thing they once did.

Prejudices manifest

Prejudices manifest, Wright said, when doctors make quality of life assessments. His research demonstrates that when simultaneous assessments of life quality are made by both physician and patient, the patient almost always scores his or her quality far higher than the physician.  “These devaluations matter,” he said.

The discrepancy, Wright argued, arises out of the drive of younger, working people towards self-affirmation. We often think, he said ‘‘I am not only alive, but my existence has meaning.’’ This quest for meaning is why the able-bodied join larger movements- political, civic or social. These movements give us worth.

“We live in an era of meaningless- now that we no longer fear the sword, plague, even hell, we fear meaningless,” he said, and this fear inhibits proper care of those we judge to have none.

Wright pointed towards the leaders of the Protestant Reformation as ones who can teach medical providers intrinsic human value. “All beings have equal value not because they earned it, but they were made that way by God, the source of all value,” Wright said. Both Martin Luther and John Calvin agreed that all of us, as humans, are not good enough, and fall short of our own expectations. However, God who loves without condition.

“We are enough as is,” Wright said, “and that gives us courage to be not as something greater.” The most successful providers see all life as equally acceptable and valuable, simply because that life is human.

“All people are created equal and remain equal throughout the course of their lives,” Wright concluded. “Only with this conviction, can we truly be trusted to value and care for the elderly in a way we all deserve.”


Vermont Votes To Allow Death With Dignity

Posted on Tuesday, May 14th, 2013 at 5:10 pm by Life Matters Media

The Vermont House approved a measure allowing physicians the ability to prescribe life-ending medications to some terminally ill patients seeking to end their lives. Vermont is set to become the fourth state allowing the legislation known as ”Death with Dignity,” following Oregon, Washington and Montana.

Photo by Jeb Wallace-Brodeur

The Patient Choice and Control at End of Life Act awaits approval from Gov. Peter Shumlin, a Democrat and supporter of the bill.

“By a 75-65 roll call vote, the House approved a bill largely that copies a law passed by Oregon voters in 1997 for three years and then shifts to a system with less government monitoring,” The Associated Press reports.

This marks the first time this type of legislation has been moved to passage by a legislature. With safeguards similar to the Oregon bill, patients seeking the prescription barbiturates must first state their intentions three times- once in writing. A second opinion from a physician indicating a patient has less than six months to live and proof of sanity, are mandatory. Patients must wait 48 hours before filling the prescriptions.

“It’s an important step for terminally ill Vermont patients,” Dick Walters, president of Patient Choices-Vermont, said after the vote. “It’s a big step forward for the region and for the country as a whole,” the AP reports.

Come 2016, changes advocated by some of the state senators seeking less government involvement during the process will go into effect, including less monitoring from physicians.

“It’s huge,” said lobbyist Michael Sirotkin, who for years has been involved with the issue in Vermont. “I think it’s going to have a major effect on other states’ willingness to vote on this,” he told USA Today.

But not all lawmakers approved of the bill’s passage. ”There can never be a dignified death using a handful of pills or a lethal cocktail,” said Rep. Carolyn Branagan, a Republican from Georgia, VT.

Other opponents were concerned about the radical changes the bill underwent while in the Senate. ”We are passing a bill that has not been vetted,” said Rep. Paul Poirier, an Independent from Barre. “Do we want to pass a bill … just accepting 100 percent what the Senate did overnight?”


Montana HB505: Outlawing Assisted Suicide

Posted on Thursday, February 21st, 2013 at 10:09 am by Life Matters Media

Flickr

Image: Flickr, Alex Proimos

Montana lawmakers are considering a controversial bill to outlaw physician-assisted suicide, a decision that opponents say would punish doctors for honoring their dying patients’ wishes. If the bill passes, physicians who provide life-ending drugs could face 10 years in prison and a $50,000 fine.

Introduced by Rep. Krayton Kerns, a Republican, HB505 seeks to clarify “the offense of assisting in suicide,” after a 2009 Montana Supreme Court decision left many confused about the issue.

Known as the Baxter Decision, the court ruled physicians that prescribe life-ending drugs are safe from prosecution, because “nothing in Montana Supreme Court precedent or Montana statutes [indicates] that physician aid in dying is against public policy.” However, the decision did not address whether assisted suicide is a right guaranteed under the state Constitution.

Kerns insists the ruling needs clarification. ”The Baxter Decision did not establish legal assisted suicide in Montana, and this has remained a gray area,” Kerns told the Great Falls Tribune. ”This bill would be a legislative declaration saying it is illegal based on constitution principles.”

According to the bill, “A person who purposely aids or solicits another person to commit suicide, including physician-assisted suicide, commits the offense of aiding or soliciting suicide.” Consent of the patient would not be a defense. However, withholding life-sustaining treatments from terminally ill patients would remain legal.

Critics argue the bill would curtail patients’ end of life choices. Opponent Bonnie Warne of Billings told the Billings Gazette that doctors who provide life-ending drugs to their patients would be unfairly attacked. “Death is inevitable and private. We do not need the state interfering with aid in dying,” she said.

Dan Lourie, from Bozeman, wrote a letter to the Montana Standard arguing that if the bill passes, he would be forced to forfeit his doctor-patient privacy. “My position is that my end-of life choices should be between me and my doctor, and the Montana Supreme Court agrees with me,” he wrote. “It should be my right, and certainly will be my desire, to discuss all of my choices with my doctor — treatment options, my choice to refuse treatment, pursuit of comfort care and assistance in dying.”

Compassion and Choices, a non-profit that serves to expand end of life options, maintains the bill would “roll-back” end of life legislation.

“HB505 goes beyond just prohibiting aid in dying by putting a physician at risk of prosecution for answering a patient’s questions about any of a variety of death hastening options, such as directing deactivation of a cardiac device, directing withdrawal of a ventilator or feeding tube, or provision of palliative sedation; and a spouse, child or friend could be prosecuted for driving the patient to the doctor’s office for the discussion,” a statement posted on their Web site read.

If the bill were to pass, palliative care would still be allowed for terminally ill patients, because palliative care serves to manage pain and ease suffering.

Hearings about the bill began this week.