Concept of brain death remains controversial
A Vancouver-area hospital was asked to keep a brain-dead patient’s heart beating for 10 days until the person could be flown — on life support — to his country of origin — all because the family’s culture did not accept brain death, a B.C. bio-ethicist has revealed.
In the wake of the unusual episode, the province declined to register the death, ruling the man “must have been alive” if he left Canada connected to a ventilator.
Details of the case, which was discussed at a recent conference, are sketchy, and both hospital administrators and B.C. government officials refused to fill in any of the gaps.
But the situation raises questions about who should cover the cost of keeping a brain-dead person partially “alive” — and the distress that doing so could have on health-care workers, Bethan Everett, a Vancouver Coastal Health ethicist, said in a précis of her presentation.
She drew parallels to the widely covered case of California parents who went to court last year to have their brain-dead teenage daughter left on life support, refusing to believe she was gone.
Dr. Peter Dodek, a veteran intensive-care unit specialist and University of British Columbia professor, said he has encountered relatives refusing to accept neurological demise on rare occasions, but acknowledged the topic is contentious.
“When the family does not accept the diagnosis of brain death, we’re in a dilemma,” said Dodek, who was not involved in the Vancouver incident. “And the dilemma is essentially our values versus the family’s.”
In the past, people were considered officially dead only when their hearts stopped beating. The notion of brain death — an irreversible loss of all brain function — emerged in the 1960s in response to medical technology that could keep the heart and lungs functioning mechanically. Blood continuing to flow through the body also presented prime conditions for removing organs for transplant.
In recent years, Canadian hospitals have repeatedly clashed with families over whether to maintain life-preserving treatment for patients considered on the verge of death or vegetative — but still actually alive.
The Vancouver case was different as it involved a middle-aged man who had already been declared brain-dead, Everett said.
His family “maintained their culture does not consider brain death as death,” said a précis of her presentation to the Canadian Bioethics Society conference in Winnipeg last month.
They “sought to have their … relative’s body cared for in the intensive care unit for 10 days and then flown on life-support to their country of origin.”
But problems ensued when the family finally took the man out of Canada. Though a doctor at the unnamed hospital had signed a death certificate, “the province refused to register the death because the patient ‘must have been alive,’ if he left the country on life support,” said the summary.
“This created a situation in which the patient’s family were unable to obtain a death certificate in either country in order to deal with the patient’s affairs.”
The case raises questions over “who pays for extended stays in the intensive-care unit and transport of the body,” Everett wrote.
There could also be moral distress for the medical team, especially nurses asked to care “for a body determined to be deceased.”
The issue for staff would not, though, be causing the person pain since, after all, they are dead, said Dr. Anand Kumar, a Winnipeg critical-care physician not involved in the B.C. situation.
“It is more dissatisfaction, frustration over what they consider to be a waste of time and effort.”
Still, the situation is not so different than that of living patients who are near death, but left mechanically ventilated until a family member can arrive, said Dodek. And there are much more questionable uses of health-care funding than keeping a brain-dead person on life support for days, he argued.
The ethnic background of the Vancouver-area individual was not revealed, but brain death continues to be a controversial issue in some countries, including Pakistan, Romania and Israel, where many Orthodox Jews refuse to accept the concept.
The U.S. states of New York and New Jersey allow religious exemptions from their brain-death policies. But a Washington hospital sued an Orthodox Jewish family in 2008 so it could remove a braindead boy from life support, saying he had “ceased to exist by every medical definition.”