That Tell-Tale Heart: Questions to ask in cases of comatose patients

Proponents of organ donations have played fast and loose with the defintion of death in order to advance their goals. Obamacare may have irrevocably changed the physician/patient relationship, thus encouraging euthanasia.

With what caution --  with what dissimulation I went to work. From: The Tell-Tale Heart, Edgar Allan Poe, 1843.
 
When discussing organ donations I am often reminded of the Edgar Allan Poe short story of The Tell-Tale Heart
 
In the story a man reveals how he plotted to take the life of an elderly gentleman using cunning and stealth. When the deed is done the killer hides the body under the floor boards of the bedroom. The killer is finally caught because he is driven mad by believing that he can still hear the man’s beating heart. Maybe the man isn’t dead, he fears?
 
The proponents of organ transplants display some of the same cunning and deception when discussing organ removal from brain dead declared donors. 
 
Organ donation proponents would have you believe that an organ donor is truly and irreversibly dead, all bodily functions totally stopped, no life at all, no life possible, at the time of the removal of vital organs. 
 
Organ donation opponents on the other hand efficiently dismember their opponents carefully crafted arguments when they point out  that the full terminology includes the words  “legally and clinically” dead. These terms are mere constructs of the law, distractions from the actual condition of the targeted patient and the fact that to perform a successful transplant there is a very short window of opportunity to obtain fresh as compared to decomposing organs, especially hearts. 
 
Dr. Paul Byrne of Life Guardian Foundation will tell you in no uncertain terms that these brain dead declared patients are still alive, their hearts are still beating, other organs are still functioning.
 
Dr. Byrne will point to reports, fashioned by self interested committees, such as a 1967 American Bar Association publication, or the 1968 Ad Hoc Committee of the Harvard Medical School report on the Definition of Brain Death or the 1981 Presidential Committee report Defining Death. Dr. Byrne will inform you that these definitions are only three of several and that they were concocted not to treat or respect the patient but to protect the Medical Community from charges of criminal conduct in killing the patient while removing his or her beating heart.
 
The use of terms to be employed to declare someone dead or to promote euthanasia: brain death, irreversible coma, organ transplants, withdrawal of nutrition and hydration (food and water) began to appear in medical journals and publications as merely interesting philosophical subjects to contemplate and write articles about. 
 
They progressed to becoming subjects for the media to report and take sides on  beginning in the 1960’s with the first heart transplant in South Africa by Dr Christian Barnard.  In the United States 1976, U. S. Supreme Court decision regarding Karen Ann Quinlan, and  whether a third party had the right to “pull the plug” and discontinue life support. the court found in favor of the parents request. 
 
Karen Ann, age 31, died in a nursing home following court authorized removal of  nutrition, hydration medications  and oxygen died shortly thereafter. Some will always wonder if, given sufficient time, she might have made some recovery, but we will never know what her wishes would have been.
 
There soon followed  other shocking cases of brain injured people being declared dead. Or the case of Elizabeth Bouvia, 1983, who became a symbol to the Right to Die Movement, went to court to ask for a declaration that, due to her cerebral palsy and severely painful arthritis, be permitted to demand that doctors, in a hospital setting, assist her suicide. She lost her case and was reported as still living in 2008 in an L. A. Times article.
 
Her case, basically began the discussion of what constitutes quality-of-life and  if it is  possible to make plans for treatment or withdrawal of treatment based on a formula for what constitutes quality of life?  QL =NE x (H+S).  Anthony Shaw, Defining the Quality of Life, Hastings Center Report, 1977.
 
But the continued interest in this subjec, though not its practice, was sidelined, beginning in 1973 with the advent of the very contentious Roe v Wade Supreme Court Abortion Decision and the so-called rights of women to freedom of choice during pregnancy.
 
Other, more recent cases have come before the public. In 1993, Robert Wendland was declared permanently and mentally disabled following a motorcycle accident in the San Jose, California, area. Sixteen months after the accident his wife, Rose, went to court to have him removed from a feeding tube and be allowed (some said required) to die. This court found that, contrary to the Quinlan court decision,  a third party, even a wife, did not have the right to refuse nutrition and hydration for a patient. The court declared that “patients unable to make a decision for themselves should receive special protection according to their constitutional right to life and right to privacy.
 
Though Mr. Wendland died from pneumonia shortly after that court finding, it was not until 2001 that the state Supreme Court finally gave a decision in that case. The judges decided that since Rose Wendland did not have a power of attorney or any written document, she lacked authority to request removal of life support.
 
This case was, I believe, very important to current events in which it is now possible through 2008 legislation for third parties, such as spouses and medical personnel, through the use of a Physicians Orders for Life Sustaining Treatment (POLST) form to authorize removal of life support or what is now called 'palliative care' with or without a signed directive.  
 
This latest trend in medicine based on economic efficiency and a parallel understanding of what constitutes quality of life for a patient, has changed the whole conversation to one of acceptance of the heretofore unthinkable situations in which the perhaps permanently disabled or comatose patient is better off dead and his or her organs donated to someone with a better potential for an improved quality of life.
 
An entire new vocabulary has been created to discuss the end-of-life issues. This vocabulary is often crafted to create the appearance of a benevolent and compassionate platform from which to allow third parties to discuss and act upon end of life decisions for others. At times organ donors voluntary or involuntary, are actually treated as heroes for forfeiting their lives through donation of their organs to others who are considered by stakeholders in the organ transplant business, to be more worthy of living.
 
This is referred to by Barry Bostrom, M.Div.,J.D., in Issues in Law and Medicine, as countertransference. This is when the physician attempts to put himself “in the patient’s shoes” in order to make clinical decisions and evaluations of “quality of life” for a highly vulnerable patient.
 
In other words, the article is saying that ill patients and or their family members are, in a time of medical crisis, vulnerable to the attitude of the physician or medical professional in determining if they, themselves, should continue to want to live.
 
The more aggressive advocates of public policy changes such as Compassion and Choices, and their local community organizers, speaking to issues of the care and handling of terminally ill patients, will paint dark and dreary scenes of patients dying along in cold and sterile hospital beds, rather than in the comfort and warmth of a family’s loving arms. This is because they did not sign up for palliative-care-only as they progressed in their illness, thereby causing hospitals to expend unnecessary amounts of valuable hospital funds to keep you, the patient, alive. They also point to the amount of money wasted on expensive medications used to preserve the lives of patients who did not sign a POLST form.
 
I’ve become rather suspicious of obituary notices that state that the family member died at home surrounded by family and loved ones. How planned, exactly, was that?
 
In truth, according to Dr. Byrne of Life Guardian Foundation, “Hospital costs are down because patients seldom die in hospitals anymore.” They die in residential care facilities after being moved out of the hospital once it is known that they have a POLST or palliative care only signed document.
 
Here is a good understanding of the current end-of-life picture.
 
On September 4, 2012, Alamo, California, Highway Patrol officer, Kenyon Youngstrom was “mortally wounded” when shot by a car driver whom he had pulled over to the side of the road in a routine traffic stop. Officer Youngstrom was a registered organ donor. Within 24 hours following the shooting he was removed from a ventilator and his organs donated to 4 recipients.
 
On April 4, 2014, almost two years later, he was memorialized at the hospital where he died, as a hero for the donation of his organs. He was not honored for his service in guarding the public’s safety. The title of the article that appeared in the Contra Costa Times, 4/5/14, was: “Cop’s widow urges organ donations.” His widow was quoted in the article saying:  “She is thankful to Herculean efforts made by civilians, law enforcement and doctors to keep her husband’s heart beating long enough to allow him to donate his organs.” She further talked about the “importance of loved ones sharing their final wishes, because her husband’s clear message made the decision easier.
 
Officer Youngstrom’s CHP partner was also quoted as saying: “It’s hard having someone lay there when they look perfectly fine, but medically you know they can’t make it, so letting your family know what you want to do in advance makes it so much easier to let go.”
 
Knowing that he was an organ donor just how hard did the doctors try to save his life?
 
I give  the widow the benefit of the doubt.  The family no doubt loved their husband and father. The wife, at least, understood that she could lose her husband in the line of service. Did she truly understand that she could lose her husband to the demands of the organ donation lobby?  Maybe they both understood that  by becoming an organ donor there was that  possibility of a double sacrifice of life, once to protect the community which he served and once to extend a chance to live by donating his organs so that others might have the chance to live that he was forfeiting.
 
Jahi McMath’s parents gazed at their beloved daughter laying in a hospital bed and knew that though declared to be brain dead she was still alive.  They said “no” to the pleadings of the organ donation team that requested release of her body for donation of organs. They would not go along with the hospital’s plan of “treatment” for their daughter.
 
There was no organ donation card in this case. When Jahi’s mother said “no,” she had to go quickly to court to get a restraining order to prevent the hospital from removing their daughter from a ventilator and IV.  The law said that the hospital could declare Jahi brain dead and that was all the organ donation teams needed to begin pressuring the mother to turn over their daughter’s supposed dead body for her organs.
 
They have not been honored by the public. They have had to remove their still living daughter from the hospital in the dark of night to an undisclosed place.
 
So, which is it?  Is the organ donor patient alive or is the patient dead? What does legally brain dead really mean?  What does a heart that continues to beat up until the time of removal from a body imply? From what, exactly, does the patient die, the gunshot wound, the disease, the dehydration resulting from removal of nutrition and hydration or from removal of any one of the vital unpaired organs, especially the heart?
 
What is illegal and criminal for the ordinary citizen is perfectly okay for the guy in the white coat.
 
Upon death a body begins to decompose immediately. Organs decompose at varying rates because no blood or air circulates to keep them going. If a patient is truly dead can any of his or her organs be of any use to anyone else?
 
The organ donor upon being declared brain dead will be placed on a ventilator to insure that vital organs are oxygenated until removed, but a ventilator only works if the patient is alive. The ventilator may push air into the lungs, but it is, according to Dr. Byrne and others, the lungs that expels the air. If the lungs are expeling the air that means the patient is alive and the heart is beating.
 
And, finally we need to begin asking ourselves, our clergy, our elected officials just whom they think is deserving of life? It is beginning to seem as though no one individual is valued but only how that individual benefits someone else.
 
Dying has become a big and, to some, a profitable business. A whole new level of medical terminology, training and counseling (persuasion) techniques have entered into the picture along with new secular and religious groups both supporting and opposing this latest version of the disposable life.
 
Patients who do not go along with the signing of advance directives, federally instigated preventive medicine routines, federally prescribed nutrition programs, mental health counseling, etc, are being looked upon as non-compliant patients.
 
To avoid misunderstandings between doctors and patients will potential patients be required to interrogate their doctors to determine if they are members of Compassion and Choices, formerly the Hemlock Society?  Will they need to question the doctor minutely on just what is to be expected or required of each patient. The doctor and the hospital, under ObamaCare are at risk of financial punishment if they fail to gain the cooperation of the patient or the patient’s family.  The efficiency and cost containment capabilities of the hospital is called into question.
 
Has the Affordable Care Act totally destroyed the unique doctor/patient relationship?
 
What does one do as a patient if your doctor suddenly declares that you have a year to live and you should sign a POLST form and move into a Hospice medical home to receive only palliative care from now on? Why wait for a whole year? Will everyone be required to do as the McMath family had to do...call a lawyer, go to court, go to the media?
 
If you are an organ donor do you know all the ramifications adherent to that form? Has your new teenage family member been encouraged by a driving class or even by a television announcement to sign on as an organ donor when signing up for a driver’s license? If your sports-minded teenager - who has signed an organ donation card - gets a concussion during a football game, will he be too quickly identified as brain dead and his organs donated to others who will take better care of them then the donor did?
 
Spero columnist Camille Giglio resides in California.
 
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NOTES:
 
Presidential Commission, 1981, Defining Death: Medical, Legal and Ethical Issues in the Determination of death, based upon the Uniform Determination of Death Act - UDDA.
 
Learn How we calculate the Quality of Life index scores. http://internationalliving.com/2010/02/learn-scores-quality/ 1) Cost of Living=15%, 2) Culture and Leisure=10%, 3) Economy=15%, 4) Environment=10%,5) Freedom=10%, 6) Health=10%, 7) Infrastructure=10%, 8) Climate=10%, 9) Safety and Risk=10%.
 
Karen Ann Quinlan, 31, Dies; Focus of ’76 Right to Die Case, The New York Times, June 12, 1985, Robert D. McFadden. The court held, in a new interpretation of the right of privacy, that Miss Quinlan's interest in having her life-support systems disconnected exceeded the state's interest in preserving life, so long as medical authorities saw ''no reasonable possibility'' that she would recover. http://www.nytimes.com/1985/06/12/nyregion/karen-ann-quinlan-31-dies-focus-of-76-right-to-die-case.html
 
Anthony Shaw, Hastings Law Report, 1977. QL=NE x (H + S)  i.e. nature and endowment, home and society.
 
Issues in Law and Medicine, March, 2014 Ed. Barry Bostrom, M.Div.,J.D.
 
Dr. Paul Byrne, Director, Life Guardian Foundation, answered the following questions:
 
Question: How long may a heart be kept fresh and usable from the time it takes to remove that heart from a body? 
 
Answer:  At normal body temperature, within 4-5 minutes without oxygen. The heart must be cooled to keep it from deteriorating. The heart is stopped just as it is removed from the donor. The kidney is about 30 minutes, then it must be cooled or there are techniques to pump fluid through the kidney to preserve it.  See: www.lifeguardianfoundation.org.
 
Elder Life Planning. Part of the “Catch” Program.
 
EMBRACE THE JOURNEY, An 8 week Anglican produced training program for preparing people for the end of their life on a journey to death. Promoted by the Life Issues Institute, Brad Mattes, Executive Director lifeissues.org/
 
When the Patient is Non-Compliant, Danielle Ofri, M.D. New York Times,Nov. 15, 2012
The views and opinions expressed herein are those of the author only, not of Spero News.

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