Sunday, February 22, 2009

Do You Know What You're Signing Up For?

As apparently due to the ever increasing demand for organ donations and the limited supply of poor saps with brain death and viable organs, the Organ Procurement and Transplantation Network and the United Network for Organ Sharing (known as OPTN/UNOS collectively, the non-profit group which determines national policy for organ donations) has lowered the bar on death as of July 2007. No longer is brain death the only standard by which organ harvesting may begin.

According to the new rules a suitable candidate for organ donation can consist of:

"1. A patient ... who has a nonrecoverable and irreversible neurological injury resulting in ventilator dependency but not fulfilling brain death criteria may be a suitable candidate for DCD [Donation after Cardiac Death].
2. Other conditions that may lead to consideration of DCD eligibility include end stage musculoskeletal disease, pulmonary disease, and high spinal cord injury."

The idea here being that once a patient is determined to be a good organ donating candidate (i.e. ventilator dependent and without likely hope of recovery), his or her doctor can (with agreement from the next of kin) switch off the ventilator, wait five minutes or so until the heart stops beating and then declare death. After which the body is taken to the OR by the organ retrieval team. But the key thing to understand is that the patient is not yet dead when the decision for organ donation is being determined!

As Dr. Keamy notes:

"For some of the pathophysiological states enumerated, this amounts to plucking the fruit off the vine shortly before it would fall anyway. But this list also includes people with advanced ALS like Stephen Hawking, who has lived in that "donation qualifying" state for two decades or so; there is no mention of brain function whatsoever in this formulation; lack of awareness is specifically not a necessary component for inclusion."

Additionally, one must recognize that this system sets an all too likely scenario where the doctor has a conflict of interest between his patient and the organs which will go to the patients' of others. He's flipping that switch on a schedule that may have nothing at all to do with the state of his patient's health status. The drugs doctors give at the end of life can be palliative but they can also double-edgedly be used euthanizing-ly. Plus, there are drugs that can be given for the sake of organs health which do nothing for the individual's length of life. For a person to become an organ donator while still alive is extremely dangerous territory. Because while we hope each physician will keep himself minding his patient's needs and only his patient's needs, organ donation can require massive coordination and it's doubtful he'd be operating in an "ethically pure" environment. Indeed, if he starts to care about the sake of those organs (as would be difficult for him not to), might he be operating at cross-purposes?

And last but not least, the Halachic implications are obvious. The person is not brain dead and is therefore NOT DEAD when the ventilator is turned off. At least according to US law, R' Moshe Tendler and HODS, that is. This method for organ donation would therefore be totally improper by those Halachic authorities which permit donation. It would in fact be murder. Though ironically, the Israeli Chief Rabbinate Council's test of "respiratory failure coupled with profound nonresponsiveness," which rejects the need to check for brain death may fit what OPTN/UNOS has decided.

Now, practically speaking, patients are pulled off of ventilators all the time even when brain death is not determined since that may have been the expressed will of the patient or the health care proxy. The secular legal precedent is already there many times over and if that's already accepted why shouldn't they schedule an organ harvest ahead of time to act upon death? Maybe this is a good call after all that will lead to more organs being available for those who need them. Maybe. For now though, adjusting the definition of death for the sake of organ donations gives me the willies.

24 comments:

Shalmo said...

heh!

I tried the world of medical science when entering university. Wasn't my cup of tea.

Good luck to you on that!

I'll be sticking with law

Anonymous said...

Yiles! Makes me re-think my frum organ donor card!

Jeff said...

OP,

Realistically, any completely ventilator assisted patient would be completely brain dead within minutes, and easily before organ donation occurred. Also, even if they were alive, there's no problem with non essential organ donation anyway - kidneys go live to live all the time. A brain will never be donated, & I doubt they'd want a vent dependant heart and lungs, so probably non issues.

In regards to doctor mixed agendas, this happens everyday with mandatory reporting of STD's vs invasion of privacy. In a larger sense, government decisions balance this out as well - Folate in bread prevents neural tube defects in infants, but masks pernicious anemia in the elderly. Granted these aren't as potent and personal, but you get the idea.

I have mixed opinions. On one hand, it would be profoundly satisfying for a dying ALS patient to know he was saving lives, on the other hand, a high cord injury patient might be killed though he was actually just profoundly depressed and suicidal.

Halachicly? I'm no expert, but my understanding of the orthodox view is that any life should be prolonged as long as possible. I know there are many other arguments such as in cases of intractable pain, etc.

...One should act as if the world was created for him, but also as if he is dust in an infinite Godly universe. And he who saves a life it as if he saved the world.

No one would argue a healthy young person should donate all his organs to save 10 lives. Is it reasonable for a high spinal cord patient who's not depressed, but simply had enough to do so?

Orthoprax said...

Jeff,

"Realistically, any completely ventilator assisted patient would be completely brain dead within minutes, and easily before organ donation occurred."

Of course, but that's not the issue. The issue is that an otherwise full-fledged living and potentially conscious patient, is being turned into an organ donor by only administrative order. The potential for abuse is wide. Will his doctor care more about his patient or his patient's organs?

"In regards to doctor mixed agendas, this happens everyday with mandatory reporting of STD's vs invasion of privacy."

Not really. They don't report who the patient is, etc. But for cases of child abuse and such there is obvious mixed interests. We also see a lot of that in OBGYN where maternal vs fetal health can often be an issue.

The ethical preference though is to keep such counter-interests at a minimum. When the end of a person's life may be being determined by factors other than those which interest the person who is dying, terrible things can happen.

"Halachicly? I'm no expert, but my understanding of the orthodox view is that any life should be prolonged as long as possible."

Yes, with exceptions. But also of prime import is how life is defined. If he's brain dead but on a vent is that a life? Some say yes, some say no. Very few would say that a non-brain dead patient on a vent is dead.

"Is it reasonable for a high spinal cord patient who's not depressed, but simply had enough to do so?"

You're going to find someone to kill him first? That's murder.

Jeff said...

OP,


I knew there were better examples. maternal fetal would certainly be, and stem cell stuff even closer to the point.

"Of course, but that's not the issue. The issue is that an otherwise full-fledged living and potentially conscious patient, is being turned into an organ donor by only administrative order. The potential for abuse is wide. Will his doctor care more about his patient or his patient's organs?"

First off, not many organ transplant docs work in the ICU or the rehab floor - so I doubt there would be much closely tied mixed interests.

Is it murder? I'm not sure, but I don't think so. Philosophically, I find great difference in removal of an artificial lifesaving device vs ending a naturally preserving life. But that's not the effective issue here - because that high quad already can drop the vent now anyway (albeit with much work).

The question is will he be coerced to do against his best interests by his physician? Maybe.

Docs help give informed consent for life and death decisions many times every day with mixed interests. Docs get paid for doing risky procedures that might not be best for the patient. Docs automatically treat some things even without consent. I see this is little different.

All the law allows is choice to enter the doctor patient relationship. Could it be misused? Of course! Could it save lives and give meaning and peace to a dying or profoundly debilitated person? Of course!

But I am more intersted in the Jewish viewpoint. My understanding is that one can not kill someone unless that person is actively pursuing another life. (or under the thousands of other Torah based punishments which don't really apply here. So maybe pulling the plug couldn't be done for most reasons. But then, if it's going to be pulled anyway? The person is dead and the body can save lives.

But yes, there's still the issue of temptation - as we should not leave valuables open to tempt someone who would not otherwise steal.

I have no idea of rulings of transplant in case of suicide - which I guess is what a high cord pulling the plug would be. But in case of inevitable rapidly approaching death, I would think it a bit different (although some might say that every moment of every life is a miracle by Hashem, that can end or continue forever based on Hasehem's will). At what point does likelyhood of death approach death enough so that lives may be saved?

Orthoprax said...

Jeff,

"First off, not many organ transplant docs work in the ICU or the rehab floor - so I doubt there would be much closely tied mixed interests."

That's not what I was talking about, but in reality if a given patient is a candidate for organ donation then it's the ICU doc who has to call in the transplant team. And the plug has to then be pulled on some sort of schedule for the proper facilities to be set up and for the wellbeing of the organs at task.

And that's besides for the plausible scenario where you have a time-conscious transplant surgeon breathing down the neck of the ICU intensivist.

"Is it murder? I'm not sure, but I don't think so. Philosophically, I find great difference in removal of an artificial lifesaving device vs ending a naturally preserving life."

Halachically, I believe it is equivalent to murder. What if I "remove" a plane's engine while it is in flight? Isn't that an "artificial lifesaving device"? Yes, the act is indirect but it's really the same thing. Human life, I believe, requires 'gezeirot' surrounding it for protection.

"At what point does likelyhood of death approach death enough so that lives may be saved?"

Some seem to be more comfortable than I in moving that sharp line away from brain death. One man's blood is no redder than the next. Killing one man prematurely to potentially save another (or several) is not something I'd be comfortable doing.

Star said...

You say the plug being pulled as if they are killing the patient when in reality the patient can no longer survive, the machines are imitating life by breathing for the patient but organ donation only occurs when the patient is not living just being kept functioning by machines and when ther is no hope of recovery.

The ICU doctor has nothing to do with the transplant surgeons, the co-ordinators are the ones called in when there is a possible donor, they assess the situation but they are not breathing down anyone's necks. Doctors do not want their ICU patient to die. On a human level, it goes against their hypocratic oath and on a professional level, it looks bad in statistics. Their concern is their patient, the team dealing with the recipient is completely seperate.

You can hardly compare a plane to a human being!You can buy toy cats that simulate breathing, are they alive? Life support does not just aid a person, it is functioning for them, they are incapable of breathing or any other life functions. It breathes for them but that is hardly sign the person is still alive.

I think it is important to know your facts before posting something like this as thousands of people die each year because of the shortage of organs and it is important to be careful about influencing people's ideas on organ donation.

Orthoprax said...

Star,

"You say the plug being pulled as if they are killing the patient when in reality the patient can no longer survive, the machines are imitating life by breathing for the patient but organ donation only occurs when the patient is not living just being kept functioning by machines and when ther is no hope of recovery."

If the patient is not brain dead then he is still alive. Period. Just because you have a man on a ventilator that is 'keeping him alive' that doesn't mean it is 'imitating life' or that he is already dead. Just the opposite, in fact, as ventilators exist primarily for the sake of keeping people alive until they can recover and be weaned.

"The ICU doctor has nothing to do with the transplant surgeons, the co-ordinators are the ones called in when there is a possible donor, they assess the situation but they are not breathing down anyone's necks."

Who are these magical co-ordinators? Doctors are the ones who call other doctors. And you are naive to think that transplant surgeons put neither pressure on the ICU or impact the patient care therein.

"Doctors do not want their ICU patient to die. On a human level, it goes against their hypocratic oath and on a professional level, it looks bad in statistics. Their concern is their patient, the team dealing with the recipient is completely seperate."

'Completely separate' is a myth. And the potential for the ICU doctor to have cross-interests for the health of the organs vs the life of the patient is very real.

"Life support does not just aid a person, it is functioning for them, they are incapable of breathing or any other life functions. It breathes for them but that is hardly sign the person is still alive."

You are 100% wrong. As an example given in the original post, Stephen Hawking has been ventilator dependent for decades!

"I think it is important to know your facts before posting something like this..."

Quite right.

Star said...

There are more ways of being dead than brain death. It depends how you define death. If, however like in brain death the body cannot function for itself and the brain is not able to function properly, I would consider that death.

We have developed technology to keep people in a life like state but if they have no chance of recovery, cannot respond and do not carry out body functions themself, how is that life?

Someone who is ill and recovering on a ventilator is not the same as someone on life support. People can be aided with breathing as they recover but with life support for possible donors the machine is breathing for them and it is an imitation of life because they are not functioning themselves and will never recover and be able to perform those functions themselves.

Actually I think it is you who is naive and you don't seem to know very much about the process if you don't know abpout donor co-ordinators. A donor co-ordinator is not the same as a Doctor and they liase between the Doctors. I have known many ICU Doctors and I have never met any who are more interested in the recipient than the patient they are treating. They are responsible for their patient alone.

It is not a myth, the Doctor may have come into contact with people waiting for organs but their responsibility is not for those patients it is for the patient they are treating.

I dont know about American hospitals but we have seperate transplant hospitals so it really is completely seperate. If you don't, maybe that's a flaw in the system.

As I have explained before life support is more than simply a ventilator and Stephen Hawking can still function. in the case of patients who cannot and will not recover, they are having life simulated for them.

Orthoprax said...

Star,

"There are more ways of being dead than brain death. It depends how you define death."

That's nice. Maybe someone who is really really sick can be defined as dead, eh? Why not? It just depends on how you define it. Can you say slippery slope?

"If, however like in brain death the body cannot function for itself and the brain is not able to function properly, I would consider that death."

Except that it's not. It's possible to have a ventilator dependent person who sustained brain damage and yet still be conscious! Ergo your definition is poor, open to interpretation and potentially open to abuse.

"We have developed technology to keep people in a life like state but if they have no chance of recovery, cannot respond and do not carry out body functions themself, how is that life?"

How is that death? Just because they can't respond doesn't mean they are not of sound mind! How would you feel, chas v'shalom, if you were in that position? Can you imagine the horror of that dying man? If they aren't brain dead then they could still be very much aware in there. That's the reason why the concept of brain death is so important.

"Someone who is ill and recovering on a ventilator is not the same as someone on life support."

Um, yes it is. They can be using the same exact machine on the same exact settings. Ventilator = life support. There is no special life support machine that they use only for organ donors.

"People can be aided with breathing as they recover but with life support for possible donors the machine is breathing for them and it is an imitation of life"

So when a machine is breathing for a recovering patient that's not an imitation of life? What if that recovering patient turns for the worse? At what point can you say that it's an imitation and when it is not?

"Actually I think it is you who is naive and you don't seem to know very much about the process if you don't know abpout donor co-ordinators. A donor co-ordinator is not the same as a Doctor and they liase between the Doctors."

That's nice. And how do these coordinators find out about potential donors? Um, do you think the ICU doc calls 'em?

"I have known many ICU Doctors and I have never met any who are more interested in the recipient than the patient they are treating. They are responsible for their patient alone."

Sure, in theory - and in general that's how it's supposed to happen. But as I've stated several times those doctors are put into a precarious position and are pressured to ensure that the organs stay well enough through the demise of the patient.

"It is not a myth, the Doctor may have come into contact with people waiting for organs but their responsibility is not for those patients it is for the patient they are treating."

I said the idea of the teams being completely separate is a myth. The concepts of idealized ethical separation is nice but simply not the way it happens in reality. See the case of transplant surgeon Dr. Hootan Roozrokh. He was acquited of criminal charges but there is little doubt that he acted inappropriately.

"I dont know about American hospitals but we have seperate transplant hospitals so it really is completely seperate."

That's really not the issue. Why do you find it so hard to believe that ICU doctors could be influenced by all the hustle and great expectations from the transplant team and potential organ recipients? It's almost inevitable. It would be very hard for an ICU doc to NOT care about his patient's organs.

"As I have explained before life support is more than simply a ventilator"

No, you didn't 'explain' - you simply asserted it. But that assertion is INCORRECT. In the ICU ventilator = life support, life support = ventilator. It's not magic.

"in the case of patients who cannot and will not recover, they are having life simulated for them."

Are they dead? Cause if they ain't dead then that's known as being alive. AKA not a simulation. Should be simple.

Star said...

What do you define as dead then?

As I have said before, there is a huge difference between someone recovering on a ventilator and someone on life support where the body cannot function for itself and will never recover. I have seen both and the second is not living, it is a machine simulating living.

Ok perhaps I should of specified, by cannot respond I meant brain cannot function, not concious, not responding, complete lack of brain activity.
They are not taking organs from people who are concious or aware, the brain is still not functioning it just doesnt match all of what we consider criteria for 'brain death'.

Actually it wouldn't be the same setting because recovering people would be being weaned off of it. The difference is they are able to do some of the functioning themselves and will improve to do the whole function. The potential donor is having a machine breathe for them and will not recover.

They are called in by the medical team but it is them who talks to the family and deals with the whole issue of donation. It is them who will have links to the recipient so the ICU doctor has no alternative motive.

Besides are you really such a cynic that you think all Doctors are murderers who just want to kill everyone off and harvest their organs? They are in a caring and difficult profession and they are concerned about their patient, they have no reason to give up on the patient unless there is no hope of recovery.

As long as the person is on life support the organs will not detoriate so that is not a reason to speed up the death. It is generally up to the family when to actually switch life support off, the Doctors don't have all the power.

How is it a myth? They don't know who the organs are going to, the patient they have met and are treating is the potential donor so why would they care more about a random patient they know nothing about?

There can't be little doubt if he was acquited, if there was enough evidence he would have been charged. Besides he is one surgeon, it's not like there are hundreds of stories of this.

Of course that's the issue. I know many people who have had transplants and they are assessed and treated at completely different hospitals so the ICU doctors don't know them. Also since a donor and recipient must be perfectly matched it's unlikely the donor will even be from the same area as the recipient.

Actually one of the reasons there is such a shortage of organs is that many hospitals have terrible donor rates because they don't encourage it. It takes time and money as the bed needs to be kept, the person must stay on life support and surgeons are needed to remove the organs so many ICUs would prefer that the person does not donate.

People who have no brain activity often need more support than just a ventilator and will need a much higher oxygen concentration because none of the breathing is them.

Yes I would say if the body cannot carry out functions such as breathing, the brain is not active and a machine is functioning for the person, they are dead.

Actually its not simple, it's you over simplifying it that seems to be leading you to the wrong conclusions.

Orthoprax said...

Star,

"What do you define as dead then?"

For someone to be a potenital organ donor?: BRAIN DEATH.

"As I have said before, there is a huge difference between someone recovering on a ventilator and someone on life support where the body cannot function for itself and will never recover. I have seen both and the second is not living, it is a machine simulating living."

Yes, you keep saying that but there is IN FACT - no visual difference. The only difference is in future expectations, not anything that you can see. And the only way to know the difference is if you test for brain function.

A guy in a coma looks identical to a guy after brain death.

"Ok perhaps I should of specified, by cannot respond I meant brain cannot function, not concious, not responding, complete lack of brain activity."

Sure, but then you missed the whole point of my article. These are people labeled future organ donors who are NOT brain dead.

"They are not taking organs from people who are concious or aware, the brain is still not functioning it just doesnt match all of what we consider criteria for 'brain death'."

Yes, they aren't taking the organs until after death, but they're causing people to be labeled as future organ donors while still alive - that's my whole point. Brain death for the OPTN/UNOS new regs is actually irrelevant.

"Actually it wouldn't be the same setting because recovering people would be being weaned off of it. The difference is they are able to do some of the functioning themselves and will improve to do the whole function."

WRONG. I don't know how to tell you that you're just making stuff up. A guy in a coma isn't going to be being weaned off anything any time soon and they can have zero apparent higher brain function. Hell, there's not even any guarantee that they will actually ever recover.

"They are called in by the medical team..."

Thank you.

"Besides are you really such a cynic that you think all Doctors are murderers who just want to kill everyone off and harvest their organs?"

No, I think doctors are people like anyone else and when they're taking care of an apparently hopeless case I can see them easily caring more about his organs than about him as a patient. Take off your rose-colored glasses and see people as they exist in reality.

"As long as the person is on life support the organs will not detoriate so that is not a reason to speed up the death."

Wrong again. A millions things can go wrong, especially in sick patients, that can lead to organs not being viable. You want them to wait a day or two so that the patient gets a UTI and infects his kidneys? How hard do you think it is for a dying patient to get septic? Or to throw a clot? Or to have metabolic imbalances?

"It is generally up to the family when to actually switch life support off, the Doctors don't have all the power."

Sure, in theory. In practice though doctors can make patients and their families do what they want them to do.

"How is it a myth? They don't know who the organs are going to, the patient they have met and are treating is the potential donor so why would they care more about a random patient they know nothing about?"

They know the organs are going to people who need them and they are coworkers with the transplant team members who don't want to be up all night. Why should they care so much more about a hopeless guy with a self-inflicted head wound who only came to the ICU that morning?

"Of course that's the issue. I know many people who have had transplants and they are assessed and treated at completely different hospitals so the ICU doctors don't know them."

No, like I said, that's actually irrelevant. The ICU docs don't need to know the recipients to know that they need the organs. Their thoughts and behavior change when a person is a potential organ donor compared to when a person is not.

"People who have no brain activity often need more support than just a ventilator and will need a much higher oxygen concentration because none of the breathing is them."

Wrong. Seriously, do you know what you are talking about at all? Are you any sort of medical professional?

"Yes I would say if the body cannot carry out functions such as breathing, the brain is not active and a machine is functioning for the person, they are dead."

Are they brain dead? If not then they're not dead. Otherwise what you may be describing is a coma or someone under general anesthesia!

"Actually its not simple, it's you over simplifying it that seems to be leading you to the wrong conclusions."

Brain death was a great, thick, dark line in the sand. I think it's dangerous that OPTN/UNOS and the likes of you want to change it to something grey and subjective. Additionally, the gross medical ignorance on your part makes you a terrible judge on this issue.

Star said...

No, ignoring organ donation for a moment. What do you define as death?

What do you mean visual difference?There is a difference as I said they would be a on a different level of ventilation and doing some of the breathing for themselves.

I'm not talking about someone in a coma, I'm talking about a recovering patient and someone whos brain function has ceased.

Their brain function has ceased, otherwise no one would be contemplating taking their organs. It is in my opinion a different type of brain death.

It's only your opinion that they are alive, it depends what we consider alive. Without modern medicine, they would be dead as they cannot function fo themselves.

Well then surely coma patients fit into the possible donor category? I'm talking about people that are recovering or are likely to recover, I never said coma patients. Coma patients are not functioning for themselves and may never recover so I'm not sure how you consider that living.

People like anyone else? Well I am a person and I would never kill someone to save someone else so how about we put that much faith in them? I do see people as they exist, Doctors are hardworking and concerned about the patient. As I said this isn't just about faith in humanity, Doctors get judged on statistics so it's not good for them professionally to lose a patient. Also Doctors are monitored and face discipline and losing their career, why risk that for a recipient they dont know?

That's not wrong, if the life support is maintaining the organs there is no reason for them to deteriorate and you say sick but it's the brain that's damaged. They aren't dying, they are dead, a machine is breathing for them.

No they cant, what kind of facist hospitals have you been in?Doctors cant make the family do anything.

You never answered my query about seperate hospitals but certainly in the UK they would not be co-workers because the transplant team would work at a specialist transplant hospital.

They care more because he is their patient and it won't look good on them if he dies.

It's not irrelevant because there is no human reason to kill a patient you are treating to save some random you dont know when your job is the patient you are treating.

You keep saying wrong but you have no evidence or answers to disprove me and since so much of what you're saying is nonsense you're not on very safe ground with that.

I don't think brain death is the only way to die, people die from other things so why should that be the criteria?In this case the brain is not functioning and will not.

I don't want to change brain death to something grey and subjective I want other problems with the brain leading to a cease in functioning to be considered a type of brain death.

Statistics show you are more likely to need an organ than become a donor. You may be waiting for an organ yourself one day and I wonder how smug you will feel then about putting people off saving lives with myths and panic responses. You claim superior medical knowledge yet you are giving the ignorant underresearched nonsense that puts people off saving lives and means more people die each year waiting.

Orthoprax said...

Star,

"What do you mean visual difference?There is a difference as I said they would be a on a different level of ventilation and doing some of the breathing for themselves.
I'm not talking about someone in a coma, I'm talking about a recovering patient and someone whos brain function has ceased."

So a person in a coma isn't recovering? Why not? Coma doesn't mean they've been sitting there for months and months. They could have sustained an injury yesterday. What if it's a medically induced coma? I was talking about a person who is 100% vent dependent with no signs of higher mental activity. Happens all the time in the ICU. But they're not dead.

"Their brain function has ceased, otherwise no one would be contemplating taking their organs."

Wrong wrong wrong wrong wrong. Are you hearing me? Did you read my article? You are incorrect! Brain function is not assessed for DCD.

"It's only your opinion that they are alive, it depends what we consider alive."

Sure, which is why I like a firm, dark line away from subjectivity. If there's no test to determine death - then I don't know!

"Without modern medicine, they would be dead as they cannot function fo themselves."

Sure, dead guys like Dr. Hawking.

"Coma patients are not functioning for themselves and may never recover so I'm not sure how you consider that living."

They might still be mentally aware! They could wake up! How can you consider them dead!?

"Well I am a person and I would never kill someone to save someone else so how about we put that much faith in them?"

Actually, sounds to me like you would do exactly that! But you wouldn't 'kill' them, you'd just redefine them as 'dead' and then turn off their vent.

"Doctors are hardworking and concerned about the patient. As I said this isn't just about faith in humanity, Doctors get judged on statistics so it's not good for them professionally to lose a patient. Also Doctors are monitored and face discipline and losing their career, why risk that for a recipient they dont know?"

Because doctors are good people and want that six year old with renal failure to get her kidney! ICU docs lose patients all the time, they are not judged by their statistics and it does not affect them at all professionally. Turning off the vent of a hopeless case is a clinical judgement call and they would never suffer any disciplinary action.

"That's not wrong, if the life support is maintaining the organs there is no reason for them to deteriorate and you say sick but it's the brain that's damaged."

Hello? Hello? Are you listening to anything I say? When I say that a person can have end stage musculoskeletal or pulmonary disease does that turn into brain to you? A person on a vent can easily get infections or throw clots, which ruin organs - which is why transplant docs are eager to get those organs sooner rather than later. It isn't rocket science.

"They aren't dying, they are dead, a machine is breathing for them."

You keep saying that like you know what you're talking about. It is obvious you do not. If you cannot assess mental status then you DO NOT KNOW.

"No they cant, what kind of facist hospitals have you been in?Doctors cant make the family do anything."

The doctor is an authority figure and the family is typically in shock. 90% of the time virtually anything he tells them to do they will do. I see it all the time.

"You never answered my query about seperate hospitals but certainly in the UK they would not be co-workers because the transplant team would work at a specialist transplant hospital."

Sure, because that ICU doctor is never going to see that transplant team ever again, right?

"They care more because he is their patient and it won't look good on them if he dies."

Wrong. It doesn't look bad at all for a patient to die in the ICU. It's one of the most popular places to die actually.

"You keep saying wrong but you have no evidence or answers to disprove me"

I tell you that a person on a vent can get infections or throw clots and you just ignore what I'm telling you. I work in the field, you don't need to believe me when I say that a person in a coma looks identical to a brain dead person and can have identical ventilator settings but then you'd better do your own research before you spout off on things you talk out of your butt about.

"I don't think brain death is the only way to die, people die from other things so why should that be the criteria?In this case the brain is not functioning and will not."

Are you not listening? In the cases I've been discussing most of the brain may very well be functioning perfectly. These are the regulations - please note how they do not discuss total brain function:

'"1. A patient ... who has a nonrecoverable and irreversible neurological injury resulting in ventilator dependency but not fulfilling brain death criteria may be a suitable candidate for DCD [Donation after Cardiac Death].
2. Other conditions that may lead to consideration of DCD eligibility include end stage musculoskeletal disease, pulmonary disease, and high spinal cord injury."'

The POINT is that at brain death you can treat the body as a former person and have no ethical qualms about ending ventilator dependency. Before brain death, the person could still be in there - we don't know! How can you dare end his support?

"I don't want to change brain death to something grey and subjective I want other problems with the brain leading to a cease in functioning to be considered a type of brain death."

Yes, that's grey and subjective. How are you to test for that?

"You claim superior medical knowledge yet you are giving the ignorant underresearched nonsense that puts people off saving lives and means more people die each year waiting."

I don't just claim it, I have it. What I'm telling you is the real McCoy and the reality of medical practice, not the pretend world of ivory tower ethics or idealized transplantation. If anyone here is 'underresearched' it would doubtlessly be you.

"Statistics show you are more likely to need an organ than become a donor. You may be waiting for an organ yourself one day and I wonder how smug you will feel then about putting people off saving lives with myths and panic responses."

I'm not smug - I think people should be organ donors. But I don't think the OPTN/UNOS should be weakening the definition of death in order to get more organs. I think this redefinition puts patients at risk and puts critical care doctors in ethically precarious positions.

The difference is as stark as picking up an apple that had already fallen from the tree vs picking the apple that's about to fall.

Star said...

No they are not recovering, they're not improving they are staying in the same state. No signs of mental activity and 100% dependant doesn't sound like they are recovering to me.

You have yet to define for me what you consider to be death.

"Person who has a NON RECOVERABLE AND IRREVERSIBLE NUEROLOGICAL INJURY"
That would mean they have assessed brain function to know there is a neurological injury the person will not recover from. Surely that is a type of brain death.

They are not going to take organs from a person with brain activity or any signs that they will recover.

You don't seem to be able to define death yet you can ignorantly make judgements on what cases are or aren't dead.

Dr Hawking has brain function and is not incapable of doing any life functions for himself.

Tests can be done on brain fuction to prove that person is not aware and they are usually able to judge whether or not they will wake up.

You are just jumping to all sorts of uniformed conclusions about what death and killing is. You have to define death before you do so. If you have so much faith in the magical recovery of people from neurological injuries I don't see why you consider brain death an acceptable judge of death? Seems to me you think we should keep all patients on life support for endless amounts of time "just in case".

Good people may want someone to live but they do not want to kill someone so that person can live. Also, did YOU read that article?
Many people have to agree with the life support withdrawal and the transplant team cannot be present for withdrawing life support and do not get to decide when it is withdrawn.

They are judged by statistics, where is your evidence for all this nonsene you are spouting? All Doctors are monitored and judged by performance including what patients die under their care.

You yourself mentioned Dr Hootan Roozrokh who apparently did what you are claiming and his actions clearly didn't go unoticed, of
course they will face disciplinary action if they make the wrong call.

If they have an end stage of one of those diseases, there is no hoppe of recovery anyway so what are you so afraid of?And point being they are not going to wheel a concious functioning person with brian function into surgery and start removing their organs.

And you do know what you're talking about do you? When you can't even provide a defintion of what you consider death. ANd if we dont know, shall we leave all people on life support for 100 years or so on the off chance they might recover?

That is complete nonsense, there is a 40% rate in the UK of next of kin ovverriding the patients wishes. That means not only has the Doctor not convinced them but neither has the patients wished. of course they wont do anything the Doctor tells them to do. i ahve had a family member in a critical condition in ICU and I can assure you I did not lose the powers of common sense or ability to have an opinion and my own mind.

Still not answering my query, suggesting you know ridiculously little about transplantation anyway. Not if they work at different hospitals, no.

Just because lots of people die there does not mean no one cares if every patient in that day dies. It is regulated like any other part of the hospital. You sound as if you have never set foot in a hospital before.

God help your patients if you work in the field. You dont seem to know very much about medicine and believe all Doctors are killers.

What you have seen is no more proof or evidence than what I have seen so dont imply I havent done my research if the best you can come up with is how someone in a coma looks.

How do you prove a non recoverable neurological injury without testing brain function?? Judging by your medical expertise, pehaps they look at the patient and go "oh that looks like a non recoverable neurological injury to me"?

Don't be so ridiculous the fact it does not need to be what is considered brain death does not mean they dont test brain function.

And your evidence is where? In the words "the real McCoy"?

You are extremely smug, you should really read your responses again and count the number of times you smugly use the word 'wrong' with no evidence that I am actually in the wrong just your opinions which prove nothing.

Well then it's a shame you are putting people off of organ donation by telling everyone Doctors are desperate to harvest your organs and dont care about your own health. A survey recently came out showing that fear is the main reason so many people are afraid to sign the register? So while supposedly supporting organ donation, you're doing your bit to stop people signing the register, feel a little less smug now?

Where is the huge difference in that?It's about to fall either way, you cant stop or help it. IUn the case of those on life support a better analogy would be an apple that has come loose from its branch but landed on another branch and is being held up before it falls.

Orthoprax said...

Star,

"No they are not recovering, they're not improving they are staying in the same state. No signs of mental activity and 100% dependant doesn't sound like they are recovering to me."

Sure, doesn't sound like it to a layman like yourself - but that person may very well be on their way to a full recovery. You simply do not know.

"You have yet to define for me what you consider to be death."

Death is the full and unrecoverable cessation of neurological activity. Any definition of death that you cannot test for is without meaning.

""Person who has a NON RECOVERABLE AND IRREVERSIBLE NUEROLOGICAL INJURY"
That would mean they have assessed brain function to know there is a neurological injury the person will not recover from. Surely that is a type of brain death."

Wrong. That's a type of brain damage. It *could* mean brain death, but it *could also* mean a minor stroke.

"They are not going to take organs from a person with brain activity or any signs that they will recover."

Again, for the umpteenth time - WRONG. Read the article. The WHOLE POINT about DCD is that these people HAVE brain activity.

"Tests can be done on brain fuction to prove that person is not aware"

Such a test does not exist. A person may be unable to react and still be 100% aware. Again, your buttocks speaks.

"If you have so much faith in the magical recovery of people from neurological injuries I don't see why you consider brain death an acceptable judge of death?"

I don't have faith in recovery from severe neurological injury. I believe that most of those people WILL die. The POINT is that at the time of assessment they are NOT dead.

"Good people may want someone to live but they do not want to kill someone so that person can live."

Sure, which is why redefining death itself is so clever!

"Many people have to agree with the life support withdrawal and the transplant team cannot be present for withdrawing life support and do not get to decide when it is withdrawn."

Yes, in theory. In practice there is hardly ever this kind of strict divide. If you have only six hours to transplant a heart, you don't think the ICU is coordinating very closely with the transplant team?

"They are judged by statistics, where is your evidence for all this nonsene you are spouting? All Doctors are monitored and judged by performance including what patients die under their care."

There's nothing legally wrong with turning the vent off a dependent person with next of kin consent. Nobody is monitoring such things because it's a valid clinical judgement call. In general too, if a sick person dies in the ICU, nobody is automatically poring over the records to figure out why. Nobody is judging and nobody keeps count.

"You yourself mentioned Dr Hootan Roozrokh who apparently did what you are claiming and his actions clearly didn't go unoticed, of
course they will face disciplinary action if they make the wrong call."

Why would they face disciplinary action on something that's grey and undefined? Dr. Hootan was just egregiously out of place.

"If they have an end stage of one of those diseases, there is no hoppe of recovery anyway so what are you so afraid of?"

That they're still alive, of course!

"And point being they are not going to wheel a concious functioning person with brian function into surgery and start removing their organs."

But they will turn off the vent of a person with brain function - which will kill them.

"ANd if we dont know, shall we leave all people on life support for 100 years or so on the off chance they might recover?"

If they're not brain dead then I'm not pulling the plug. It's not a matter of maybe they'll recover one day, it's a matter of not killing people prematurely. Are you a supporter of euthanasia?

"That is complete nonsense, there is a 40% rate in the UK of next of kin ovverriding the patients wishes. That means not only has the Doctor not convinced them but neither has the patients wished."

Sure, next of kin override the patient's will all the time. That has little to do with the will of the doctor.

"of course they wont do anything the Doctor tells them to do."

Uh huh. If you say so. Doctors hold all the cards and have all the knowledge. The power differential is huge and doctors can be very persuasive. In general people defer almost entirely to the doctor's judgement.

"Still not answering my query, suggesting you know ridiculously little about transplantation anyway. Not if they work at different hospitals, no."

LOL! Right, that transplant team is never going to be called to that nearby ICU for another potential transplant for the rest of their careers, eh? What's your question? It's almost comical how you think you have superior knowledge.

"Just because lots of people die there does not mean no one cares if every patient in that day dies. It is regulated like any other part of the hospital. You sound as if you have never set foot in a hospital before."

LOL! People die, it happens. Sick people are expected to die in the ICU. Nobody gets called out when that happens.

"What you have seen is no more proof or evidence than what I have seen so dont imply I havent done my research if the best you can come up with is how someone in a coma looks."

LOL! Do you still think "life support" is an uber fancy ventilator?

"How do you prove a non recoverable neurological injury without testing brain function?? Judging by your medical expertise, pehaps they look at the patient and go "oh that looks like a non recoverable neurological injury to me"?"

That's actually 100% correct. By mechanism of injury, radiographic findings, neurological exam and so on they can judge the type of injury and whether it is recoverable. But it's an inexact science and often they are wrong! It's a clinical judgement and typically it doesn't matter how inexact it is because no matter what, the goal is to keep the person alive and recover as much as they can.

"Don't be so ridiculous the fact it does not need to be what is considered brain death does not mean they dont test brain function."

The point was that they don't need to test for brain death. They do not test for awareness. Brain function may still exist but they don't need to check for it. But they can pull the plug regardless.

"You are extremely smug, you should really read your responses again and count the number of times you smugly use the word 'wrong' with no evidence that I am actually in the wrong just your opinions which prove nothing."

They're not my opinion. When I say you are wrong, it's not my opinion, it's that you are so COMICALLY wrong about the plain facts that I just need to correct you. Do I need to prove that the earth is round? You need to do some more reading and less butt talking.

"Well then it's a shame you are putting people off of organ donation by telling everyone Doctors are desperate to harvest your organs and dont care about your own health."

I didn't say that at all. I said DCD is putting doctors in ethically insecure positions where they may care too much about organs and their care for the person may suffer.

"A survey recently came out showing that fear is the main reason so many people are afraid to sign the register? So while supposedly supporting organ donation, you're doing your bit to stop people signing the register, feel a little less smug now?"

Frankly, with DCD I am less willing to register myself. If you want people to feel confident and unafraid then the OPTN/UNOS should do away with DCD and back to making sure a person is truly brain dead before their organs can be harvested.

"Where is the huge difference in that?It's about to fall either way, you cant stop or help it."

It's the difference between murder and not murder. Killing someone who is about to die anyway is still murder.

I guess little quibbles about human life don't bother you - and you wonder why people are reluctant to sign up to donate! With supporters like you who needs opponents?

"IUn the case of those on life support a better analogy would be an apple that has come loose from its branch but landed on another branch and is being held up before it falls."

Actually that is a worse analogy. Life is defined by that stem and it is either intact or it is not.

Star said...

Ok firstly, what the hell is a layman?
You could say that for any neurological injury if you don't trust the tests, how long do you want to leave people on life support for?

You can test for Cardiac Death, they're not just going to decide the person looks a bit dead, of course they will do tests and if you read the link YOU posted it lists all the controls over it.

Show me WHERE in that article it says the people have brain activity or a chance or recovery, where?

Well if you think they wont recover and arent functioning where is your issue with cardiac death?

It is not in theory, hospitals have to adhere to strict procedures and rules. No they are not, once again you don't seem to know anything about the transplant system in the US which doesnt help much certainly in the UK they are kept seperate.

That is rubbish, all patients that die have thorough records kept and if anything seems amiss the Doctors involved will have to answer for it. Why you work in medicine when you seem to have so little faith in the system is beyond me.

It's not grey and undefined, what you posted what a clear objective definition of what defines cardiac death.

They are not alive, they are not functioning or aware or recovering there is such a tiny gap between that and brain stem death I dont see your issue.

They were dead already, the machine is living for them.
Yes I agree with Euthansia in some cases so pehaps that is where we differ. I don't see the point of leaing people to suffer in an undignified way when they are beyond help. We put animals down when they are beyond help because it's more humane I dont see why we shouldnt help out fellow humans.

If they can override the dead persons wished they can disagree with a Doctor. They do not hold all the cards, I doubt you would believe what they say since you think theyre all manipulative killers so why should anyone else?

There actually seems to be something wrong with you when it gets to this issue. DIFFERENT HOSPITALS. What part of that do you not understand? If there are different hospitals there is no transplant team being called to ICU, the transplant is at a DIFFERENT HOSPITAL. Am I supposed to be expressing this in pictures or something?
I'm guessing they didn't test you for intellect when you started working in medicine.
What are you in medicine by the way? The hospital cleaner pehaps?

Do you work in a third world hospital or something? In what hospital do they not record and monitor patient deaths? I have never come across such a hospital.

A neurological exam is not the same as "that patient looks a bit dead to me". There are plenty of tests done and precautions taken.

Once again where are you getting these assumptions from? They are certainly not in the article you posted.

It is your opinion because you have no evidence to back it up. You could prove the earth is round, you dont seem to be able to prove any medical knowledge. You do how ever seem to possess the mental age of a 4 year old and the ability to use the word butt, how very clever of you.

That is what you said!You said Doctors would kill one patient to save another and you are discouraging signing the register and saving lives.

It's not murder, if you read my version of your able analogy, the person has stopped functioning for themselves and will reach the falling off the tree, why hold them up for longer when there is no chance of recovery and the machine is living for them anyway?

The stem would be living when they could breathe and function for themselves, they have seperated from that stem and just because they have not hit the ground yet does not mean they are alive.

Orthoprax said...

Star,

"Ok firstly, what the hell is a layman?"

A non-professional; ignorant of specialized knowledge. The internet is a wonderful resource for looking up words you don't know - try it sometime, eh?

"You could say that for any neurological injury if you don't trust the tests, how long do you want to leave people on life support for?"

I trust the tests for brain death.

"You can test for Cardiac Death..."

Sure - after they *caused* it.

"Show me WHERE in that article it says the people have brain activity or a chance or recovery, where?"

The whole point about DCD is that they are not brain dead - ergo they have some brain activity. Why is this so hard for you?

"Well if you think they wont recover and arent functioning where is your issue with cardiac death?"

I feel like I'm talking to a wall here. The issue is not with cardiac death, the issue is the state of the person before the plug is pulled. Pulling the plug is what causes their death. They are alive before that happens. Get it?

"It is not in theory, hospitals have to adhere to strict procedures and rules."

How naive are you? Seriously.

"That is rubbish, all patients that die have thorough records kept and if anything seems amiss the Doctors involved will have to answer for it."

Except nothing seems amiss because the action is a legitimate clinical judgement call.

"Why you work in medicine when you seem to have so little faith in the system is beyond me."

Why should I have faith in any system? It's run by people - and people make errors all the time. This DCD protocol leaves room for very bad errors to occur.

"It's not grey and undefined, what you posted what a clear objective definition of what defines cardiac death."

Can you please pay attention? Just a tiny bit?

"They are not alive, they are not functioning or aware or recovering there is such a tiny gap between that and brain stem death I dont see your issue."

This is my issue - the fact that you cannot see the difference between life and death only certifies how right I am. These people may even be aware!

"Yes I agree with Euthansia in some cases so pehaps that is where we differ. I don't see the point of leaing people to suffer in an undignified way when they are beyond help. We put animals down when they are beyond help because it's more humane I dont see why we shouldnt help out fellow humans."

I didn't go into medicine to kill people. Clearly for you, human life has a flexible value. I consider it absolute and I won't let the likes of you chip away at it lying down.

"If they can override the dead persons wished they can disagree with a Doctor."

You just don't listen, do you? In theory of course they can, in practice they are in shock or grief and they'll do whatever they're told.

"They do not hold all the cards, I doubt you would believe what they say since you think theyre all manipulative killers so why should anyone else?"

That's stupid, I don't think doctors are manipulative killers, nor did I ever imply it. But you seem to have serious trouble following what I'm saying so I'm not suprised.

"There actually seems to be something wrong with you when it gets to this issue. DIFFERENT HOSPITALS. What part of that do you not understand? If there are different hospitals there is no transplant team being called to ICU, the transplant is at a DIFFERENT HOSPITAL."

Why do you not get the idea that there are only so many ICUs in the geographic location that a transplant hospital would serve? That same transplant team will invariably find themselves working with that same ICU again and again and again. Maybe you should draw yourself that visual aid!

"Do you work in a third world hospital or something? In what hospital do they not record and monitor patient deaths? I have never come across such a hospital."

I didn't say they don't record deaths, I said that nobody is monitoring deaths for suspicious activity or anything like that. Patient dies, the documents gets filed, it goes into the archives - nobody need review it.

Unprofessional behavior and such needs to be actively reported, there's no Big Brother eyeing the records.

"A neurological exam is not the same as "that patient looks a bit dead to me". There are plenty of tests done and precautions taken."

There are good tests for brain death. There are no good tests for awareness. Tests in between consciousness and brain death are often unclear. That's the nature of the beast.

"Once again where are you getting these assumptions from? They are certainly not in the article you posted."

I don't know what this is referring to.

"It is your opinion because you have no evidence to back it up."

LOL, ok. I hope you're reading up on life support and neurology.

"That is what you said!You said Doctors would kill one patient to save another"

No, I said that it could happen. I did not say doctors are desperate to get organs and I did not say that doctors don't care about the patient's health. I said that these regulations put them at cross purposes which could result in poor outcomes for their patients. Caring *at all* about their organs changes clinical behavior.

"and you are discouraging signing the register and saving lives."

I am neither encouraging or discouraging that here. I am encouraging them to change the current regulations.

"It's not murder, if you read my version of your able analogy, the person has stopped functioning for themselves and will reach the falling off the tree, why hold them up for longer when there is no chance of recovery and the machine is living for them anyway?"

Cause they ain't dead, sista! You want to put a happy face on killing people?, go right ahead - I'm not fooled.

"The stem would be living when they could breathe and function for themselves, they have seperated from that stem and just because they have not hit the ground yet does not mean they are alive."

How many times must we go over this? If they're not brain dead then they ain't dead. They could still be 100% aware - how can you call them dead?

I'm glad you don't work in an ICU!

Star said...

I could have searched it online but your petty insults aren't really worth the bother thanks.

No, not after, they can asses the situation before changing anything and there are clear stipulations for what counts as cardiac death.

Where does it say they have brain activity? That is completely your assumption. Just because they don't fit the brain death criteria does not mean there isdefinetly brain activity.

I get that your OPINION is that they are alive. The fact this has been labelled cardiac DEATH suggests others disagree. I'm with them, what's your opinion worth?
Why should I take your view over the professionals and my own, what supports yours?

I'm not naive, you're cynical.

Because the majority of Doctors are competent, hard working and want what's best for their patient.
That's why. And I still trust them to define death and handle organ donation more than I trust you with it, funny that.

Read the form YOU posted, there are clear defined rules.

Once again, it's your opinion that they are alive. Somehow I still think these rules and decisions have been made by people more intelligent and experienced than you.

Well why did you go into medicine?Since its apparently full of killers?

It's not a flexible value for me at all I think clear lines indicate death I just agree with the lines around cardiac death.

I listen, but I disagree. You have said nothing that makes me respect your opinion any more than any other random I meet on the street.

Of course you did, you think a Doctor will kill a live person for organs and you think they will manipulate the family into agreeing.

Wow you're really not very bright for someone in medicine. DIFFERENT HOSPITALS means they do NOT work with the ICU, they work in their own HOSPITALS.

Of course the deaths are monitored and Doctors have to answer for their actions. You're jsut making this up!

I love how you're backtracking now and suddenly Doctors aren't killers and don't want organs. Glad I've convinced you though.

You are discouraging organ donation because you're promoting the ignorant myths that put people off.

Using the word 'sista' doesn't make you sound very intelligent or knowledgable on this issue. Mind you neither does anything else in your responses or this blog.

I can call them dead because their brain is no longer functioning, they cant carry out processes that define them as alive such as breathing and they will never recover the ability to do so. How is that living?

Once again this is a matter of your opinion but I trust the medical professionals that have defined cardiac death over your uniformed ramblings.

And you never said what you work as in medicine? Does that mean I'm right and you're the cleaner? I hope so, for the patients sake.

Orthoprax said...

Star,

"I could have searched it online but your petty insults aren't really worth the bother thanks."

It's not an insult. You are an outsider who thinks she knows what she's talking about, but actually does not.

"No, not after, they can asses the situation before changing anything and there are clear stipulations for what counts as cardiac death."

I cannot believe I need to explain this yet again. The person is not in cardiac death - and then he is - after he is taken off the ventilator. Taking him off the ventilator is what causes cardiac death. Taking him off the ventilator is what kills him. Do you get this?

"Where does it say they have brain activity? That is completely your assumption. Just because they don't fit the brain death criteria does not mean there isdefinetly brain activity."

If the brain is tested and determined to not be dead then that NECESSARILY means, by definition, that there is brain activity. This isn't an assumption, it's true by definition. Do you get this?

"I get that your OPINION is that they are alive. The fact this has been labelled cardiac DEATH suggests others disagree."

Do you have some sort of mental block? They are labeled to be in a state of cardiac death only after the vents are pulled. Before that they are not in a state of cardiac death. This has to be the ninth or tenth time I've gone over this, right?

"Why should I take your view over the professionals and my own, what supports yours?"

Because you have reading comprehension problems?

"Once again, it's your opinion that they are alive."

And state law too, but that shouldn't matter. If you refuse to listen to reason when I tell you that these people *can still be aware* I don't have much recourse to convince you of anything.

"And I still trust them to define death and handle organ donation more than I trust you with it, funny that."

Funnier than you think.

"Read the form YOU posted, there are clear defined rules."

Sure - rules that permit wide allowance of subjective clinical judgement. They are bad rules -hence this post.

"It's not a flexible value for me at all I think clear lines indicate death I just agree with the lines around cardiac death."

You can't agree with lines that you plainly do not even understand.

When do you think it's ok to take someone off of a vent? Cardiac death - literally - has nothing to do with it since that's what happens only after the guy is off the vent for five minutes.

"Wow you're really not very bright for someone in medicine. DIFFERENT HOSPITALS means they do NOT work with the ICU, they work in their own HOSPITALS."

Goddam, you are dumb as a plank of wood. They work in terms of close communication and coordination - and sometimes it's the same transplant surgeon who comes in to (that far away dreamland hospital with the foreign ICUs) take out the organ from the donor and bring it to recipient. The ICU docs are under pressure to deliver good organs.

"Of course the deaths are monitored and Doctors have to answer for their actions. You're jsut making this up!"

Answer for what actions? Again and again (and again and again) I've said that turning off a vent is a valid clinical judgement call. There's no reason at all for any actions to be put under review.

"I love how you're backtracking now and suddenly Doctors aren't killers and don't want organs. Glad I've convinced you though."

I never said they were! You are intentionally and maliciously misrepresenting my statements - generalizing what I said in specific.

"Of course you did, you think a Doctor will kill a live person for organs and you think they will manipulate the family into agreeing."

No - I said the potential is there. I also happen to think that turning off the vent of a non-brain dead person is killing the person and that this has been common practice for decades. I think that most doctors are excellent individuals - but I also believe that given perverse and ethically dubious situations some people will inevitably succumb. The current regulations on DCD present just those situations.

"You are discouraging organ donation because you're promoting the ignorant myths that put people off."

Ironic actually, since what I've said is true and you have throughout this discussion shown gross inability to comprehend half of what I say. If anything, you promote ignorant myths to promote people to donate.

"I can call them dead because their brain is no longer functioning, they cant carry out processes that define them as alive such as breathing and they will never recover the ability to do so. How is that living?"

How many times do I need to repeat myself? ONE - THEIR BRAIN IS STILL FUNCTIONING. TWO - BREATHING DOES NOT DEFINE LIFE. THREE - WHAT REMAINS OF THEIR BRAIN MAY STILL BE AWARE! Unless you manage to get these facts through your head this whole exercise is pointless.

The fact that they will not recover merely means that they are dying, not that they are dead.

"Once again this is a matter of your opinion but I trust the medical professionals that have defined cardiac death over your uniformed ramblings."

You are hilarious!

"And you never said what you work as in medicine? Does that mean I'm right and you're the cleaner? I hope so, for the patients sake."

LOL! The fact that I want to keep patients alive will no doubt endanger them! What I do is in my profile.


Now I think this discussion has run it's circular course more than once already and I'm losing the inclination to try and make you see what is apparently beyond your ken. If you show a basic comprehension of at least some of the statements I've left in capitals above then we can continue, but otherwise this is just a huge waste of time for me.

Star said...

Of course it's an insult, your insults throughout this discussion show a real lack of maturity and dignity.

Once again what you are trying to explain is merely your opinion. The person is no longer functioning for themselves with no hope of recovery, this is believed to be death so the machines living for them are removed.

I have already answered that repeatedly, nowhere in that document does it say there is brain activity and brain death is just one particular set of measures to prove lack of brain activity.

You cannot claim to know better than medical professionals, scientists and philosophers where life begins and ends. There is debate over this topic but not everyone ahs to agree with your arrogant opinion. I dont consider a machine breathing and functioning for you while you are not concious, have irreversible brain damage and no hope of recovery living,I consider that patient dead and withdrawal of life support simply stopping simulating life.

It's not refusing to listen, its disagreeing, I know you think a lot of your opinions but you have nothing to back them up and therefore a fair chance of being wrong.

They are clearly defined rules with plenty of precautions. I understand perfectly well and agree with them. Deal with that.

That's because it's the vent that is providing any pretence of living, they cannot function and will never function, that person has died and we are just keeping the body in a life like state.

It's nothing to do with ICU docs what quality the organs are in, that responsibility is with the transplant team.

It is sttill a judgement call and one that will be checked by others and can be reviewed if anyone believes it was taken for the wrong reasons.

Yes you did!You said that they would kill a living person to help the donor. I didn't agree with your opinion but trying to backtrack out of it is pathetic.

"happen to think"- see that is the key issue there, think= an opinion. You don't know, you think.

Once again you confuse not understanding with disagreeing.

ONE- You don't know and cannot prove the brain is functioning
TWO- Breathing is a life process and people die if they cannot breathe. If someone has permanently lost the capability to breathe, they are dead. Making a machine breathe for them doesn't change that.

Ah so you're a student, so you are not remotely qualified to make these judgements. Still judging by your imamture insults and inabiliity to read and understand I'm pretty impressed you got onto a course in the first place, doesn't mean you'll qualify though which is reassuring as I pity your future patients.

I also think if you actually had the experience of working with people waiting for transplant you would re-think encouraging ignorant myths that put people off donation.

I don't mind if you want to continue or finish but I think your arrogance will prevent you from understanding the concept of someone disagreeing with you rather than misunderstanding and until you get over that and mature a bit, this discussion won't be able to progress.

Orthoprax said...

Star,

"Of course it's an insult, your insults throughout this discussion show a real lack of maturity and dignity."

Calling someone a layman isn't an insult - calling you dumb and such, those were intended to be offensive - primarily intended to make you at least reconsider some of the dumb things you say.

"Once again what you are trying to explain is merely your opinion. The person is no longer functioning for themselves with no hope of recovery, this is believed to be death so the machines living for them are removed."

I don't know how to tell you that this isn't opinion. I've tried a dozen different ways. If the person isn't brain dead then he could still be aware. Medical professionals do not consider that a state of death, nor does the state. You are alone here.

"I have already answered that repeatedly, nowhere in that document does it say there is brain activity"

It says that the person is not brain dead...

"and brain death is just one particular set of measures to prove lack of brain activity."

No, you're wrong. It is the ONLY way to prove it. Your plain ignorance on this matter is again highlighted.

"You cannot claim to know better than medical professionals, scientists and philosophers where life begins and ends."

I don't claim to know better about the metaphysical definition of death - but I do know better (than you at least) about the limits of our tests and the potential that lies behind the inherent ignorance.

"I dont consider a machine breathing and functioning for you while you are not concious, have irreversible brain damage and no hope of recovery living,I consider that patient dead and withdrawal of life support simply stopping simulating life."

And again - the person could still be aware on some level. This is never ruled out. You have never responded to this possibility, but you're still all too eager to pull the plug. Why is this so?

"It's not refusing to listen, its disagreeing"

When I tell you that total brain function is not ruled out and therefore awareness may still be present, this isn't my opinion. To disagree you have to actually address this point. So far you just ignored it or denied (based on one absurd misunderstanding after another) that it was possible.

"They are clearly defined rules with plenty of precautions. I understand perfectly well and agree with them. Deal with that."

No - you plainly do not. For two whole posts you were sure the regulations were about defining cardiac death. Not so much.

"That's because it's the vent that is providing any pretence of living, they cannot function and will never function, that person has died and we are just keeping the body in a life like state."

There is a dozen+ situations that can mimic brain death, yet the person could still be aware and very much alive in there. This is the reason we check for brain death. You are either intentionally ignoring that - even after I point it out again and again and again and again and again, or you are so caught up in your own fantasies about organ donation that psychologically you cannot accept what I'm telling you.

"It's nothing to do with ICU docs what quality the organs are in, that responsibility is with the transplant team."

100% wrong. This yet again reflects your gross ignorance on the subject. It also reflects the reason why you seem to have zero comprehension of what I've been saying. Frequently drugs are given and procedures performed in the ICU solely for the sake of the organs' health. The classic case extensively discussed in the literature is giving heparin to prevent clotting in the organs, but which could theoretically hasten death by causing internal bleeding.

A shocker, eh? Do read up on it, my impassioned apprentice.

"It is sttill a judgement call and one that will be checked by others and can be reviewed if anyone believes it was taken for the wrong reasons."

It's not something regularly checked by anyone - and it's unlikely for people to believe it was done for the wrong reasons. That likely requires lawyers and such to get involved.

"Yes you did!You said that they would kill a living person to help the donor. I didn't agree with your opinion but trying to backtrack out of it is pathetic."

I'm not backtracking out of anything - I am clarifying. You were trying to generalize my statement saying that I think doctors in general are bad people who would go out of their way to kill people in order to get their organs. My actual view is that the situation is perverse and good doctors will be lead into making decisions not in the true interests of their patients per se, of which early termination is a possibility.

""happen to think"- see that is the key issue there, think= an opinion. You don't know, you think."

Yes, I think it is killing the person - other people would say they "are allowing the person to die." Nobody says that the person is already dead - except the likes of you.

"ONE- You don't know and cannot prove the brain is functioning"

What exactly do you think brain death is? Now what do you believe happens if the person is not brain dead? Duh...some brain is still alive - i.e. some brain is still functioning. DUH.

"TWO- Breathing is a life process and people die if they cannot breathe. If someone has permanently lost the capability to breathe, they are dead. Making a machine breathe for them doesn't change that."

Duh, like that rolling corpse Stephen Hawking. There are thousands of people, conscious and very much alive who cannot breathe on their own. That you continue to retread over this same exact ground which we covered ten posts ago shows me that something just isn't making it into your head. Maybe you're wasting my time on purpose!

"Ah so you're a student, so you are not remotely qualified to make these judgements. Still judging by your imamture insults and inabiliity to read and understand I'm pretty impressed you got onto a course in the first place, doesn't mean you'll qualify though which is reassuring as I pity your future patients."

LOL! Yeah, maybe I'll fail out in my final year of med school! Touche! Can you imagine it? - in one year I'm going to be one of those people with them fancy letters after their name - people who folks like you trust to determine life and death.

"I also think if you actually had the experience of working with people waiting for transplant you would re-think encouraging ignorant myths that put people off donation."

Ironic! I have! But I also have experience in the ICU, from the donor's point of view. What I've been saying are not myths - I simply care strongly about not killing people (I know, how strange of me, right?). I want people to donate - and I want the regulations to ensure that donors are not abused. I want to be able to say that the only way organs can be donated is if the donor are truly dead - i.e. brain dead. YOU just don't care about the donors and are all too eager to label them dead.

"I don't mind if you want to continue or finish but I think your arrogance will prevent you from understanding the concept of someone disagreeing with you rather than misunderstanding and until you get over that and mature a bit, this discussion won't be able to progress."

LOL. I love it when someone calls other people immature, what does that even mean? I've been rip-roaringly RUDE and OFFENSIVE, but immature? Isn't that what elementary school kids call each other? How old are you?

The fact is that I of course know the difference between disagreement and misunderstanding - and I'm calling what went on above (and seems likely to continue) a case of ignorant misunderstanding on your part.

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