We have another Terri

And we will have another Jahi. (If things don't change.)



I'm actually surprised we don't have more high-profile cases on end-of-life issues. I am. You know why? Because doctors have not used these, for lack of a better word, opportunities to educate the public as much as we should. In the case of Terri Schiavo, debates on the definition of brain death reached the US Supreme Court and both lawyers and politicians battled over this and related terms. The voice of Medicine could not be heard. I suspect it was absent. And if it was there, it was definitely drowned out by the masses.

What do the masses think about brain death? If we take a look at our primary learning tools (i.e. TV and the internet), the mark of death goes like this: BEEP. . . BEEP. . . beeeeeeeeeeeeeeeeee. The camera pans to the heart monitor, showing a flat line.

Is it any wonder then why Jahi's mother refuses to accept that her daughter is dead so long as she still has a heartbeat?

Why DOES she still have a heartbeat, anyway? If you asked yourself that question, you're not alone. As I stated earlier, we (doctors) have not done the best job at educating the public about this. A person can have a persistent heartbeat during mechanical breathing support because the artificial respirations we create for them can trigger the heart to beat. And I should add that this heartbeat tends to be very weak and very slow. Moreover, to end up on mechanical support one often receives a CPR protocol that involves pumping adrenaline-like drugs into the body and this too can contribute to a pulse.

So if one has a pulse and "can breathe," albeit not on their own, what makes them dead? One answer is this occurs when the brain's "switch" is turned off. In that case, not only is there no brain activity (i.e. no consciousness), there is also no connection between the rest of the body and the brain. In the case of Jahi, we are told that an EEG did confirm brain death.

But they say Jahi is moving and responding to touch! This is a very confusing and even painful thing for family members of the patient to observe. They're being told to pull the plug, but it appears as though the patient is fighting for life. What's actually happening is occurring at the muscle and peripheral (i.e. not inside the skull) nerve level. It is not conscious. Muscle needs energy to lengthen. A dead body doesn't make energy and so their muscles shorten, making it look like the person is gradually flexing their body. The nerve situation is even more remarkable. Now that the brain is dead, the nerves are having their final hurrah without the brain telling them what to do. They can become highly reflexive such that the slightest touch can cause the toes to go up or even the arm to withdraw. Eventually these activities extinguish, but until then you can see how upsetting their presence can be to one trying to accept their loved one is gone.

I know a lot of people are frustrated with the McMath family for not accepting "reality", but my question is, why do we expect them to accept something they might not fully understand to begin with? Patience and education, that's the place to start and (hopefully) minimize struggles like this in the future. Also, what reality are we speaking about here? A beating heart is real enough to them, and that's worth consideration, or at least an increase of compassion toward the McMaths.