Sunday, January 25, 2009
The Greatest Gift
She was already dead when I came in to work. Blunt head trauma sustained during a common winter activity. Not breathing, and intubated on scene by paramedics. Despite two emergent neurosurgeries, there were no signs of improvement. The day before she had failed neurologic and apnea testing.
For some reason, the weekend team did not want to declare her brain dead the day before, so we waited, as a re-evaluation by neurosurgery had been promised. When I first examined the patient that morning, her family members were yelling at her nurse for not supporting their hopes that she would wake up. I just quietly listened to the patient, and did a quick neuro exam and let them be.
When we rounded as a team, the child's father told us that they were waiting for a miracle. He said that he believed in the Bible and there were cases where people had been brought back from the dead. He didn't believe that God would allow his daughter to survive the accident only to die now. My attending said that he believes in miracles, but that from his exam, the child was clinically brain dead. He apologized to her father, but said that in his opinion, their daughter did not survive the accident. He told them that they should talk to only the loved ones whose opinions they valued. They would have some decisions to make, including possible organ donation, if the child was confirmed brain dead by neurosurgery later as he suspected.
Neurosurgery finally came back to the bedside and the same tests from the day before were repeated. Again, there were no signs of brainstem functioning or breathing. Time of death was declared, and the family was given time to talk with their pastor and social workers.
It was an awkward situation for us to walk into that morning, having not met the family beforehand, but I think that my attending handled it pretty well. I believe in miracles, too. I would have also added that miracles and unexpected outcomes happen in spite of what we do. As a physician, there is nothing that I can do to stop one of God's miracles from happening. Some people recover in spite of showing up late in their disease, while others seek treatment immediately, get treated aggressively, and still die. Life is unpredictable. While I have not seen anyone declared brain dead recover, I have seen a patient recover from removal of life support when it was expected to be a terminal wean. Maybe that's how I rationalize dealing with my own values though, when sometimes families and powers of attorney make different decisions than what I would do. However, at the same time, I think that saying something like that also helps the family to move through their grief. To the family members, there is never going to be an acceptable time to remove life support. They will wait, day in and day out for weeks, and even months. It's horrible to watch families camp out in hospitals, losing sleep and sometimes risking their jobs to be at the bedside of a loved one non-stop, especially when there is not expected to be any recovery.
In the end, the patient's family decided to donate her organs. An organ transplant service was contacted, and they set out immediately looking for matches across the country. Things got a little hairy while we waited as the patient developed renal failure, had great swings in blood pressure and glucose levels, and lost the ability to concentrate her urine (likely due to pituitary infarction). It took about 36 hours of constant work to arrange, but three separate surgical teams were flown in and coordinated to harvest her heart, lungs, kidneys, pancreas, small intestine, corneas, bone, and skin. In the end, she helped about 50 people, a significant number of which were probably children.
I think that this child was part of a miracle, it just wasn't one for her family. It was amazing that she was able to help so many others, and that her family was able to make the decision to donate in spite of the shock of an unexpected death.
For the last couple of weeks, "Grey's Anatomy" has been focused on a small boy needing organ donation. However, in their scenario, the surgeons are running all over the hospital testing critically ill patients to look for a match, and pressuring their family members to donate. In reality, this is prevented by the use of independent organ donation teams. Once we find a donor (typically emergency and ICU patients), the procurement team is contacted and they come in and run the show as far as looking for matches on the national database.
While it makes for good drama on TV, there are obvious ethical concerns about having the same doctor caring for a potential donor and a potential recipient. We can't randomly test people for matching a recipient without their knowledge, and have no control in regards to what order on a recipient list a patient is. So get it together, TV writers, that was just ridiculous-- I'm not running a chop shop here!