Irvin Madrid - Hospital Unilaterally Disconnects Ventilator

Irvin Madrid had been in a persistent vegetative state for 17 months, since February 2010.  By late June 2011, providers at the Nebraska Medical Center unanimously decided that it was best to take him off life support.  But Irvin's father, Alfonso, disagreed and refused permission.  

NMC then obtained an independent medical assessment.  That physician agreed there is "no chance for recovery" and that withdrawal was appropriate.  The family then tried to transfer Irvin, but could find no willing facility, perhaps because he was uninsured.  The hospital ethics committee then approved the withdrawal decision.  After eventually reaching Alfonso to notify him of the decision, NMC disconnected the ventilator on July 12, 2011.  (Omaha World Herald 1; Omaha World Herald 2).

I cannot tell from the reports, but trust that NMC did all this in a compassionate manner.  I commend NMC for having the courage that many other hospitals lack in these circumstances to provide appropriate medicine.  While the hospital may have to deal with some negative press, its decision may have been facilitated by the fact that it appears there is little risk of liability or even litigation.  Nev. Rev. Stat. 30-3423 provides: "No attending physician or health care provider acting or declining to act in reliance upon the decision made by a person whom the attending physician or health care provider in good faith believes is the attorney in fact for health care shall be subject to criminal prosecution, civil liability, or professional disciplinary action."

Autopsies and the Elderly

ProPublica, in collaboration with PBS Frontline and NPR (National Public Radio), is exploring the low rate of autopsies for older people and the possibility that elder mistreatment is therefore missed.  Reporters working on this national news story about the under-investigation of elder deaths are seeking leads on cases in which (1) an autopsy (private or official) was key to uncovering abuse/neglect/medical malpractice or (2) there were problems obtaining autopsies or with the thoroughness of the death investigation.  Confidentiality will be protected if required by a source.

The focus on autopsies of older people relates to a broader series on death investigations published by the three outlets.  Prior stories can be found here.  ProPublica is a national investigative news organization founded in 2008, and it won the Pulitzer Prize for investigative reporting in 2010 and 2011.  Reporter Chisun Lee at ProPublica will appreciate hearing about cases as soon as possible, at chisun.lee@propublica.org.  Please send your stories directly to her. 

Dr. William Lloyd Bassett - Accused of Hastening Death

A General Medical Council disciplinary panel is holding a three-day hearing in the case of Dr William Lloyd Bassett.  Bassett is accused of injecting around 10 times the accepted amount of diamorphine into a 65-year-old man who was suffering from terminal lung cancer in  May 2009.  

In his notes, Bassett described telling the family about what he had done.  He said they discussed the high dose of morphine and were "told honestly what morphine did, ie) hasten death". The notes also said: "Family accepts this."  The hearing was told Dr Bassett said in his notes it was "large dose but he is dying and I would like him to die in peace."  

The doctor accepts that he administered 100mg of diamorphine, that he took no action to reverse it, and that his actions put the patient at risk of respiratory failure.  But he denies he did it to hasten the patient's death.  (Independent; Shropshire Star)

MOLST - Final Delaware Regulations

On August 1, the Delaware Department of Health and Social Services promulgated the final regulations (HTML here)  authorizing Medical Orders for Life-Sustaining Treatment (MOLST).  I am glad to have been a (small) part of that.  Now for the far tougher work of training, education, and implementation.

PVS Seen as State Worse than Death

Patients in persistent vegetative state (PVS) may be biologically alive, but experiments by psychologists in the University of Maryland's "Mind Perception and Morality Lab" indicate that people see PVS as a state curiously more dead than dead.  The results of the experiments were just published online in COGNITION.  

Experiment 1 found that PVS patients were perceived to have less mental capacity than the dead.  Experiment 2 explained this effect as an outgrowth of afterlife beliefs, and the tendency to focus on the bodies of PVS patients at the expense of their minds.  Experiment 3 found that PVS is also perceived as “worse” than death: people deem early death better than being in PVS.  These studies suggest that people perceive the minds of PVS patients as less valuable than those of the dead – ironically, this effect is especially robust for those high in religiosity.

Unilateral DNR Okay; Lack of Transparency Not Okay

Carl Winspear, who suffered from cerebral palsy, died from pneumonia at Sunderland Royal Hospital in January.  An inquest into his death recorded a verdict of natural causes.  But the 28-year-old’s family has raised concerns over a “Do Not Resuscitate” order (DNR) which was placed on Carl’s file while he was in hospital.  (Sunderland Echo) 

“The doctor made the order, as he believed that in the event of a cardiopulmonary arrest, resuscitation would be unsuccessful.  “Attempted CPR is an active intervention that can be traumatic and can both cause harm and result in death occurring in a manner that the patient and people close to the patient would not have wished.  “The doctor therefore made this decision in what he believed was Carl’s best interest at the time.”

The family say the order was made at 3am one day after a decision taken by doctors.  They were not informed until the following day.  They concede that the DNR order was made because it was physically impossible to resuscitate him due to his condition.  His mother said: “It’s not that fact that they are issuing DNRs, but the fact that they are not informing the families.

It is unclear what exactly the family is asking for here.  It seems rather odd to say, "We are going to make your son DNR because resuscitation would be physiologically futile in any case."  Why disclose treatments that are not real options, not real choices?  Granted, a tougher question is whether DNR should be presented as an "option" when it has a likelihood of success greater than 0%.