Futility in End-of-Life Care: Why the Suffering of a Brain-Dead Patient Should Uneqivocally End

You know the phrase "Cut off the head of the snake and the body dies"? I'm sure that applies to every living creature out there... except for maybe starfish because those guys don't even have heads. Anyways, I'm writing on this topic because I've come across countless cases where brain-dead patients are forced to suffer untreatable and progressive end-organ damage in a slow, agonizing death because family members and MPOA's cling to the delusional hope that, somehow, a brain that has been literally killed by anoxic injury will receive the same blessing Jesus gave to Saint Lazarus of Bethany and somehow flicker to life. Futility is defined by many scholars as a less than 1% chance of management success. One such scholar, Griffin Trotter, defined it as occurring in the following setting:

1. There is a goal
2. There is an action and activity aimed at achieving this goal
3. There is virtual certainty that the action will fail in achieving this goal

Take, for example, a patient who sustained massive, almost whole-brain cerebral edema due to continued, generalized, uncontrolled seizure activity. More importantly, think of the status-post cardiac arrest patient who was deprived of oxygen to the point that his entire brain stroked out and became edematous. The case to treat surgically is futile because although the surgery aims at reducing intracranial pressure by allowing the brain to expand outward as opposed to downward, the failure rate is high due to brainstem compression and subsequent respiratory failure which may have already happened in this setting of downward transtentorial herniation. Brain death is almost always present in such cases due to deprivation of oxygen and necessary nutrients.

Therefore, by definition, brain death is futile: there is no chance for recovery. However, many physicians have been unable to communicate the risks associated to the family involved. Such a landmark case involved one Jahi McMath, a 13-year-old who underwent a tonsillectomy in 2013 and suffered cardiac arrest, resulting in brain death. Per the San Francisco chronicle around that time,

The family of a 13-year-old girl who has been declared brain-dead has found a nursing home that will keep her on a breathing machine while relatives pray for a miracle, the family’s lawyer said Thursday. However, Children’s Hospital Oakland, where Jahi McMath underwent tonsil-removal surgery... and then suffered cardiac arrest, objected to the transfer and said it was not authorized by the judge who ordered the girl kept on a ventilator. After hospital physicians’ finding of brain death was confirmed by a court-appointed doctor, Alameda County Superior Court Judge Evelio Grillo ruled Tuesday that the girl was legally deceased and that the hospital could discontinue medical care. But he extended... a restraining order requiring connection of the breathing apparatus. Jahi’s family contends she is still alive and spent Christmas at her bedside. Their lawyer, Christopher Dolan, said... that a nursing home has agreed to take her, and he is negotiating with Children’s Hospital and insurance companies to insert breathing and feeding tubes that would allow her to be moved… The hospital said it “does not believe that performing surgical procedures on the body of a deceased person is an appropriate medical practice.” [1]

It is the delusion of false hope in "miracles" that causes breakdown of understanding between those who believe in them and those who would rather hedge their bets on evidence-based medicine. Per the former party, the patient still has a slim chance of recovery. The latter party, however, believes - rightly so in 100% of brain dead cases, in my humble opinion - that the patient is now a cadaver who can't be resuscitated, a statement based on history, physical examination from multiple physicians, and electrophysiological data. Clearly, the evidence is on the side of the physicians, yet due to the lack of trust in the medical system and the lack of respect for the field, physicians are forced to yield their logic to the emotion of families still in denial over the fact that they, at that point in time, just lost a loved one. This, as one writer pointed out, prolongs the suffering of families as they watch their loved ones waste away on a ventilator.

Obviously, there are serious ethical and public health implications to maintaining such futile care. The suffering people go through when their body's major organs are deprived of their necessities to live is a mountain in the face of what a pregnant woman goes through when giving birth or what a man with a kidney stone suffers as a piece of calcium oxalate painfully weaves its way through his renal system. The idea of non-maleficence is thrown out the window when such suffering is allowed to continue. To make matters worse, a non-functioning brain means a slowly dying, non-functioning body which could potentially become a reservoir for all sorts of nasty superbugs and infectious diseases. Public health comes into play when a corpse in the ICU is literally fostering an environment that could worsen the outcomes of patients in the vicinity just on the virtue of being there. There was one patient I took care of who within days of admission grew a nasty bout of super-resistant Klebsiella sp. ESBL in his blood. This wouldn't have happened if care was withdrawn at the appropriate moment and the patient's body harvested for organ donations where appropriate, or sent to the morgue/cemetery and away from the hospital environment, where others are exposed to such unnecessary risk. Finally, on a less important note, expenses incurred by both the institution and the family are usually inexorable and only build up when futility prolongs the inevitable, and those are incurred as a result of damage control of all the above-mentioned parameters.

Anyways, that's all I have to say on the topic.

Salaam