Killing a Patient to Save His Life(nytimes.com)
nytimes.com
Killing a Patient to Save His Life
http://nytimes.com/2014/06/10/health/a-chilling-medical-trial.html
6 comments
I'm annoyed by the headline. I know it's meant to grab attention by seeming counter-intuitive, but as it is, the headline is simply wrong. This medical procedure does not involve "killing" the patient. It involves cooling the patient down internally to essentially suspend them, so the doctors have a greater window of time to perform the necessary procedures. The best way of doing this happens to be to temporarily replace the patient's blood with a saline fluid, and if you think that's "killing" the patient, then I suggest you grab the nearest dictionary and smack yourself with it.
> happens to be to temporarily replace the patient's blood with a saline fluid
Which, according to the article, has the effect of stopping the heart as well as brain activity. This seems pretty close to "death." If someone decided to stop the operation halfway through without replacing the saline solution or reviving the patient, it would make sense to me to claim that the "time of death" was the time at which brain activity ceased.
Which, according to the article, has the effect of stopping the heart as well as brain activity. This seems pretty close to "death." If someone decided to stop the operation halfway through without replacing the saline solution or reviving the patient, it would make sense to me to claim that the "time of death" was the time at which brain activity ceased.
General anesthesia also stops brain activity, and you can die during open heart surgery. The time of death won't be the time of loss of consciousness.
It is about conserving information. As long as your brain can be turned back on you're still alive.
It is about conserving information. As long as your brain can be turned back on you're still alive.
Do you have a source for that? Obviously it suspends consciousness, in a more dramatic way than even falling asleep, but I find it difficult to believe that all brain functions are suspended. At the very least, with some varieties of general anesthesia, the brain stem keeps vital functions working.
Edit: Looking at wikipedia a bit, it looks like "brain death" is currently defined as including a dead brain stem. Kind of seems like an ethical gray area when the cerebrum really is dead (non-recoverable), not merely suspended. Still, I'm not convinced that general anesthesia fully suspends the cerebrum. I believe at least some forms merely suspend the ability to form memories.
Edit: Looking at wikipedia a bit, it looks like "brain death" is currently defined as including a dead brain stem. Kind of seems like an ethical gray area when the cerebrum really is dead (non-recoverable), not merely suspended. Still, I'm not convinced that general anesthesia fully suspends the cerebrum. I believe at least some forms merely suspend the ability to form memories.
The brainstem is not needed to sustain the heart beat and blood pressure. It participates in its regulation, but both parameters have "sane defaults" without any input.
Furthermore, while necessary, the brainstem is not sufficient to sustain consciousness.
Third, phenobarbital at a sufficient dose completely wipes electric brain activity (metabloism goes on, at a lower pace).
Fourth, even if you suspend someone using the procedure described in the article, there is still residual biologic activity in the cells. Chemical reactions are slowed down, but not stopped.
Furthermore, while necessary, the brainstem is not sufficient to sustain consciousness.
Third, phenobarbital at a sufficient dose completely wipes electric brain activity (metabloism goes on, at a lower pace).
Fourth, even if you suspend someone using the procedure described in the article, there is still residual biologic activity in the cells. Chemical reactions are slowed down, but not stopped.
"Without heartbeat and brain activity, the patients will be clinically dead."
As far as I can tell, that statement is correct. The headline is drawing attention to the evolving nature of just what constitutes "death" and how this particular procedure is pushing it out even further.
As far as I can tell, that statement is correct. The headline is drawing attention to the evolving nature of just what constitutes "death" and how this particular procedure is pushing it out even further.
Clinical death is a lack of blood pulse and breathing. Hence the modern meaning of "resuscitation" for "rebooting the heart".
It hasn't been a synonym for "death" for a few decades.
"Brain death" is a total and irreversible loss of brain function.
It hasn't been a synonym for "death" for a few decades.
"Brain death" is a total and irreversible loss of brain function.
I think I've seen this House episode before. Spoiler alert: The chick dies in the end.
Seriously though, with these new types of procedures I feel like we need another checkbox next to the organ donor one that says: "Try risky medical procedures if the attending doctor honestly thinks it gives me a better chance of living with no permanent brain damage when compared to conventional treatment." Or probably something a little more succinct.
Seriously though, with these new types of procedures I feel like we need another checkbox next to the organ donor one that says: "Try risky medical procedures if the attending doctor honestly thinks it gives me a better chance of living with no permanent brain damage when compared to conventional treatment." Or probably something a little more succinct.
I like something more along the lines of "Trust the judgement and expertise of medical professionals, especially in emergency situations."
Well they need to know your wishes. If this procedure has a 60% success rate but 95% of those people only survived with 75% brain function would you want it done? Vs a procedure that has a 10% success rate but 95% of people who survived had complete brain functionality restored.
Personally I'd want to take the 1/10 chance, but I'm sure there are a lot of people who would want to live even if it meant diminished mental capacity.
Personally I'd want to take the 1/10 chance, but I'm sure there are a lot of people who would want to live even if it meant diminished mental capacity.
I agree. I am more than okay for them to try anything possible if I was already dying. I am an organ donor already, why not? At least they tried and the process would be a part of a greater study to improve modern medicine.
I am curious how much organ they could still harvest after performing such procedure though.
I am curious how much organ they could still harvest after performing such procedure though.
It should be harmless to the organs. If they can be carried around in a freezer I'm sure they won't get damaged from being injected with freezing salt water.
How about: "I reserve the right to have my life terminated if I come out of a procedure with no brain activity"?
Edit: From the older discussion on HN: "Assuming they (patients) have been getting 'good' CPR for the 10-15 minutes the ER team spent attempting to resuscitate them, there is still a good chance that their brain was not being perfused."
CPR is nearly worthless, but not always.
A 2+% chance to either save a life or reduce the chances of brain damage is worth ~20 minutes. And that's for a full recovery the odds of a partial recovery can be as high as 50%. http://www.cnn.com/2013/07/10/health/cpr-lifesaving-stats/
With current thinking you don't even need to do mouth to mouth disease transmission is a vary low risk.
With current thinking you don't even need to do mouth to mouth disease transmission is a vary low risk.
That's just a living will. Anything done after the procedure can be more deliberate. You only need the shortcut of a checkbox on your ID for things that need to be figured out right away.
Reported on and discussed here a few months ago:
https://news.ycombinator.com/item?id=7477801
https://news.ycombinator.com/item?id=7477801
They are not dead until they are warm and dead.
There are enough cases known to science where cold has done wonders. And the technology seems viable. I say go for it. At worst we will be getting valuable knowledge.
There are enough cases known to science where cold has done wonders. And the technology seems viable. I say go for it. At worst we will be getting valuable knowledge.
Yep.
If your odds are already very low taking a risk for better odds seems like a good deal to me.
You're most likely dead anyway why not try something new to give you a better chance.
If your odds are already very low taking a risk for better odds seems like a good deal to me.
You're most likely dead anyway why not try something new to give you a better chance.
"But researchers at a number of institutions say they have perfected the technique, known as Emergency Preservation and Resuscitation, or E.P.R., in experimental surgeries on hundreds of dogs and pigs over the last decade."
Did they actually do dry runs of the surgery from shooting to triage to finish? I wonder whose job it was to shoot the dog with a .45
Did they actually do dry runs of the surgery from shooting to triage to finish? I wonder whose job it was to shoot the dog with a .45
Huh. More medical organizations should do this sort of training.
I like the 'out-of-the-box' thinking. The 'opt out' if you don't want to, in combination with a high change of poor black males being the guinea pig... Not so much.
"The 'opt out' if you don't want to, in combination with a high change of poor black males being the guinea pig... Not so much."
My understanding is that they only use this procedure if your chances of otherwise surviving without this are very slim, per the article the injuries are the kind where "Less than 1 in 10 survive". As for the opt-out/opt-in, you cannot really opt-in to any procedure if you're undergoing cardiac arrest, so perhaps we should let anyone in this scenario die since they cannot truly consent?
My understanding is that they only use this procedure if your chances of otherwise surviving without this are very slim, per the article the injuries are the kind where "Less than 1 in 10 survive". As for the opt-out/opt-in, you cannot really opt-in to any procedure if you're undergoing cardiac arrest, so perhaps we should let anyone in this scenario die since they cannot truly consent?
It's not so simple, I'm afraid. People have opt-out of a lot of things to prefent them 'turing in to a plant' as the popular saying is. Things like DNR or even human blood (religion based opting out). There was no ad-campagin in the region informing people what could happen. There is a specific demographic (poor black people) so they could target them with information about what's going on and specifically what the risks are. Other than that, they could ask a relative/parent/child's permission if possible.
-1 for the strawman: The alternative to "opt-out before" is "opt-in before", not "opt-in afterwards".
Both are alternatives since this is not a dichotomy: a potential patient can opt-in before, opt-out before or they can leave the status unspecified until they arrive in the ER. Someone must make a decision for them and it will be either opt-in afterwards or opt-out afterwards.
Since the group leaving the status unspecified is by far the largest, your practical ability to evaluate the procedure depends on what default is selected for the patients who haven't decided beforehand.
Given the need, potential to save lives and widespread agreement among the public, I'd say there is no real ethical controversy here.
Since the group leaving the status unspecified is by far the largest, your practical ability to evaluate the procedure depends on what default is selected for the patients who haven't decided beforehand.
Given the need, potential to save lives and widespread agreement among the public, I'd say there is no real ethical controversy here.
Most people won't opt in before, so I think his question is entirely legitimate: in an emergency situation, the patient often can't give consent, and most of them won't have the foresight to give it in advance, so are we to simply let them die?
That depends a lot on the quality of the treatment. If it is a good treatment with some risks, that makes sense. However, if you don't enforce any minimum quality for the treatment, this is nothing more than misusing the patient's situation for scientific experiments.
Rephrased with some exaggeration: "Our patient will die anyway, so let's run the experiments. Maybe one of our experiments is successful. If not, who cares?"
I believe the main dissent here is whether to think of this as a medical treatment with minor risks, or as an experiment done on defenseless victims.
Rephrased with some exaggeration: "Our patient will die anyway, so let's run the experiments. Maybe one of our experiments is successful. If not, who cares?"
I believe the main dissent here is whether to think of this as a medical treatment with minor risks, or as an experiment done on defenseless victims.
I believe this is a case for Dr. Jay Freireich who was considered a barbarian and labeled as a pariah in the medical community because he gave out experimental treatments on childhood leukemia patients who had no chance of survival outside of a few months. Mind you this treatment is literally poisoning the patient and hoping the cancer dies while the patient still has a thread of life remaining. There was also a very good chance that the chemicals would end up doing the job the cancer was already doing.
He was able to save very few of his patients from the same end, as well as developing what would become modern chemotherapy that's saving countless more cancer patients today.
So a better question is: is the situation we're presented with so grim that we're willing to use a method that's just as deadly as the disease/injury but has a glimmer of hope for survival?
He was able to save very few of his patients from the same end, as well as developing what would become modern chemotherapy that's saving countless more cancer patients today.
So a better question is: is the situation we're presented with so grim that we're willing to use a method that's just as deadly as the disease/injury but has a glimmer of hope for survival?
It's not exactly "who cares?" but more like, "it's unfortunate, but they were dying and we tried something that gave them a better chance of survival."
It's experimental, but they also have good reason to believe that it works. Now it's being tested in a scenario where it's likely to save lives.
I can understand the objections overall. But in this particular case, where it's being used as a last-ditch effort to save people who otherwise are almost certain to die, seems pretty reasonable.
How else are medical researchers to advance the state of the art in emergency care? I assume that we don't want to just take what we have now and set it in stone forever, but I don't see any other way to validate new procedures.
It's experimental, but they also have good reason to believe that it works. Now it's being tested in a scenario where it's likely to save lives.
I can understand the objections overall. But in this particular case, where it's being used as a last-ditch effort to save people who otherwise are almost certain to die, seems pretty reasonable.
How else are medical researchers to advance the state of the art in emergency care? I assume that we don't want to just take what we have now and set it in stone forever, but I don't see any other way to validate new procedures.
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What's the alternative to test the thing practically? Getting people to opt in before they got stabbed or shot or whatever would be phenomenally difficult - making contact with that demographic - and could delay the study by years or decades. And in the mean time more people would possibly be dying, something they haven't consented to either.
It's not like they're selecting for poor black males. Remember, if this treatment works, it's not going to be primarily applied to rich whites; it's going to be applied to the exact same demographic as the guinea pigs.
Also science does not stand still. If this improves outcomes for stabbed black men (of which we have a vast supply compared to other subjects), there are a zillion logical next research steps none of which necessarily involve stabbed black men.
So... if "generic major surgery" goes horribly wrong, they'll chill you and fix it rather than letting your brain die.
I wonder if you could come up with a cancer chemotherapy treatment that has such severe effects that the patient literally can't live thru it, but if you chill them first and then reboot them with a clean blood supply... imagine something that successfully kills tumors but coincidentally liquifies brain tissue. Well, just shut off the brain for awhile by shutting off its flow of blood. Can't poison something if no poison ever gets there. Do the treatment and kill the cancer, then flush out the circulatory system with saline, replace with fresh blood, reconnect the brain to the circulatory system (note to self; don't forget this step) and then reboot them.
I would have to think if there's anything else interesting you can do with a complete "flush -n- fill" of the circulatory system. Maybe treat horrific industrial or research lab accidental poisonings. Sure maybe its less risky to just pour in and drain out 100x your blood capacity to flush it, but what if the industrial accident affected 50 people, that's 5000 people's worth of blood, lots will have to die untreated unless you find a more scalable treatment.
So... if "generic major surgery" goes horribly wrong, they'll chill you and fix it rather than letting your brain die.
I wonder if you could come up with a cancer chemotherapy treatment that has such severe effects that the patient literally can't live thru it, but if you chill them first and then reboot them with a clean blood supply... imagine something that successfully kills tumors but coincidentally liquifies brain tissue. Well, just shut off the brain for awhile by shutting off its flow of blood. Can't poison something if no poison ever gets there. Do the treatment and kill the cancer, then flush out the circulatory system with saline, replace with fresh blood, reconnect the brain to the circulatory system (note to self; don't forget this step) and then reboot them.
I would have to think if there's anything else interesting you can do with a complete "flush -n- fill" of the circulatory system. Maybe treat horrific industrial or research lab accidental poisonings. Sure maybe its less risky to just pour in and drain out 100x your blood capacity to flush it, but what if the industrial accident affected 50 people, that's 5000 people's worth of blood, lots will have to die untreated unless you find a more scalable treatment.
> Remember, if this treatment works, it's not going to be primarily applied to rich whites; it's going to be applied to the exact same demographic as the guinea pigs.
What are you basing this on?
Chances are this is absurdly expensive (ICU stays can cost millions) and may be unlikely to see wide use in poor areas - the hospitals'd be eating the cost most of the time.
What are you basing this on?
Chances are this is absurdly expensive (ICU stays can cost millions) and may be unlikely to see wide use in poor areas - the hospitals'd be eating the cost most of the time.
If it works, it'll also be used for soldiers. These are not usually rich people, and not predominantly white.
Do US hospitals ever turn away people from the ICU because of cost? If so, how do they verify the ability of an unconscious person to pay before treatment?
I was under the impression that they already ate those costs.
I was under the impression that they already ate those costs.
You're right. Legally ERs can't turn away patients. They have to "stabilize" them before discharge.
However not all ERs are equal. It's entirely possible that procedures like this wouldn't be available in a less well funded (read: poorer) hospitals. At least until it becomes what's known as the "standard of care", where the healthcare provider can be culpable for not providing the treatment.
Though, honestly, I don't really see that happening. If this is successful, I would expect to primarily see first adoption in hospitals which already have high trauma rates. Which, typically, are hospitals serving poorer areas.
However not all ERs are equal. It's entirely possible that procedures like this wouldn't be available in a less well funded (read: poorer) hospitals. At least until it becomes what's known as the "standard of care", where the healthcare provider can be culpable for not providing the treatment.
Though, honestly, I don't really see that happening. If this is successful, I would expect to primarily see first adoption in hospitals which already have high trauma rates. Which, typically, are hospitals serving poorer areas.
My brief googling turns up the Emergency Medical Treatment and Active Labor Act, and an accompanying FAQ:
http://www.emtala.com/faq.htm
> 13. Can the hospital inquire about the patient's ability to pay?
> Yes, but timing is everything. The statute does not prohibit an inquiry into availability of medical insurance; it does provide that neither examination nor treatment may be delayed to make the inquiry.
> Prior to 2003, some knowledgeable commentators had suggested that no discussion of any payment issues should take place before the medical screening examination and any needed stabilizing treatment are provided. CMS has even recommended that hospital personnel not answer any questions initiated by the patient, apparently on the theory that some patients may be dissuaded from staying if they learn that they will be financially responsible for the treatment, even if they are assured that they will be seen without consideration of payment issues. Such recommendations, however, do not arise to the level of a definitive statement of what is required.
I don't know if the Affordable Care Act changed any of this.
http://www.emtala.com/faq.htm
> 13. Can the hospital inquire about the patient's ability to pay?
> Yes, but timing is everything. The statute does not prohibit an inquiry into availability of medical insurance; it does provide that neither examination nor treatment may be delayed to make the inquiry.
> Prior to 2003, some knowledgeable commentators had suggested that no discussion of any payment issues should take place before the medical screening examination and any needed stabilizing treatment are provided. CMS has even recommended that hospital personnel not answer any questions initiated by the patient, apparently on the theory that some patients may be dissuaded from staying if they learn that they will be financially responsible for the treatment, even if they are assured that they will be seen without consideration of payment issues. Such recommendations, however, do not arise to the level of a definitive statement of what is required.
I don't know if the Affordable Care Act changed any of this.
Are you really suggesting a Hitleresque racial motive behind these experiments? Or just sad that black males (in that locale) have a higher incidence of homicide, and therefore more likely to be suitable for this procedure?
I did not. As the article stated: poor (black) people do have a significant higher change to end up in that experimental room.
Your comment did made me think about not-so-old CIA experiments on poor powerless people: http://en.wikipedia.org/wiki/Unethical_human_experimentation...
But lets be clear: this is not CIA stuff.
Your comment did made me think about not-so-old CIA experiments on poor powerless people: http://en.wikipedia.org/wiki/Unethical_human_experimentation...
But lets be clear: this is not CIA stuff.
Black males have a lot going against them, which makes them vulnerable to all kinds of things. Sure they're more likely to be victims of violence, but this makes them more open to any abuse going on at hospitals. It's just a compounding of an already bad situation - now you got stabbed and experimented on.
(Hitlerian? as if Americans aren't racist.)
(Hitlerian? as if Americans aren't racist.)
It sure is racist. They would never do this in a region where there are not a lot of stabbings, so I as a rich white person living in an area with mostly rich white people have no chance at receiving experimental treatment if I get stabbed, so I would most likely die.
You make it sound like being experimented on is a bad thing, when you have only a 10% chance of surviving. There's thousands of people out there who would do anything for an experimental treatment funded by the government.
You make it sound like being experimented on is a bad thing, when you have only a 10% chance of surviving. There's thousands of people out there who would do anything for an experimental treatment funded by the government.
It's not about dying vs not dying. It's about maybe surviving with horrible pervasive problems caused by having no pulse for an hour.
If this were in an area with more white people, they would ask for permission first because they respect you more than they respect these black people who are getting stabbed. <- Speculation, but plausible.
If this were in an area with more white people, they would ask for permission first because they respect you more than they respect these black people who are getting stabbed. <- Speculation, but plausible.
History would prove you right, unfortunately. (Although these days it's more like the poor vs the not poor).
It's not plausible, because they can't ask for permission.
There are only four possibilities: perform the procedure on everybody, perform the procedure on nobody, allow people to opt out, allow people to opt in. They've settled on the third. It's possible that they'd settle on a different one in an area with more white people, but it has to be one of those four.
There are only four possibilities: perform the procedure on everybody, perform the procedure on nobody, allow people to opt out, allow people to opt in. They've settled on the third. It's possible that they'd settle on a different one in an area with more white people, but it has to be one of those four.
Edit: never mind, this is wrong.
The point is, they never asked the community they're in. They didn't try to get consensus, or make sure that most people around them are OK with it. They just unilaterally decided that the trauma victims in that neighborhood were guinea pigs.
The point is, they never asked the community they're in. They didn't try to get consensus, or make sure that most people around them are OK with it. They just unilaterally decided that the trauma victims in that neighborhood were guinea pigs.
Yes they did: "In order to obtain an exemption to federal informed consent rules, the hospital held two town hall meetings on the university campus, placed advertisements on buses, and made sure the news got in newspapers catering to minority readers."
Why only males? What about black womans? Aren't they even more vulnerable?
Well, not for this kind of thing. Here's the PDF linked from the article: http://www.vpc.org/studies/blackhomicide14.pdf Of the 6,309 black homicide victims, 5,452 (86 percent) were male, and 854 (14 percent) were female.