Critical Care Medical Panel
Posted by Jeriaska on December 6th, 2007
Cryonics researchers Chana de Wolf and Aschwin de Wolf
Moderated by Aschwin de Wolf, the critical care medical panel of the 7th Alcor Conference addressed the current status on laws that affect the practice of cryonics, the ethical debate concerning non heart-beating organ donation (NHBD), and comparisons between organ procurement procedures and cryonics. Questions were fielded by participants Tanya Jones (Alcor’s Chief Operating Officer), David Crippin (Associate Professor of Critical Care Medicine at the University of Pittsburgh Medical center) and Leslie Whetstine (Ph.D. in Health Care Ethics).
Tanya Jones, David Crippin, and Leslie Whetstine at the 7th Alcor Conference
The following transcript of the 7th Alcor Conference Critical Care Medical Panel has not been approved by the authors. A DVD set of the conference is available for pre-order at the Alcor website.
Critical Care Medical Panel
Aschwin de Wolf: In today’s panel we will discuss the relationship between medicine and cryonics in the light of recent debates about organ donation and determination of death. Before we start, I would like to ask each panel member to briefly tell something about his or her professional background work, especially their relationship with cryonics. I would like to start with Leslie.
Leslie Whetstine: I have a PhD in bioethics and I did my dissertation on the definition of death. I was very much concerned with determining what makes a human being dead and why, at what particular point? I was focused on a particular type of organ donation procurement known as Donation After Cardiac Death. I only peripherally have experience with cryonics, my work has been in transplantation, but certainly I am interested in the definition of death.
David Crippin: I am director of neurosurgical S.U. at the University of Pittsburgh Medical Center. I am an associate professor there. My interest is in brain death as it pertains to neuro critical care patients, because of the fact that we have the potential intensive care medicine to prolong vital signs for a very long period of time. This has become an interest of mine as it pertains to transplantation, especially in neuro ICU, where we deal with a big number of brain injuries. When it comes to the brain it is sometimes very difficult to determine what is going on with the patients. As it pertains to cryonics, I have a peripheral interest.
Tanya Jones: I’m Tanya. I think you know who I am and why I’m involved in this. I’ve been working on cryonics cases for about 17 years now. I’m largely responsible for the negotiations that go on in hospital settings with medical examiners. I’m particularly interested in the donation after cardiac death, if the definitions of death are changing, is directly going to impact the kind of care that we provide for our members and our patients.
Aschwin de Wolf: I would like to start with a question for each one of you, to provide some context for this panel. In your dissertation you state that the cardiorespiratory criterion of death is not the diagnosis of permanence of death. Can you explain what you mean by that?
Leslie Whetstine: My dissertation involves a chronological discussion of the definition of death. When I started looking prior to the 20th century I saw that death was defined when cardiorespiratory failure occurred, because when the heart and lungs stopped, the organs would quickly fail. This worked for awhile, although there were cases of misdiagnosis and premature burial. But then, with the advent of chemical ventilation, we saw that death was now fragmented. They devised death on neurologic criteria. That really created a problem of there being two types of death: brain death and cardiorespiratory death. Certainly, the idea was that death should be a unified phenomenon in which we could diagnose it in two distinct ways. The problem is that only neurologic criterion is both necessary and sufficient for death.
What I mean by that is that the heart could still be beating in a brain dead body. Only the neurologic criterion is death itself. The heart and lungs will prognosticate death. Their failure will lead to death. But all death is in fact brain death.
Aschwin de Wolf: David, how was your experience shaped your own position on this issue of cardiac death versus breath? You also have written about information theoretic death. What is your position on that?
David Crippin: In the neurointensive care unit is unique in that we deal with gradations of brain injury much more than other intensive care units. The problem with us is that we have the potential with our mechanisms and our high technology, we have the potential to maintain what is sometimes called life and death indefinitely. We can maintain vital signs, ventilation, heartbeat and multiple metabolic functions, but in the middle of all that is a patient that may or may not be viable. The reason it matters to us is because sometimes it is extremely difficult to tell if the brain is legally dead. There is a legal definition of death that we must adhere to, being clinicians.
That legal definition as we understand it is that brain death equals death. There are a lot of reasons for that, which I’m sure you are familiar with. But as far as we can see from our position, legally the patient must be brain dead in order for us to declare a patient dead enough to be able to take organs. The reason that matters is because we can keep people on mechanical ventilators that are dead for long periods of time that give them the appearance of viability. It’s sometimes very difficult to tell when the brain is completely dead. The diagnosis of brain death is a diagnosis of what is, not what might be.
We use a very objective list of criteria that must be met in order to diagnose brain death. Once those criteria are met, the patient is legally dead. At that point, transplantation and organ donorship may occur. Because of our difficulty in determining when brain death actually occurs, because brain death is continuing, it does not just happen all at once, it happens in a progressive continuum, it’s sometimes very difficult to tell where we are in that continuum. I’ve developed an interest in this because we are constantly formulating new ways to determine whether or not the brain is really dead, or the brain is going to die. There is a difference. It doesn’t really work if the brain is not quite dead but going to die, that patient is not suitable for transplantation. That is until you get into the situation involved in donation after cardiac death, and that’s a whole different discussion. But as far as we are concerned, legally in order for us to take organs the brain must be dead.
Aschwin de Wolf: Tanya, do different hospitals have different guidelines for dealing with organ donation after cardiac death? And do different guidelines fit your ability to obtain access to the patient?
Tanya Jones: For the most part, conventional transplant procedures and protocols don’t affect us directly, except as far as a hospital administrator or hospital personnel would have familiarity with organ donations as a whole. Our procedures are very different. Sometimes when an individual finds out that a member is there, the first thing they ask is where is the gift paperwork. It goes right up front in the chart so that everyone who is providing care to that individual knows about that organ donation. However, they often ask, “Do you want us to wait for brain death to provide pronouncement?” Obviously, for our purposes, the answer to that is no. We strongly prefer the cardiac criteria, because that protects the organ that we are most concerned about.
It really varies. Most people don’t have familiarity with cryonics directly. The biggest response I often get is, “Oh, I’ve never seen this before.” So it’s very important to distinguish our particular procedure from what conventional transplantation does and requires.
David Crippin: The discussion of difference between brain death and donation at cardiac death is a very long talk. We really can’t do justice to it in the small amount of time that we have. What has happened has happened for two reasons. One is to get more organs, obviously. The other reason is that there are a lot of families that want to donate if the patient isn’t quite dead yet. They kind of want to get around the rules by saying there is no intent to resuscitate and we would like to give the gift of their organs, and can’t we get around this rule of being brain dead? That is basically the way donation after cardiac death evolved. They creatively interpreted a passage in the donor rule that said either brain death or cessation of cardiac would kind of equal death. Then what happened was they said, “Well, if there’s no intent to resuscitate, and if the patient is very close to being dead, and will progress to death inevitably without any possibility of resuscitation, then we can kind of call that death.”
That’s what cessation after cardiac death is. There are numerous problems with that definition. Some of the problems are political and some of the problems are philosophical, but that’s the way it works. Briefly, I’ll tell you how it works. A patient goes down to the operating room. Everyone in the operating room leaves, except me and a nurse. There are no surgeons in the room. The surgeons are prepped and ready outside the door. The patient is prepped and draped for surgery. The ventricular tube is removed and we wait. When the line for cardiac function goes flat, then I pronounce the patient dead, then two minutes goes by to ensure no potential for spontaneous regeneration, which is virtually impossible. Then bam, the door comes open and the surgeons take the patient’s organs.
That’s how DCD works. DCD is a situation in which the patient is going to die inevitably and resuscitation is not in the mix because there is no intent to resuscitate. Technically the best way to describe this is the patient is not irreversibly dead but permanently dead. You see a difference. Technically the definition is there must be irreversible cessation of the organism as a whole, but if they change the wording a little bit and call it permanently dead, it’s kind of the same thing. You might want to call it intellectual gerrymandering.
Leslie Whetstine: I would say there are insufficient studies to say that auto-resuscitation won’t occur.
David Crippin: We’ve never seen it. It’s never been recorded.
Leslie Whetstine: That’s technically incorrect. There are 108 case observations.
David Crippin: Who invited her?
[Audience laughter]
Leslie Whetstine: There were 108 case observations of the Lazarus phenomenon. But not after two minutes, only after 65 seconds. However the article from just a few years back, they did a study with 11 patients and what they found was that even though they didn’t have pump functions sufficient to generate circulation, they still had ventricular fibrillation even after up to ten minutes. Certainly, that is not donation after cardiac death but the heart is still beating to some extent. The Institute of Medicine requires five minutes of flat via the arterial line, but at the University of Pittsburgh, they do two minutes. So they are not following the IOM guidelines.
David Crippin: The gold standard is a flat line. You still have electrical activity on the EKG, but if the arterial line is flat then that is the standard.
Leslie Whetstine: I’m not arguing the point, but I am saying that it is somewhat intellectually dishonest to call it donation after cardiac death.
Aschwin de Wolf: As Tanya said, cryonics actually benefits from the cardiac criterion of death. Would you say that in the case of cryonics it makes a lot of sense to use the cardiac criterion of death?
Leslie Whetstine: My position is that you cannot really rely on the cardiorespiratory criterion of death because it’s not death. I find that there is a difficulty with cryonics, because even you admit that they are not dead yet, but you want to legally declare them. It’s a problem.
Aschwin de Wolf: Yes, it seems we have a problem in cryonics where I think we would strongly disagree with the cardiorespiratory definition of death, but we benefit from it because it gets us access to the patient.
Leslie Whetstine: I think that you can certainly utilize the wiggle room that the Uniform Declaration of Death Act, just like donation after cardiac death is doing.
Tanya Jones: Yes, but one of the issues that we are going to face eventually, especially if the research that we are doing continues to its logical conclusion, is that we are going to be able to prove that the brain itself is viable after this procedure occurs. At which point we are going to have to face a transition from being an anatomical donation and an after-death procedure and face the fact that this is going to have to become a medical procedure done in hospitals by other personnel, not us.
David Crippin: There’s no question at all that the brain is viable, because as the old saying goes, you’re dead when the doctor says you’re dead. In cryonics, presumably, the doctor says you are dead and when that happens you become legally dead. All the rules change when you become a corpse. Then, at that point, when resuscitation is employed, then the patient is incubated, ventilated, placed on a thumper, those patients kind of wake up now and then, which makes you kind of wonder if they were ever dead.
Leslie Whetstine: Certainly not dead on either criteria.
David Crippin: At some point you are probably going to have to change your thrust of the definition and get away from the “death” thing. You are intervening somewhere in the continuum of death. As you know, death does not happen immediately, death is a continuum. My guess is you will probably have to find a way to say you are intervening in a death process, at that point we are then changing the definition of what constitutes death. It may be something that will need to be worked out with hospital administrations because of the legal thorniness around it.
As Leslie says, the continuum of death is becoming more and more elucidated and complicated because of our ability to maintain it so long. You have a situation where at some point you say the patient is clinically dead.
Aschwin de Wolf: That leads me to another question I wanted to ask. There are many ways we can define cryonics. Sometimes it is presented as a scientific experiment done on humans. The direction that we are headed in now is to present it as a long-term form of critical care medicine. Would you agree to such a definition of cryonics?
David Crippin: I’ll give you the long answer. If you look back through the history of medicine you see that up until about 100 years ago most medical practitioners were outright crooks, charlatans, or sleight of hand artists who would kill their patients outright or even worse. For the past 100 years or so, we’ve discovered some things that actually did kind of work, but we haven’t really figured out how to use them to their best advantages in a lot of cases. For example, Semmelweis begged and pleaded his colleagues just to simply wash their hands to avoid killing women wholesale and they all scoffed at him. If you delve through the history of medical discoveries, most of them were scoffed at, until it became obvious that it worked. Right up until the guy who discovered that Helicobacter was involved with peptic ulcers disease, they laughed this guy right out of the medical community.
The point is, doctors tend to be a rather stilted lot. They don’t necessarily embrace things that work just because they work. They have to go through a kind of culturalization. As far as cryonics goes, leaving the realm of science fiction and entering the realm of critical care medicine, the entry point will be fairly rigorous and will involve randomized double-blind studies to show potential. Of course, you have to remember that the whole point of science is imagination. This is imaginative. Anything that is imaginative is welcome. If it can be shown to have some scientific rationality, if it can be shown to make sense, eventually it will slowly blend into a very stilted bunch of people who don’t accept things readily.
Aschwin de Wolf: Leslie, cryonics as a form of long-term critical care medicine, what do you think of that?
Leslie Whetstine: I’m troubled by trying to say that such patients are dead. At least we can hope that they are not. But I guess I’m worries because you are making a legal pronouncement and your patients, I assume their legal rights and responsibilities are transfered to others. I don’t know how that is going to work. How would you rectify the problem of trying to call it long-term critical care?
Tanya Jones: From our perspective at least, right now the process is signifcantly easier if we have them declared legally dead and use this as an anatomical gift. If we were to try to make the argument that they are potentially alive today, because certainly they are, I think it would change the entire climate of the way. That’s a challenge we are not yet ready for.
Leslie Whetstine: Do you feel it’s a type of academic dishonesty calling it “death?”
Tanya Jones: What I usually say is that they are only mostly dead. It’s true. We have to go through the process of having people declared legally dead because that is the way the business was established. It’s not a recognized medical procedure. It’s not being done by medical professionals. Until such time as we undertake that legal and cultural battle to have the entire environment change, we have to operate under the guidelines that allow us to do what we need to do.
Leslie Whetstine: I don’t understand that much about cryonics, to be totally honest. But frozen embryos certainly seem to be mainstream.
Tanya Jones: That is one of the analogies that we use when we are talking to people, but embryos aren’t people. Some people can accept it quite readily, some people scoff. It depends on the individual, their background and their perceptions.
David Crippin: Where you’re going to go with this I predict is you will follow the path of least resistance until someone decides to examine it in court. You all know that the role of lawyers is to tell you what you can get away with. What that means is that this probably has worked in the past and will continue to work, but someday, somewhere I would guess that somebody is going to have a look at this and challenge it. If that’s the case you may end up legally trying to define whether or not this jives with our current definitions of death.
Tanya Jones: My preference would be to go on the offensive. When research is complete enough, when we have political and social support, we should be the ones taking the step to get the situation resolved. I don’t think that we should wait for someone to attack us. This has been a problem in cryonics for a long time. There are a lot of things that go on where we get dragged into the middle, and this is too critical a point for us to leave to others to initiate.
David Crippin: As far as your research goes, is this research being done anywhere near authentic traditional work?
Tanya Jones: We’re just getting started. It is our intention to have people affiliated with universities involved in the program. We have several consultants that are assisting with establishing our pulminary bypass model, so the expectation is that we will be moving forward in that way by conventional scientific standards. We are not trying to do this on the fringe. We don’t intend to publish these results in Cryonics Magazine alone.
David Crippin: I would advise you from my experience that that’s exactly what you should do, because traditionally doctors are a pretty stilted lot. They don’t believe just anything that comes down the road. If they see something that’s really good, logical, interesting and makes sense in the New England Journal, which is the Holy Grail, then it’s going to be taken seriously.
Tanya Jones: That’s going to take time.
Aschwin de Wolf: We would like to have a smooth transition from the conventional criterion of death to the information theoretic death model, but do you fear there will be a transition period?
Tanya Jones: I do rather fear such a transition period. I’ve had to go in and negotiate under those circumstances before, and it’s a very delicate and difficult negotiation. We’ve never had brain death criteria be applied to our patients and I hope it doesn’t start anytime soon. The cardiorespiratory model is much better for us. One of the things that I would like to see in this transition phase is in some cases in anatomical donations today they actually place cannula in the patients before legal death, before the heart stops. What I would like to see is that our patients take advantage of that procedure: get the cannulation while their heart is still beating to reduce the ischemic insult. What I would like to know is how we transition into that in particular, rather than brain death criteria.
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