The Prognosis for Whole Brain Death is…

Recent court proceedings bring the case of Jahi McMath back into the bioethical news. As you will recall, she had medical complications following a surgical procedure in 2013 and was declared brain dead. The family argued for continued life support, which the hospital denied (since she met the criteria for whole brain death). After much legal wrangling, she was transferred to New Jersey, where she remains alive on ventilator and nutritional support. This case has been reviewed in this blog (here and here). Professor Thaddeus Pope has followed this case from a medicolegalethical standpoint on his Medical Futility Blog, which is generally where I keep up with the case. His catalogue of the legal proceedings is complete, and while I disagree with many of his bioethical positions, I appreciate his rational discussion of those issues. For the remainder of this blog, I wish to focus upon the issue of brain death in the case of Jahi McMath and specifically our ability to accurately determine it.

No one, and as far as I can tell I mean absolutely no one, denies that Jahi met the criteria for whole brain death by late 2013. Her EEG was isoelectric (flatline – no brain electrical activity), radioisotope cranial blood flow studies showed no cortical blood flow (which normally results in cell ischemia, and, if not immediately corrected, brain cell death), brainstem auditory evoked responses (BAERs) were absent (usually indicating future inability to receive auditory input even if there were an otherwise healthy brain ready to receive that input) and somatosensory evoked potentials (SSEPs) were absent above the neck (usually indicating inability to receive sensory input from the body). As a result, she met the criteria for whole brain death in California and was issued a death certificate. Since that declaration, she has shown signs of entering puberty (which requires a minimally functioning portion of the brain called the hypothalamus), her heart rate has been noted to change when she hears her mother’s voice (which should not be possible given her BAER results) and she has moved her right arm to verbal command (an act that would require the ability to receive the auditory input, left hemisphere cortical brain processing of that input, signal transfer within the left hemisphere of the brain to the motor area that controls the right arm, and finally signal transfer down through the brainstem to the portion of the spinal cord that controls the right arm). If any of those are true, Jahi McMath fails to satisfy the criteria for whole brain death. Here is the testimony of Dr D.Alan Shewmon, emeritus professor of pediatric neurology at UCLA and an expert in pediatric brain death. His 26-page testimony provides an excellent discussion of the problems of determining whole brain death, particularly in the case of Jahi McMath.

The problem of potential reversibility after a determination of whole brain death hits home professionally for me. I have cared for patients in an inpatient rehabilitation hospital setting who suffered severe head injuries, as well as consulted on several more who never made it our rehabilitation hospital because of brain death. This included assisting in the discussion of whether to discontinue ventilator, nutrition and hydration support following a proper determination of whole brain death. And, while I think similar discussions are reasonable in individuals sustaining injuries leaving them in a persistent vegetative state (PVS, i.e. having brain function that only acts reflexively without awareness or capability for any cognition, perhaps a better description of Jahi McMath’s current status), no such discussion should happen until brain recovery has reached its maximal endpoint. With whole brain death, those discussions can happen immediately because that endpoint has been reached. Dead brains, by definition, do not recover.

Until now?

The initial determination of whole brain death in Jahi McMath appeared proper.

If the reports of her responsiveness are true, Jahi McMath clearly no longer meets the criterion for whole brain death. The very fact that she has remained alive over three years after the determination of whole brain death argues against whole brain death. Artificial life support has advanced but not to the degree that we can mimic all of the routine vegetative functions controlled by the brain necessary to keep the body alive. It is “easier” to keep an individual in PVS alive because the brain is still doing a large part of its bodily maintenance/regulation work.

At the very least, even if none of the above observations of Jahi McMath are true, the prognosis for whole brain death, while still very, very, very poor, is no longer zero.

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Noam Stadlan
Noam Stadlan
4 years ago

The health of brain death is actually quite robust. Despite Ms McMath’s body being supported for a number of years, there still is no credible evidence for any return of function. Unverified videos are exactly that- unverified videos. Dr Shewmon bases his entire position on these videos. I have enormous respect for Dr Shewmon and his contributions to the field are huge, but proof of consciousness needs more basis then just videos taken without any outside monitors and without any unbiased medical personnel present. Dr. Shewmon’s religious and bioethical objections to brain death are well known and well argued, but this case should be evaluated on the facts.
His theory regarding low flow certainly is possible and it is theoretically possible to have a situation where blood flow is transiently low enough to be absent on a test, but recover in time before permanent global ischemic damage occurs. Which is why the entrance criteria for brain death is the suspicion that brain death has occurred and that there is imaging evidence of an intracranial disaster. In order to be certain that brain death has occurred, it might be necessary to repeat the blood flow study to be sure that the low/absent flow state has persisted long enough to be sure that the clinical state of brain death is irreversible.
In conclusion, even if it ultimately is shown that Ms McMath has some return of function, it means that we need to examine the criteria and fine tune them. I would note that an article in the Protocols of the Royal Society of Medicine documented over 25 cases of people regaining function after being declared dead by cardio/respiratory criteria but no one is calling for a re-evaluation.

Thaddeus Pope
4 years ago

The several ongoing legal cases concern whether she meets the current standards for brain death. The family has submitted evidence that she does not meet those standards. But that evidence has not yet been evaluated by the court.

You are correct that the case implicitly challenges the criteria for death themselves. if Jahi can continue as she does, then the prevailing medical criteria do no seem to measure what the law requires: complete and orreversible cessation of “all” functions of the entire brain.

Noam Stadlan
Noam Stadlan
4 years ago

I would note that the law requires the cessation of circulation and respiration. However, if an artificial heart was pumping blood through a body where every cell was dead- we would still consider that person dead.
On a related issue, what is missIng from the definitions of death is a definition of the term ‘body’. What function or anatomy has to be present for it to be considered a ‘body’, as opposed to just ‘functioning human parts’? That has not been clarified. Left as is, an isolated leg with circulation proved by a pump is an alive human being- fulfilling the criteria of having circulation

Mark McQuain
Mark McQuain
4 years ago

I appreciate Dr. Stadlan’s and Professor Pope’s comments.

I agree with Dr. Stadlan that the video evidence of Jahi following commands to move her right arm may be simply be video of spinal reflex movements that randomly occurred subsequent to her mother’s verbal command not as a result of that command (i.e. 99.99% of a continuous recording would fail to show movement following the same command). But I am guessing and will await the court’s assessment of the facts properly presented.

My main interest in the case is both from the standpoint of a rehabilitation physician who cares for individuals with acute and chronic CNS injury as well as one interested in the bioethical question: What part of me has to function at what level for me to be considered me,such that society has an ongoing interest in protecting my life, or at least not actively moving to shorten my life? A diagnosis of whole brain death is very different from PVS. California issued a death certificate following Jahi’s whole brain death diagnosis. They do not do so for PVS. In other states in which I have practiced, I never received a rehabilitation consultation from my neurosurgical colleagues to transfer a patient to our rehabilitation unit who had whole brain death while routinely receiving transfer requests for patients with PVS. None of the families that I have worked with discussing decisions to remove life support wanted to do so if there existed a chance to recover brain function. Accurately knowing the brain’s status (and therefore, prognosis) is obviously key. Perhaps re-evaluating the criteria for whole brain death is all that this case needs to teach us?

As to the definition of “body”, except for the human brain, we seem to be able to remove, transplant, artificially simulate every other organ/body part and still consider ourselves alive, and, perhaps more importantly, that “I” still exist. So the status and prognosis for the brain seems key. One of my partners who is an orthopedic ankle/foot surgeon remains convinced that the rest of the body is just an elaborate support system for the human foot, so one’s vantage point is obviously important.