IRELAND: BREAKING NEWS Clinically dead woman being kept on life support because she is pregnant - 23 December 2014
Clinically dead woman being kept on life support because she is pregnant
23 December 2014
Summary from several sources
This case has been ongoing but not public since the first few days of December. The story broke in the media on 17 December in the evening. The mother of two was in her 20s and around 16-17 weeks pregnant when she suffered a catastrophic internal injury as a result of a blood clot, which killed her, but left the baby alive. Doctors were unable to save her, but kept her on life support so "her unborn baby could have a chance of life".
The woman's parents expressed a clear wish that the life support be switched off and took the case to court. The hospital was also seeking legal advice on whether it can legally accede to her parents' wishes. "The legal advice would be there is one life here and it is the unborn child. Everything practicable has to be done - and that's both under the constitution and the legislation passed last year. There is also a high possibility the unborn child will not survive," a senior source said last night. The case was heard on 23 December.
The Abortion Rights Campaign has called for resolution of this case in accordance with the wishes of the family, so that they can begin the process of mourning their daughter.
This isn't the first time a case like this has happened nor just in Ireland either
It took the widower of Marlise Muñoz, a pregnant American woman who collapsed following a blood clot in her lung, two months and a lawsuit to force a Texas hospital to take his brain-dead wife off a ventilator. In a situation shockingly similar to the case of the unnamed Irish woman, Muñoz suffered oxygen deprivation and brain death in her 14th week of pregnancy, but was kept on life support against her family's wishes when hospital administrators misread a state law that mandated lifesaving measures be maintained if a female patient is pregnant. That Muñoz was technically dead and that the bill's own author thought the law was being misapplied didn't matter to the hospital.
By Scott Bixby: http://mic.com/articles/106836/abortion-foes-are-forcing-a-brain-dead-pregnant-woman-to-incubate-her-fetus
One life ends, another begins: Management of a brain-dead pregnant mother - a systematic review
This is a systematic review of 30 "scientific" articles in BMC Medicine, published in November 2010, written by five clinicians at the University of Heidelberg, Germany, on keeping pregnant brain-dead women alive until viability in order to try and deliver the baby alive. Their specialities include general, visceral and transplantation surgery, neurosurgery, obstetrics & gynaecology, anesthesiology, and paediatrics.
Methods To obtain information on brain-dead pregnant women, we performed a systematic review of Medline, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL).The collected data included the age of the mother, the cause of brain death, maternal medical complications, gestational age at BD, duration of extended life support, gestational age at delivery, indication of delivery, neonatal outcome, organ donation of the mothers and patient and graft outcome.
The management of a brain-dead pregnant woman requires a multidisciplinary team which should follow available standards, guidelines and recommendations both for a nontraumatic therapy of the fetus and for an organ-preserving treatment of the potential donor.
"In 12 (63%) of 19 reported cases, the prolonged somatic support led to the delivery of a viable child. We did not find any information about the fate of the fetuses in the published case series. Children who were born included 1 female and 10 male infants. No information regarding sex was given about one infant. The average birthweight was 1,384 g (range, 815-2,083 g), and the mean Apgar score was 7 and 8 at 1 and 5 minutes, respectively. Congenital defects were reported for only one infant, who was diagnosed with fetal hydantoin syndrome resulting from previous chronic phenytoin usage by the mother. Four infants required temporary mechanical ventilation because of neonatal respiratory distress syndrome or pneumonia. Fungemia was diagnosed in one infant, and he was treated with amphotericin B. However, not every infant was sufficiently followed to determine the long-term effects of prolonged maternal life support. Postnatal follow-up up to 24 months was available only for six infants. All of them developed normally and apparently had no problems related to their exceptional intrauterine circumstances."
Discussion This section discusses at length the need for cardiovascular, respiratory and endocrine support, thermoregulation, nutritional support, dealing with infection, prophylactic anticoagulation , obstetric considerations, fetal and neonatal considerations, organ donation and transplant outcomes. Finally, they reach ethical and legal issues:
Ethical and legal issues "Many ethical and legal questions arise in cases of maternal BD. Although it was not the focus of this review, we briefly discussed various aspects of ethical and legal issues such as "the mother's body as a cadaveric incubator," "mother as the organ donor and fetus as the recipient" and the concern for "possible damages to the fetus". Some professionals believe that it is not ethically acceptable to maintain the mother's body after BD to use it as a "fetal container." Such a decision should not be simply assumed, but it must be debated. If the mother is to be considered a "cadaveric incubator" with no autonomous rights, the rights of the fetus should legally prevail. Another argument claims that the prolonged somatic support itself is actually organ donation with the fetus as the recipient. In that case, if the mother had previously indicated a wish to donate her organs, it would be appropriate to proceed with the extended somatic support. Finally, some believe that strategies used to maintain maternal somatic function are still in the experimental stage. Not every adverse effect of medication used on the fetus during an extended somatic support is known. The next of kin must therefore be informed about the existing life maintenance strategies and the possible damages they may cause to the fetus. Psychological consultation should certainly be beneficial in this situation."
"Since such catastrophic cases are so infrequent, the mother's wish is in effect rarely known. For this reason, it is strongly suggested to engage the family in the planning of the care. The physician and transplant coordinator should not impose all available procedures against the wishes of the family. Sperling et al suggested that questions be answered on a case-by-case basis with the involvement of the hospital's ethics committee. One also needs to consider that while nowadays somatic support in the case of maternal BD is technically possible, there is still no legal document which asks a pregnant woman about the fate of her unborn child in the event of BD. It is highly recommended that this question be added to the advance directives of any woman of childbearing age and routinely discussed in standard prenatal interviews."
The 62 references to the paper are fascinating. Now let's turn to the reality of the dead woman's situation and the actuality of her death, which is described in highly upsetting details in the following article of 23 December:
Chances of baby being born alive and intact are small, doctor tells High Court
A former Master of Dublin's Rotunda Hospital has told the High Court if the somatic treatment currently being administered to a pregnant woman on life support was to continue, this would represent a move from the "extraordinary" to the "grotesque". Dr Peter McKenna said the chances of the baby being born alive are small and the chances of intact survival are "even smaller".
A three judge High Court will rule on Friday (26 December) on whether the young pregnant woman's life support may be turned off in accordance with her family's wishes. The woman was declared brain dead on December 3rd last when she was about 15 weeks pregnant.
A consultant neurologist who treated the woman in the Dublin hospital where she was declared brain dead on December 3rd said he had looked from December 1st for written legal advice as to whether the hospital could cease administering the treatment to the woman but, to date, this had not been received. He said he had never before been in a situation before where he could not grant a family's wish to cease life support and he was humbled by the attitude of the woman's family in this case.
He and his colleagues are doctors, not lawyers, and three of them had sat around trying to interpret the 1983 anti-abortion amendment but were very uncomfortable as to whether or not they could accede to the family's request, he said, adding that like all clinicians, they had erred on the safe side.
The court heard evidence on Tuesday afternoon on behalf of the HSE which is seeking a declaration that it is lawful to cease the somatic treatment which, on legal advice, has been administered to the woman since she was deemed clinically dead so as to try and maintain viability of the foetus. The court earlier heard evidence on behalf of the woman's family who appealed for orders permitting the somatic treatment be stopped. The evidence has now concluded and legal submissions will be heard tomorrow.
The President of the High Court, Mr Justice Nicholas Kearns, said the court, after hearing submissions on behalf of all the parties, will deliver its ruling on Friday. Dr Timothy Lynch, a consultant neurologist, said he was satisfied the woman met the criteria for brain death. One of the tests was to assess the brain's response when a ventilator is switched off but, while that test was not carried out here, he was satisfied the woman met other criteria and is brain dead. The absence of inter-cranial blood flow was a clear indication of death, he said. In response to Cormac Corrigan SC, representing the interests of the woman, he said the woman can have no concept of pain.
Dr Frances Colreavy, a consultant in intensive care medicine, said the woman is dead about three weeks and she had viewed her yesterday.
"She does not look good," she said. A photograph beside the woman's bed shows she was "a very pretty young girl but the deceased in the bed does not resemble her", Dr Colreavy said. When she saw the woman, make-up had been applied to her because the woman's children were going to visit her. Her eyes were so swollen they do not close, she said. The woman's little girl, when she saw her for the first time, was distressed, she said.
There were also six syringe pumps beside the woman's bed for her various treatments, Dr Colreavy said. She needed nutrition, bowel support, drugs for infections, a head wound needed to be dressed and she had to be turned to avoid pressure sores. There was concern about ongoing infections when a patient becomes brain dead and this woman had shown signs of pneumonia and other infection, she added.
Dr Colreavy said she has practised intensive care medicine in Ireland and Australia but has never experienced this kind of case before, where somatic treatment has been applied for 20 days to a person who is brain dead. "The heart will stop, there is no machine in the world that will maintain the heart beat indefinitely," she said. The woman's brain is also rotting and she is being treated for a form of meningitis.
The pregnant abdomen looks unlike any other she had seen and she was worried that indicated an infection underneath, the doctor said. All the sources of infection had not been identified, she added.
The woman is also suffering from hypertension, high blood pressure, which is unusual and very worrisome, she added. This was "uncharted territory" in her experience. The possible effects of the drugs on the woman's pregnancy are uncertain, she said.
In her view, continuing the somatic support was not appropriate and amounted to "experimental medicine". There are continuing unusual fungal infections in this patient and they are unlikely to result in a positive outcome, she said.
In response to Mr Justice Kearns, she said the medical findings in relation to the woman were "grossly abnormal".
She told Mr Corrigan she did not believe anything more could be done to help the woman. She understood the drugs were being continued for the foetus but their effects were uncharted.
Dr McKenna said the woman's last period was August 16th and he calculated she was about 15 weeks pregnant when declared brain dead on December 3rd.
The effect of the woman's high temperature of some 37 and 38 degrees on the foetus is worrying, he said.
Babies are not designed to be incubated at anything other than normal temperature because oxygen supply supplied at all times is borderline, he said. The baby is not designed to be exposed to temperatures of 38 and 39 degrees for long periods. This caused concern the baby was utilising the precarious supply of oxygen more quickly than it should be.
"We are all in uncharted territory," he said.
Very few drugs are licensed for use in pregnancy, the drugs being administered to the woman as of now are not licensed and it was not possible to say what their effects would be, he said.
At 28 weeks gestation, there is a chance of 98 to 99 per cent survival and that would be the ideal to aim for in relation to viability of the fetus, he said. That was ten weeks from now, Dr McKenna added.
The single most important feature relates to the gestation at the time brain death occurs, he said. If this had happened at 28 weeks, doctors could look to sustain the intra-uterine environment. However, when brain death occurs much earlier, the situation was different.
The chances of the fetus being born alive are small and the chances of intact survival are even smaller, he said. His view in that regard had hardened given the evidence about the woman's current state.
"I would be firmly of the view the appropriate thing now is not to continue with the support." He would also be reluctant to continue treatment without the support of the woman's family.
He said an expert group met last Thursday to inform the HSE concerning many of the factors in this case. The group included senior administrators, clinicians and people with an ethical and legal background. All the parameters of this case, why Ireland was unique and the relevant literature were considered, he said.
He did not consider there were any significant differences between his opinion and that or other members of the group.
In reply to Conor Dignam SC, for the unborn, he said a high temperature in labour is regarded as very serious. The brain of a foetus is most likely to be affected by deprivation of oxygen and persistent high temperatures would be likely to lead to abnormality in the developing brain, he said.
In reply to Mr Corrigan, for the woman, Dr McKenna said, if the views of the woman herself were known, he would have regard to them but would not consider himself bound by them because of the "extraordinary nature" of the treatment involved.
In reply to Ms Justice Baker, he said this is "not the normal incubator" for a foetus because of the difficulty of maintaining normal bodily parameters in someone who is brain dead.
A fetus born at 24 weeks has a very poor chance of survival, he said. However, he believed it was possible to achieve better survival rates for a foetus born at 28 weeks than some of the reports indicated.
"If this somatic treatment was to be continued, we would be going from the extraordinary to the grotesque."
He could not say the foetus was experiencing pain but he believed the ultimate outcome would be very poor and the baby would not be unaffected in its growth and measurements.
A consultant obstetrician involved in treating the woman and her unborn child told Gerard Durcan SC, for the HSE, he had provided a report, dated December 19th, for the court.
He had heard of the dreadful state the woman is in and he had great concern about her somatic care, he said. The somatic care applied to the woman in his hospital was based on the care regime set by the Dublin hospital. The law was she had to be kept alive because of her pregnancy and that was followed at his hospital.
He had had a patient in similar circumstances who was further on in her pregnancy but who only lasted two and a half weeks with somatic treatment, he said.
He honestly did not think there was any hope of the baby surviving "with the storm going on around it".
"I would give up any hope for the baby."
He said her father's "little girl" is dead, and is "deteriorating rapidly". While his report said the baby was developing, the storm around it has not reached it yet, he said. He agreed his report also stated the biggest danger to the baby was premature delivery.
He agreed his report had not expressed concern the baby would not reach viability. When preparing the report, his concern was to develop a plan that would get the baby on to 32 weeks, he said.
What is happening now takes time but will eventually affect the baby and make its condition unviable, he said.
His view had changed because the infections in the woman seemed to be taking over in the last few days. Her brain was liquefying and pouring toxins into the blood stream ad that would not help the baby. The deterioration in the woman's condition would affect the baby and he did not believe the baby would be viable.
"Her temperature is rising, we have all the signs of the perfect storm and it does not seem to be improving."
"Yes, she is deceased. She's a little girl with painted nails and her nail varnish on and her make up on but....I know she is dead."
He agreed the care plan for the woman stated no extraordinary measures should be used to keep her alive. Such measures are happening now, he believed the team were now doing things that are extraordinary "and we're being pushed more and more in that direction". He agreed her family had said they did not want such treatment when there was no guarantee the baby would be born healthy.
The family's suffering is palpable and he had tried to assure them on December 10th last, given his experience of another case where another woman only survived two and a half weeks on somatic treatment, their suffering would not go on too long.
He agreed he probably told them the doctors were "stuck in a hole", there is a baby there, "the law ties our hands" and the chances of the baby surviving was very small. When the woman was returned to his hospital, he felt his hands were tied by legal considerations.
A neurosurgeon at the Dublin hospital involving in treating the woman said they became involved in her treatment after she collapsed at the other hospital on November 29th. A CT scan noted a large cystic mass that had compressed her fourth ventricle and as a result she had a massive build up of brain fluid.
The view was there was no hope but he decided a drain should be inserted for a one in 1,000 chance of some sort of recovery, he said. He had told the family on November 30th the likely outcome was appalling, she was likely to be brain dead but they would have to wait 24 hours.
Other media reports: