How Should End Of Life Be Determined?

Jan 28, 2016

Credit Joe Gratz / Public domain

Last year, a University of Nevada, Reno student was at the center of a contentious legal battle that raised serious questions about what constitutes the end of life. That student died before a judge could issue her final ruling. Reno Public Radio’s Noah Glick reports.

Aden Hailu was a freshman when she checked herself into Saint Mary’s Regional Medical Center last April for abdominal pain. During surgery, she suffered complications and fell into a coma. Doctors diagnosed her as brain dead, even though she showed brain functioning in three EEGs, or electroencephalograms, which are tests that detect electrical activity in the brain.

“If you have brain function as determined by an EEG, you cannot determine brain death.”

That’s David O’Mara. He’s the attorney who represented Hailu’s family in a lawsuit they filed against Saint Mary’s. He says the standards used by Hailu’s doctors didn’t go far enough in determining brain death.

“Our position is that EEGs should be the accepted medical standard when determining brain dead.”

Lawyers for Saint Mary’s argue that their doctors follow nationally-accepted standards when making their determination of brain death. Those standards don’t require EEGs.

Dr. J. Ivan Lopez is the Chair of the Department of Neurology at the Nevada School of Medicine. He backs up those claims and says the current standards are sufficient.

“We don’t have to get EEGs, we don’t have to get pet scans, we don’t have to get any test," Lopez says. "So we get a good history, we perform a good exam, we don’t need anything else.”

So, EEGs or no? Across the nation, people watched and waited to get a court ruling, an actual case precedent on what should determine end of life.

Her case was scheduled to be heard last week in Washoe County District Court, where Judge Frances Doherty was set to make a ruling, based on the results from a new, court-ordered EEG.

Aden Hailu died on Jan. 4, before those questions could be answered.

Currently, the federal definition of brain death is found in the Uniform Declaration of Death Act, or the UDDA. O’Mara says Hailu’s EEG results show that Saint Mary’s was in violation of this legal definition.

“They failed to follow the criteria or meet the standards of the UDDA, which requires all functions cease of the entire brain, including the brain stem," O'Mara says. "And we contended that Aden was alive because her brain had not ceased to function.”

The problem with the UDDA’s definition, though, is that it’s vague. There are no rules about how to determine that all brain functions have stopped. The American Academy of Neurology, or the AAN, has created guidelines to help standardize this practice, guidelines that have been adopted by medical professionals across the country.

And according to the AAN, in order for a patient to be considered brain dead, she first must be comatose. Then, she must show an absence of brainstem reflexes, something Lopez says can easily be tested.

“So I look at the size of the pupil and see if they respond to light. I very gently touch the cornea, either with a Q-Tip or a piece of cloth, to see if they blink," Lopez says. "Then I open their eyes and move their head side to side to see if their eyes move. Then I put a Q-Tip in the back of their throat to see if there is any gag.”

The AAN’s final condition for brain death is the absence of a breathing drive, which can be confirmed with an apnea test. This means that when a patient is taken off of a ventilator, she shows no visible signs of breathing, and her blood shows increased CO2 and decreased oxygen.

Now back to the case. Doctors at Saint Mary’s followed these AAN guidelines, and in doing so, determined that Hailu was dead. But is that enough?

“Actually brain death is one of the most clearly defined and well accepted diagnoses. It’s very rare where experienced clinicians will get that wrong.”

That’s Lawrence Gostin, the O’Neill Professor of Global Health Law at Georgetown University. He says once a brain death diagnosis is made, it’s clear that hospitals should not continue treatment.

“I think they would be acting in an unethical way if they did," Gostin says. "Unethical because it’s keeping a corpse alive, but also unethical because we live in a world of strained resources and if you’ve got somebody on a ventilator, it means that ventilator can’t be used for someone else.”

But David O’Mara, the attorney for the Hailu family, says the current standards aren’t sufficient in determining brain death, which is why an autopsy has been ordered and further litigation surrounding the cause of her death is likely.