8 year old and fentanyl?

[deleted162650]

I agree the best practical solution in these hopeless situations is to take organs from not brain dead, not cardiac dead but still living donors. Unfortunately that is unlikely to ever happen.

You mean like this?

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[nimbus]

You mean like this?

Yes

Dead vs alive
Ga vs MAC

The world is not clear. If the patient is imminently going to die, maybe we should reconsider the prohibition against "hastening death".

 

[WholeLottaGame7]

If this does indeed go to court, the case will likely turn on what the family says. If they say he was suffering and Dr. Brill made him comfortable to pass in peace, I can't see a jury convicting her of anything. If the family is against her for any reason, she'd better have a good attorney.

Hard to tell from the article, but it certainly sounds like the family had nothing to do with pushing the case. Doesn't even sound like the 2nd pathologist was particularly motivated, he just didn't feel like putting up a fight against someone on a mission and the path of least resistance was signing off on it.

I doubt this case ever sees a court room. Charges haven't even been filed. I suspect more reasonable heads will prevail.

With re: to the anesthesiologist in the PICU. Many PICUs (even academic ones) used to be partially staffed by anesthesiologists and were grandfathered in without peds CC boards. Both my residency and fellowship programs had such setups within the past 10 years (though both are now fully peds CC staffed). We had quite a few peds anesthesiologists who did peds first, then anesthesia, but no fellowships.

 

[Hamhock]

What's troublesome, if there's anything troublesome in this story other than this nurse, is the entire concept of "donation after cardiac death".

Yeah, let's take a perfectly good set of organs and deliberately extend ischemic time by waiting until cardiac death, for fuzzy reasons. If this was my child, I'd be upset that his final gift of life to others was being compromised in this way.

I was going to post this exact sentiment and concept.

I didn't because I too vividly recall the admonishment (almost administrative censure) that I received when discussing this idea with a few ICU nurses one day after "loosing" organs due to waiting for 'cardiac death'. Of course, this was recently a catholic hospital and the religious are not known for reasoned consideration of nuance and modernity.

In fact, I have had a family not only upset that the "gift of life to others was being compromised in the this way" -- but actively begging me to push more opioid to hasten apnea and asystole. Later a brother asked why we must have the heart stop in the body before it can be removed and inserted into another body.

HH

 

[Pharmado]

I was going to post this exact sentiment and concept.

I didn't because I too vividly recall the admonishment (almost administrative censure) that I received when discussing this idea with a few ICU nurses one day after "loosing" organs due to waiting for 'cardiac death'. Of course, this was recently a catholic hospital and the religious are not known for reasoned consideration of nuance and modernity.

In fact, I have had a family not only upset that the "gift of life to others was being compromised in the this way" -- but actively begging me to push more opioid to hasten apnea and asystole. Later a brother asked why we must have the heart stop in the body before it can be removed and inserted into another body.

HH

Obviously the family you speak of had come to terms with their loss and was truly looking to make something of their tragedy. It is too bad that we have to do things to cover ourselves when what this doctor did was likely in the best interests of everyone. I am one of these "religious" people, but I would argue that this child was already gone. Did fentanyl play a roll in the childs death at the end? Probably. If the fentanyl wasn't given would the outcome have been better for anyone? No. I don't fault Dr Brill for her actions assuming she was trying to minimize the suffering of the family. Unfortunately, doing the right thing isn't always the best thing in the eyes of the law. It should be, but it's not.

 

[Mman]

Agree it is an interesting discussion. While 500mcg for a 49lb child sounds high harm is a judgement made by intent in this case. Palliative cares may hasten death if the primary intent is not to hasten death. It is difficult to determine beyond a reasonable doubt that the intent of the amount of administration was to hasten death.
The fact that any dose brings about later judgement in this case is in my mind the most concerning thing. So if one was to determine that 500mcg was too much after the fact, what about 475, 450, 425...100, 75, 50, or 25mcg? To my knowledge there is no absolute guideline for maximum dosage of opiates in a comfort care setting. There is no protection from prosecution at any dosage. The slippery slope potential in this is titanic. This may bring about serious changes in end of life care that may result in patient suffering regardless of the outcome in this case.

While I sort of agree with you in theory, you are discussing the dose of fentanyl on a forum of anesthesiologists that give fentanyl over and over and over and over day after day at work. We write the book on this one. A dose of 500 mcg is roughly 25 mcg/kg to this patient. That's a lot. That's the kind of dose you could give to a similar patient and then have 8 hours of surgery without redosing. It's more than an order of magnitude greater than what we'd give this kid as a patient in pain in the PACU if they just had surgery.

Now a very good argument can be made that this patient has probably already been receiving narcotics for days as part of this incident (although likely not mega doses since there was no large painful injury or chronic cancer pain) so they'd need bigger doses than you'd otherwise expect, but honestly that'd likely be a small change in dose for this patient.


Now I'm not arguing in a legal setting that there should be doses picked out ahead of time by lawyers that are acceptable for various needs. That's stupid. But on a medical forum of experts, we are certainly free to debate the difference between a 500 mcg bolus of fentanyl to a 49 lb patient versus a bunch of 50 mcg doses over 20 minutes. I mean let's be honest with ourselves. If a terminal patient is having pain we wish to help alleviate, there is a difference between walking in their room and giving them 1000 mg push of morphine versus giving them 10 or 20 mg. That's why titrating in doses in medically reasonable amounts is going to look a lot better to both other physicians as well as lay people seeing a paper trail afterwards.

 

[vector2]

While I sort of agree with you in theory, you are discussing the dose of fentanyl on a forum of anesthesiologists that give fentanyl over and over and over and over day after day at work. We write the book on this one. A dose of 500 mcg is roughly 25 mcg/kg to this patient. That's a lot. That's the kind of dose you could give to a similar patient and then have 8 hours of surgery without redosing. It's more than an order of magnitude greater than what we'd give this kid as a patient in pain in the PACU if they just had surgery.

Now a very good argument can be made that this patient has probably already been receiving narcotics for days as part of this incident (although likely not mega doses since there was no large painful injury or chronic cancer pain) so they'd need bigger doses than you'd otherwise expect, but honestly that'd likely be a small change in dose for this patient.


Now I'm not arguing in a legal setting that there should be doses picked out ahead of time by lawyers that are acceptable for various needs. That's stupid. But on a medical forum of experts, we are certainly free to debate the difference between a 500 mcg bolus of fentanyl to a 49 lb patient versus a bunch of 50 mcg doses over 20 minutes. I mean let's be honest with ourselves. If a terminal patient is having pain we wish to help alleviate, there is a difference between walking in their room and giving them 1000 mg push of morphine versus giving them 10 or 20 mg. That's why titrating in doses in medically reasonable amounts is going to look a lot better to both other physicians as well as lay people seeing a paper trail afterwards.

I agree that some pre-determined dose shouldn't be picked out by lawyers, but speaking as someone about to finish up CCM fellowship, there absolutely should be some form of protocolized 'comfort care' opioid order set created by anesthesiologist, palliative, and CC physicians for this very purpose. Set the drips and have very specific up titration and prn boluses instructions and a defined patient comfort goal (i.e. RR 8-10, no agonal breaths etc). When done in this fashion, there is a degree of CYA because everyone is on the same page and is acting under hospital standard of care.

 

[nimbus]

A pertinent question to ask would be, "Has Dr. Brill or anyone else at UCLA given similar doses of fentanyl to other dying children who are not organ donors?" Do they use comfort care measures that are different between the 2 groups, DCD vs non-organ donors. Did the fact that this child was an organ donor affect his "comfort care"? If they haven't given similar doses to non-organ donors that would be incriminating. Those patients deserve the same level of comfort care as this patient.

 

[nimbus]

I agree that some pre-determined dose shouldn't be picked out by lawyers, but speaking as someone about to finish up CCM fellowship, there absolutely should be some form of protocolized 'comfort care' opioid order set created by anesthesiologist, palliative, and CC physicians for this very purpose. Set the drips and have very specific up titration and prn boluses instructions and a defined patient comfort goal (i.e. RR 8-10, no agonal breaths etc). When done in this fashion, there is a degree of CYA because everyone is on the same page and is acting under hospital standard of care.

And if the same order set was used for both organ donors and non-organ donors, there would be no question that comfort care measures weren't used to hasten death in DCD donors.

 

[Mman]

I agree that some pre-determined dose shouldn't be picked out by lawyers, but speaking as someone about to finish up CCM fellowship, there absolutely should be some form of protocolized 'comfort care' opioid order set created by anesthesiologist, palliative, and CC physicians for this very purpose. Set the drips and have very specific up titration and prn boluses instructions and a defined patient comfort goal (i.e. RR 8-10, no agonal breaths etc). When done in this fashion, there is a degree of CYA because everyone is on the same page and is acting under hospital standard of care.

I agree that hospitals should likely have their own protocols developed by physicians for this purpose and perhaps individual medical societies could come up with suggested guidelines that they can reference or use.

 

[IlDestriero]

With the way opiates are micromanaged to the extreme, I'm sure there's a paper trail of what that child received and when.
Sad case.
The defense will need those records and testimony of suffering for the acquittal. Of course the bad press damages transplant and physician trust either way.


--
Il Destriero

 

[GravelRider]

I'm not sure we need another set of guidelines...especially for a process that should be very individualized, like dying. It's hard to speculate on what Dr. Brill did and why without the full story. Instead of guidelines, what we need is a real conversation that we have as a society regarding death and dying. It's difficult because death is such a taboo subject. We all remember the "death panel" hysteria. However, by avoiding the subject we are doing our patients a disservice by potentially prolonging suffering at the end of life and wasting limited resources (both organs and ICU resources). We are long overdue to have this debate as a society. If this case helps to encourage that conversation then maybe that's a good thing.

 

[drmwvr]

Of course, this was recently a catholic hospital and the religious are not known for reasoned consideration of nuance and modernity.
HH

Indeed. Then could one say that the irreligious are not known for any meaningful knowledge of history? The notion of objectification of people as ends to a means is hardly "modern". I doubt Pol Pot was seen in church too often.

The nobility of a cause doesn't give license to cross difficult ethical lines which exist to prevent nightmarish scenarios, the likes of which are being discussed here. Practically speaking, I can't imagine what such cavalier thinking would do to damage the cause of transplant medicine once families, having had some time to reflect on the death of a child or spouse under less emotional circumstances, raised objections.

The ethical lines exist as much for the credibility of the transplant services as they do to protect patients and families.

 

[Robotic Wis-Hipple]

I agree that some pre-determined dose shouldn't be picked out by lawyers, but speaking as someone about to finish up CCM fellowship, there absolutely should be some form of protocolized 'comfort care' opioid order set created by anesthesiologist, palliative, and CC physicians for this very purpose. Set the drips and have very specific up titration and prn boluses instructions and a defined patient comfort goal (i.e. RR 8-10, no agonal breaths etc). When done in this fashion, there is a degree of CYA because everyone is on the same page and is acting under hospital standard of care.

If this case goes anywhere that's exactly what will happen. Then we'd need a study 10 years from now comparing DCD organ recipient outcomes against pre-protocol days.....

My point is that yes, I 100% agree that comfort care may need a more controlled regimen to remove all doubt/concern of physician "hastening" of death. But I'm not sure end of life comfort care and DCD donation is the same thing.

 

[Hamhock]

Indeed. Then could one say that the irreligious are not known for any meaningful knowledge of history? The notion of objectification of people as ends to a means is hardly "modern". I doubt Pol Pot was seen in church too often.

You are right, I should not have brought religion into this discussion disparagingly.

However:
1. Please review the definition of "modernity", as it is used in discussions like these.

2. Religion must be part of the discussion, unlike 'atheism'.

3. Pol Pot in no way represents the "non-religious"; just as Robert Dear does not represent Christians. However, failure to consider "nuance and modernity" with reason and empiricism is characteristically representative of religion -- indeed, it may be a defining feature (ie faith). Please don't perpetuate the "atheist atrocity fallacy".
The Atheist Atrocities Fallacy — Hitler, Stalin, and Pol Pot

Again, I apologize for bringing religion into this discussion the way I did. I hope my brief error in judgement does not ruin this otherwise informative and inquisitive thread.

HH

 

[Hamhock]

Before atheists object to my last post:

I am fully aware that Robert Dear was partially motivated and inspired by Christian doctrine and that the motivating and inspiring ideology for Pol Pot was not athesim (not even sure this is possible), but the suboptimal comparison was needed in this context/for the current audience for reasons of efficiency mostly.

I hope the ethicists and atheists and philosophers on this board will forgive me.

HH

 

[nimbus]

If this case goes anywhere that's exactly what will happen. Then we'd need a study 10 years from now comparing DCD organ recipient outcomes against pre-protocol days.....

My point is that yes, I 100% agree that comfort care may need a more controlled regimen to remove all doubt/concern of physician "hastening" of death. But I'm not sure end of life comfort care and DCD donation is the same thing.

Comfort care is obviously not the same thing as DCD donation. But this child was given a large dose of fentanyl in the name of comfort care. The only other reason he would be given such a large dose of fentanyl would be to hasten death.

 

[OB1🤙]

I think many are framing their reactions to the fentanyl doses based on doses they are familiar with in opiate naive patients who might experience a conscious episode of pain, and whom we would hope to continue breathing once extubated.

This is some different stuff going on.

Could a 50mcg dose cause apnea? If it could, why is that ok and 500mcg not?

Why is ANY fentanyl ok in someone who is essentially brain dead and not having a conscious experience of pain?

I mean, if you're ok with terminal extubation and then a 50mcg fentanyl bolus for "comfort," even if it might have the side effect of apnea, I don't see how 500 mcg is any ethically different.

 

[nimbus]

I think many are framing their reactions to the fentanyl doses based on doses they are familiar with in opiate naive patients who might experience a conscious episode of pain, and whom we would hope to continue breathing once extubated.

This is some different stuff going on.

Could a 50mcg dose cause apnea? If it could, why is that ok and 500mcg not?

Why is ANY fentanyl ok in someone who is essentially brain dead and not having a conscious experience of pain?

I mean, if you're ok with terminal extubation and then a 50mcg fentanyl bolus for "comfort," even if it might have the side effect of apnea, I don't see how 500 mcg is any ethically different.

I have no ethical problem with what went down. She did the right thing in my view. But it seems clear to me that a large dose fentanyl was given to hasten death.

 

[Robotic Wis-Hipple]

Comfort care is obviously not the same thing as DCD donation. But this child was given a large dose of fentanyl in the name of comfort care. The only other reason would be given such a large dose of fentanyl would be to hasten death.

Hawaiian Bruin expressed my thinking much more eloquently than I could. My point was that DCD and comfort care are two different things. Reacting to this case with comfort care protocols will only serve to potentially increase suffering during end of life care with the hopes of preventing the occasional appearance of over-zealous dosing or "hastening" of death in this setting.

In the setting of DCD, those same protocols would extend the time to procurement and likely negatively impact the organ milieu. I think we all know what happened here in this case. And as Bruin said, the dose really doesn't matter.

 

[GravelRider]

I have no ethical problem with what went down. She did the right thing in my view. But it seems clear to me that a large dose fentanyl was given to hasten death.

You are speculating on what her intention was. That's an important difference. No one, except for Dr. Brill herself, will ever know what her intention was.

 

[drmwvr]

This is some different stuff going on.

Could a 50mcg dose cause apnea? If it could, why is that ok and 500mcg not?

Why is ANY fentanyl ok in someone who is essentially brain dead and not having a conscious experience of pain?

I mean, if you're ok with terminal extubation and then a 50mcg fentanyl bolus for "comfort," even if it might have the side effect of apnea, I don't see how 500 mcg is any ethically different.

It comes down to maintaining the integrity of the process. Consent of the patient/family is just one piece of the equation. The other part is a declaration of death or natural death/death by double effect of sedation. Intentionally hastening death violates that process. Why not just go to the OR and harvest if the stops are so malleable?

As to the difference, 50 mcg could cause apnea but it's a reasonable, defensible dose of fentanyl for sedation. 10 ml will cause apnea and it amounts to a hypnotic dose. But if 50 could, why bolus 500?

If that is what happened, it was a regrettable, probably impulsive reaction to a lousy situation.

 

[anbuitachi]

I mean lots of stuff hasten death. terminal extubation hastens death. 100 mcg of fentanyl probably would hasten this kids death too. This kid can't breath adequately on his own, which is why he was on a vent, probably any thing that makes it more difficult would hasten his death

 

[nimbus]

I mean lots of stuff hasten death. terminal extubation hastens death. 100 mcg of fentanyl probably would hasten this kids death too. This kid can't breath adequately on his own, which is why he was on a vent, probably any thing that makes it more difficult would hasten his death

Median survival after terminal extubation in this study was 7.5hrs. She gave a ridiculous dose of fentanyl. When was the last time you gave 500mcg to a 21kg kid? It's disingenuous to say she wasn't hastening death. The elephant is in the room.


Withdrawal of life support in the neurological intensive care unit. - PubMed - NCBI

 

[anbuitachi]

Median survival after terminal extubation in this study was 7.5hrs. She gave a ridiculous dose of fentanyl. When was the last time you gave 500mcg to a 21kg kid? It's disingenuous to say she wasn't hastening death. The elephant is in the room.


Withdrawal of life support in the neurological intensive care unit. - PubMed - NCBI

Yea its the dose that's the issue. Though i think that study is done in adults not kids

 

[Pharmado]

If indeed the dose was 500 mcg, then it would almost certainly have sped his death. The article says that the coroners records state that the dose was 500 mcg. If that was the dose it would be difficult to argue that this didn't speed his death. What if they have the dose wrong in the article though? Perhaps this was the dose that was estimated by this RN. We can only speculate, but unfortunately a great doctor is facing a significant threat to both her practice and her freedom. I would really like to hear her side of the story and get the details of what really happened.

 

[pgg]

If that was the dose it would be difficult to argue that this didn't speed his death.

Well, since it's perfectly OK if a palliative medication hastens death, I don't really see why that argument would matter.

 

[Pharmado]

Well, since it's perfectly OK if a palliative medication hastens death, I don't really see why that argument would matter.

It would matter because it is illegal to speed death in order to harvest organs. I doubt that was what she was doing, but militant RN from the coroners department saw it that way. If the case wasn't DCD I don't think it would matter. Honestly, I didn't realize they did autopsies on pts that had undergone organ donation. Seems like an odd practice to me.

 

[dpmd]

It would matter because it is illegal to speed death in order to harvest organs. I doubt that was what she was doing, but militant RN from the coroners department saw it that way. If the case wasn't DCD I don't think it would matter. Honestly, I didn't realize they did autopsies on pts that had undergone organ donation. Seems like an odd practice to me.

The reason for the autopsy would be the initial reason for hospitalization (being found head first in a washing machine). Makes it automatically a coroner's case in this state. Has nothing to do with whether or not there was organ donation.

 

[deleted171991]

Well, since it's perfectly OK if a palliative medication hastens death, I don't really see why that argument would matter.

It's actually not. Legally. That's the hypocrisy in the law.

 

[nimbus]

It's actually not. Legally. That's the hypocrisy in the law.

And the hypocrisy in the current DCD policies. Everyone knows what's going on but nobody will own up to it. Society can't swallow that pill so we deny what's happening and spin the story into a more palatable form.

 

[drmwvr]

And the hypocrisy in the current DCD policies. Everyone knows what's going on but nobody will own up to it. Society can't swallow that pill so we deny what's happening and spin the story into a more palatable form.

But it does have to be "palatable". It has to come with the territory. And as inconvenient as that is, without it, there is no transplant system. Unless the system is immune to or totally unconcerned with at least the appearance of scandalous breaches of ethics (like the Chinese), the PR problem would be too much to overcome.

 

[anbuitachi]

But it does have to be "palatable". It has to come with the territory. And as inconvenient as that is, without it, there is no transplant system. Unless the system is immune to or totally unconcerned with at least the appearance of scandalous breaches of ethics (like the Chinese), the PR problem would be too much to overcome.

i mean you can make it like in some countries in europe where you are automatically a organ donor unless you choose to deny it..

 

[nimbus]

But it does have to be "palatable". It has to come with the territory. And as inconvenient as that is, without it, there is no transplant system. Unless the system is immune to or totally unconcerned with at least the appearance of scandalous breaches of ethics (like the Chinese), the PR problem would be too much to overcome.

I don't consider it a breach of ethics to hasten the death of someone who will die imminently in order to improve the chance of successful transplantation of their organs.

 

[dpmd]

I don't consider it a breach of ethics to hasten the death of someone who will die imminently in order to improve the chance of successful transplantation of their organs.

Nor do I. It is illegal though. Also, there are issues people have with organ donation in that they think that doctors will try to do things to make a donor brain dead where they would instead try to save the person if they weren't a donor. Avoiding things that feed that fear is helpful to increase the number of donors. In a similar vein I have no ethical issue wrapping the head of someone who had a craniectomy but is not showing and meaningful sign of recovery in the hopes they herniate and become brain dead to avoid making the family have to decide about withdrawal of support. It also happens to give them a chance of becoming an organ donor but it wouldn't be prudent to go around announcing that. The times I have been involved with it the neurosurgeon met with the family and framed things as "re-creating the cranial vault" to return the patient to the preoperative state and see what happens naturally. If family objected it wouldn't be done but none did. However despite that another physician involved objected to this and effectively brought it to halt (with the unintended side effect of the neurosurgeon being more selective in their craniectomies following significant trauma). Had they persisted over the objections and the other physician decided to press the issue there could have been similar bad press and potential charges for those involved. Just goes to show that you have to be careful about perception not just what you feel is right.

 

[anbuitachi]

Nor do I. It is illegal though. Also, there are issues people have with organ donation in that they think that doctors will try to do things to make a donor brain dead where they would instead try to save the person if they weren't a donor. Avoiding things that feed that fear is helpful to increase the number of donors. In a similar vein I have no ethical issue wrapping the head of someone who had a craniectomy but is not showing and meaningful sign of recovery in the hopes they herniate and become brain dead to avoid making the family have to decide about withdrawal of support. It also happens to give them a chance of becoming an organ donor but it wouldn't be prudent to go around announcing that. The times I have been involved with it the neurosurgeon met with the family and framed things as "re-creating the cranial vault" to return the patient to the preoperative state and see what happens naturally. If family objected it wouldn't be done but none did. However despite that another physician involved objected to this and effectively brought it to halt (with the unintended side effect of the neurosurgeon being more selective in their craniectomies following significant trauma). Had they persisted over the objections and the other physician decided to press the issue there could have been similar bad press and potential charges for those involved. Just goes to show that you have to be careful about perception not just what you feel is right.

That sounds like borderline comfort care.. cause you'd have to not monitor ICP

 

[dpmd]

That sounds like borderline comfort care.. cause you'd have to not monitor ICP

Well, there isn't anything about wrapping the head that provides comfort to anyone besides the family who then doesn't have to decide whether to kill their family member (because that is technically what choosing to withdraw care means even if we frame things in a nice way, I certainly would prefer being told my loved ones is now dead over having to decide to let them become dead).

 

[Mman]

I think many are framing their reactions to the fentanyl doses based on doses they are familiar with in opiate naive patients who might experience a conscious episode of pain, and whom we would hope to continue breathing once extubated.

This is some different stuff going on.

Could a 50mcg dose cause apnea? If it could, why is that ok and 500mcg not?

Why is ANY fentanyl ok in someone who is essentially brain dead and not having a conscious experience of pain?

I mean, if you're ok with terminal extubation and then a 50mcg fentanyl bolus for "comfort," even if it might have the side effect of apnea, I don't see how 500 mcg is any ethically different.

1) I agree with making a kid that is dying comfortable. End of story.
2) It's legally relevant what kind of dose and how it was given. 50 or 100 mcg is a likely defensible dose given for pain relief. 500 mcg over the course of 20 minutes is possibly right there as well. A 500 mcg bolus? Not so much in my professional opinion. That's not a dose that might cause apnea, that's a dose that couldn't possibly do anything except cause apnea immediately. I mean this wasn't some chronic pain patient that had years of narcotic tolerance built up. They were an opioid naive kid that would've only had any narcotic as part of the ventilator sedation for a non painful injury they sustained a few days prior.

 

[sigrhoillusion]

1) I agree with making a kid that is dying comfortable. End of story.
2) It's legally relevant what kind of dose and how it was given. 50 or 100 mcg is a likely defensible dose given for pain relief. 500 mcg over the course of 20 minutes is possibly right there as well. A 500 mcg bolus? Not so much in my professional opinion. That's not a dose that might cause apnea, that's a dose that couldn't possibly do anything except cause apnea immediately. I mean this wasn't some chronic pain patient that had years of narcotic tolerance built up. They were an opioid naive kid that would've only had any narcotic as part of the ventilator sedation for a non painful injury they sustained a few days prior.

That's the problem with the law, it's to black and white. You have in this situation a kid that is going to die regardless. How much was the kid "living" is the other question. Whether it's in 5 minutes or 5 days the kid is going to die without the breathing tube. Technically pulling the tube is the initial event that hastened his death. Seems obvious that the fentanyl dose was used to hasten apnea and death from "Who knows when" to "sooner rather than later". The big question is what was the harm? Did the family consent to care withdrawal? Was the kid harmed in any way? Was the family harmed in any way? Did they suffer with his speedy death? Or would they have preferred him to writhe around and gasp for minutes or hours? Were they planning on re-intubating the kid if it was taking too long...?

This is such a waste of time and resources. Just like keeping this kid intubated and in the PICU forever would have probably been a waste of time and resources. People talk about "they are here to protect patients from the mean and greedy doctors" but what greed are we talking about? Can't make money off a dead patient. Obviously the transplant surgeons are going to "Make money" off of this incident but it's to try and prevent death in another patient who needs organs. I feel like once the decision by the family is made to terminate care, then you do what's right for everyone and you move on. Why are they dragging this case out?

 

[WheezyBaby]

I have seen a few of those kids go on to "live" after withdrawal of support. Not the best outcome

 

[fakin' the funk]

You can't kill a dead person.

This being a DCD, it's not a "dead person," it's a patient.

 

[fakin' the funk]

It is also troublesome that the transplant team was in the hospital waiting to harvest the organs. Were they prepared to wait hours or maybe even a day or 2 if the boy's heart didn't stop right away?

Do you literally understand zero about DCD?

 

[fakin' the funk]

It's not clear when this 500mcg fentanyl was given. Or even where you guys are getting this figure.

The criminality of such an act seems like it would hinge on "intent" -- i.e., the intent to hasten death so as to provide better organ preservation. This seems like it would be very difficult to prove, especially since the anesthesiologist documented "comfort measures" etc. The principle of double effect would apply here.

500mcg is a large or huge dose for a 47# kid -- but this patient by definition has a disordered CNS and these patients can show massive resistance to opioids during the huge sympathetic discharges before and at the time of circulatory/respiratory arrest.

Arguing that the death was due to "fentanyl toxicity" is like arguing that the death of a demented patient with pneumonia is due to "morphine and scopolamine toxicity."

 

[fakin' the funk]

Yeah, let's take a perfectly good set of organs and deliberately extend ischemic time by waiting until cardiac death, for fuzzy reasons. If this was my child, I'd be upset that his final gift of life to others was being compromised in this way.

You're advocating for procuring organs from living patients? Under which circumstances?

 

[dpmd]

You're advocating for procuring organs from living patients? Under which circumstances?

I would advocate for allowing families who have decided on terminal extubation the option of living donation rather than DCD. But I recognize that efforts to legalize that could backfire and worsen donation rates (plus I recognize that not everyone would agree with me that it should be allowed since it would be directly killing a living person)

 

[nimbus]

Do you literally understand zero about DCD?

That's very helpful.

I understand that these not yet dead patients are expected to die quickly after terminal extubation. But what is the contingency when they don't die quickly? Do they move the process along? Or wait?? My own group has a prohibition against participating in the donor end of DCD because the answers to these questions and the ethics of DCD are unclear. What am I missing?

Just because DCD has become an accepted practice doesn't mean we can't continue to examine the ethics and reality of how it is practiced. I don't think ethically there's much of a difference between this and using still living donors as suggested in the post above.

 

[Mman]

It's not clear when this 500mcg fentanyl was given. Or even where you guys are getting this figure.

From the article linked in the original post...

"Bertone's suit and coroner's records state that the administered dose was 500 micrograms."

 

[dhb]

This being a DCD, it's not a "dead person," it's a patient.

Why is organ harvesting being planed if the person is not dead?

 

[IlDestriero]

The family was electing to remove support and move to comfort care only. I do a fair amount of cases on kids that have static encephalopathy, completely non fictional, etc. I think it's a huge waste of time, money, and resources. They should have considered that option years ago. Think about all the trach and PEG stroke patients getting maximal support in full care facilities because their family/kids feel guilty about any number of things.


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Il Destriero

 

[WheezyBaby]

The family was electing to remove support and move to comfort care only. I do a fair amount of cases on kids that have static encephalopathy, completely non fictional, etc. I think it's a huge waste of time, money, and resources. They should have considered that option years ago. Think about all the trach and PEG stroke patients getting maximal support in full care facilities because their family/kids feel guilty about any number of things.


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Il Destriero

These kids are heartbreaking. I feel a lot of the difficulty for parents and caregivers of these patients have withdrawing care / recommending withdrawal of care is the neurologic insults occur during infancy, and adorable babies with static encephalopathy still basically look like... Adorable babies. And there's almost always some measure of doubt with regard to prognosis given the neuroplasticity in infants. Then over time the trach, ventilator, peg, tpn, dysautonomia, intractable epilepsy, etc get normalized and withdrawal of that support becomes untenable to parents until there's some deterioration that ultimately compromises cardiorespiratory function, which may not occur for years. I don't have a good solution beyond early discussion and palliative care involvement