Brain-dead mother kept alive for weeks to deliver 25 week twins

[Socrates25]

http://www.cbsnews.com/8301-504763_...m-gives-birth-to-twins-while-on-life-support/

Thoughts?

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[michigangirl]

I don't have any ethical concerns with sustaining this woman through brain death to deliver these children. I am sure that, unlike what the article suggests, this woman did not experience any pain or suffering during the month she was on a ventilator. Brain death is just that-- NO PERFUSION to the brain. No pain, no sensation.
BUT there are two very important concerns.
a. What are the intricacies of fetal development in a brain-dead host? There is a reason we proceed to organ donation with brain death as soon as logistically possible-- no matter what, the milieu of the body is not ideal for growth, and there are of course markers of inflammation that are increased as well as the actual biologic manifestations of brain death itself.

b. The amount of resources that were utilized to sustain this woman for one month are no doubt astronomical, not to mention the resources for these premature infants. I am curious to find out who footed the bill for her care during that month.

 

[Perrotfish]

I would bet that reactions to this article split pretty much along pro-life/pro-choice fault lines. If you're pro-life, and you firmly believe a 21 week old fetus is a human life (just like a baby) then this is a beautiful story about medical science pulling out all the stops to give two children the best possible outcome from even the worst possible situation. If you're pro-choice and you believe that a 21 week old fetus is a potential human life (like a sperm or an egg) then this is a macabe story about medical science spending millions of dollars in ICU care and subsequently NICU care to create an a pair of orphans, orphans who are statistically likely to have serious deficits because of their premature birth.

I'm pro-life. It was a beautiul story.

Even then, though, I'm not clear why they perormed a C-section at 25 weeks. If she's been kept alive by artifical means for a month anyway, why wouldn't you wait another few months and give birth to relatively mature babies? It seems like it would have been both safer and cheaper than NICU care. I hope it didn't come down to the fact that the government would foot the bill for NICU care, but not for care of the brain dead.

 

[Socrates25]

Even then, though, I'm not clear why they perormed a C-section at 25 weeks. If she's been kept alive by artifical means for a month anyway, why wouldn't you wait another few months and give birth to relatively mature babies? It seems like it would have been both safer and cheaper than NICU care. I hope it didn't come down to the fact that the government would foot the bill for NICU care, but not for care of the brain dead.

She developed uncontrollable hypertension after a few weeks so the docs had no option but to go ahead and deliver the babies.

 

[Perrotfish]

She developed uncontrollable hypertension after a few weeks so the docs had no option but to go ahead and deliver the babies.

Ah, missed that. Thanks

 

[oldbearprofessor]

If you're pro-choice and you believe that a 21 week old fetus is a potential human life (like a sperm or an egg) then this is a macabe story about medical science spending millions of dollars in ICU care and subsequently NICU care to create an a pair of orphans, orphans who are statistically likely to have serious deficits because of their premature birth.

I'm as pro-choice as one can be and have no problems at all with what was done. That is, I neither support nor oppose it. Any decision made by the family and caregiving team in this type of situation would be something I could and would support. The babies are not orphans, they have a living father. The risk of "serious" (severe) long-term deficits, as defined typically as cerebral palsy, major visual impairment or severe neuro-cognitive problems is about 20-25%, not "statistically likely". The reference provided has typical data, more recent data are similar although the long-term trends are a bit more encouraging.

 

[Perrotfish]

I'm as pro-choice as one can be and have no problems at all with what was done. That is, I neither support nor oppose it. Any decision made by the family and caregiving team in this type of situation would be something I could and would support. The babies are not orphans, they have a living father. The risk of "serious" long-term deficits, as defined typically as cerebral palsy, major visual impairment or severe neuro-cognitive problems is about 20-25%, not "statistically likely".

If you are pro-choice then, even assuming the children are healthy, this story is about spending well over a million dollars of public funding on what is equivalent to a fertility treatment. If these children weren't really human beings yet at 21 weeks, is really reasonable for a family to make a choice to spend that much of somebody else's money to make the babies?

I'll be honest, I've always thought of the NICU in general as a pro-life enviornemnt (or at least pro-life after the first trimester), for basically that same reasons. Abortion must necessarily be predicated on the idea that the fetus you're terminating is not a human being and does not have a right to live. Otherwise the physician is a self acknowledged child killer. At the same time it seems like the NICU is predicated on the idea that such a fetus IS a human being and does have an intrisic right to life. Otherwise the NICU is just a giant sinkhole for public treasure, spending millions to create children, often with poor support systms and often with severe deficits (20-25% is still a lot), when our society lacks the resources to care for the healthy children we already have. Its morally equivalent to the fertility speciality who tansplanted those eight fetuses into octamom, despite knowing she had no means to care for the children she already had.

I'm just curious, if you're pro-choice, what inspires you to take care of infants who don't have loving parents that want to take them home? I suppose I can see wanting to take care of twins like this for the father, for him they're all he has left of his wife, but what about when all you have is a drug addicted mother who doesn't want the child? Do you consider the 25 weekers under your care people or potential people? Do you think there is an ethical difference between a child in the womb and child of equivalent age outside the womb?

Feel free to ignore me if this is coming off as more offensive than curious, I've just always thought NICU was interesting from an ethical perspective. It's kind of a wierd match with pediatrics: I feel like the rest of the field has the best ethical clarity in medicine (you always do everything, no matter what) and then 100% of the ethical uncertainty got dumped on NICU.

 

[oldbearprofessor]

Sorry, but debating abortion related issues on SDN is much like debating affirmative action. No good to that discussion ever can occur so I don't want to perpetuate a discussion I am not interested in. Just consider what "choice" means. Women should be allowed to choose, not forced into any decision.

There are many many ethical papers and discussions in the literature and the internet about NICU cost:benefit and outcome considerations. These issues exist for many pediatric fields, including PICU and pedi cards. Many years ago I chose not to generally participate in these, here or in the private forum. Others are welcome to that discussion in the public forum.

Regards

OBP

 

[SurfingDoctor]

It's kind of a wierd match with pediatrics: I feel like the rest of the field has the best ethical clarity in medicine (you always do everything, no matter what) and then 100% of the ethical uncertainty got dumped on NICU.

This is certainly not true. For example, a 16 year old who is in a persistent vegetative state has a cardiac arrest. Performing CPR is not ethically clear.

Not related to this story or the discussion, but all fields in pediatrics have ethical issues they encounter. Medicine, in general, is like that.

 

[michigangirl]

This is certainly not true. For example, a 16 year old who is in a persistent vegetative state has a cardiac arrest. Performing CPR is not ethically clear.

Not related to this story or the discussion, but all fields in pediatrics have ethical issues they encounter. Medicine, in general, is like that.

Exactly. Ethical issues abound in all aspects of pediatrics. Surfingdoctor's example is one we could see in the PICU or ER. The geneticists deal with deciding whether offering a trach to a patient with hurler's syndrome is the right thing to do. The oncologists deal with whether intubating the kid with metastases to his lungs and horrible disease is ethical. The peds surgeons and anesthesiologists decide whether not transfusing the 5 year old Jehovah's patient is ethical, the peds cardiologists wrestle with complex with poor prognosis heart disease and recommending palliative surgery...the list goes on....

 

[Socrates25]

IMHO this was a tremendous waste of resources. I might be able to go for it if the woman was at 30 weeks and you just needed to keep her on teh ventilator for 24 hours until the twins could be delivered.....but keeping her on a vent for a whole freakin month to salvage 20 weekers? Thats way too much intervention.

 

[McGillGrad]

IMHO this was a tremendous waste of resources. I might be able to go for it if the woman was at 30 weeks and you just needed to keep her on teh ventilator for 24 hours until the twins could be delivered.....but keeping her on a vent for a whole freakin month to salvage 20 weekers? Thats way too much intervention.

I agree, a total waste of resources. I guess that you could justify the cost as a macabre experiment that adds data to an unexplored area of medicine, but it doesn't help the family involved.

I know that there are happy endings for 25 weekers, but these are twins at 25 weeks. Whole different ball of wax.

My opinion.

 

[oldbearprofessor]

I know that there are happy endings for 25 weekers, but these are twins at 25 weeks. Whole different ball of wax.

My opinion.

The data show a significantly worse outcome for extremely low birth weight twins (and higher order multiples) than singletons. Here is the full text twin study.

However, the relative risk increase was not huge and was smaller than the risk associated with being a male.

I'm not sure I'd call that a "whole different ball of wax", but to each their own interpretation of the data.

 

[McGillGrad]

The data show a significantly worse outcome for extremely low birth weight twins (and higher order multiples) than singletons. Here is the full text twin study.

However, the relative risk increase was not huge and was smaller than the risk associated with being a male.

I'm not sure I'd call that a "whole different ball of wax", but to each their own interpretation of the data.

I understand, and respect, the experience and knowledge that you bring to this topic. On the other claw, after personally spending several months in different NICUs, I have not seen many normal, non-complicated, outcomes for twins under 30 weeks. In fact, I have rotated in services where 25 weeks is the cut off for intervention for singletons.

Just because we can doesn't mean we should.

 

[bjackrian]

The ethics nerd in me has to point out that the title of the thread is misleading. The woman was not "kept alive" as she was brain dead which means she was, well, dead. I grant that we don't have a good word for what to use in situations like this, but a lot of the popular press stories have used similar language that I think is confusing for non-medical people. We already have a hard enough time convincing families that brain death = death, and stories like this (meaning the original news story, not the OP) don't help that problem.

 

[sandnsurf]

Sorry, I don't mean to bump an old thread, but I think I have a relevant question or two to ask:

(1) Is it possible to become a NICU or PICU physician who has an interest in academia as well as ethics and thus to also work as an ethicist? Or is that mainly for PhDs in the arts and humanities?

(2) If it is possible, how practical would that be? Would it take away from clinical time, etc.?

Just curious.

Thanks!

 

[oldbearprofessor]

Sorry, I don't mean to bump an old thread, but I think I have a relevant question or two to ask:

(1) Is it possible to become a NICU or PICU physician who has an interest in academia as well as ethics and thus to also work as an ethicist? Or is that mainly for PhDs in the arts and humanities?

(2) If it is possible, how practical would that be? Would it take away from clinical time, etc.?

Just curious.

Thanks!

yes to 1, it is increasingly common and would be part of your academic responsibilities so would not take away from clinical work any more than research, education or any other form of academic work. Often, neonatologists who have a strong interest/involvement in ethics work closely with non-physician experts in ethical principles.

 

[sandnsurf]

Cool, that makes sense. Thanks, OBP!

 

[Stitch]

Sorry, I don't mean to bump an old thread, but I think I have a relevant question or two to ask:

(1) Is it possible to become a NICU or PICU physician who has an interest in academia as well as ethics and thus to also work as an ethicist? Or is that mainly for PhDs in the arts and humanities?

(2) If it is possible, how practical would that be? Would it take away from clinical time, etc.?

Just curious.

Thanks!

I know a couple of PICU docs who do this. They also got a masters in ethics during their fellowship and coordinate/work with the PhD ethicists who consult in the unit. Ethical issues come up frequently in the ICU, and it's often useful to have their input. One of our ethics/PICU docs where I currently am is also setting up and expanding the palliative care service. This time counts as her research/QI time and gives her a break from the unit.