Thursday, February 13, 2014

Brain-dead patient taken off life-support

Excerpted from “Brain-dead Texas woman taken off ventilator,” CNN Health. January 27, 2014 — A wrenching court fight—about who is alive, who is dead and how the presence of a fetus changes the equation—came to an end Sunday, January 26 when a brain-dead, pregnant Texas woman was taken off a ventilator. The devices that had kept Marlise Munoz's heart and lungs working for two months were switched off about 11:30 a.m. Sunday, her family's attorneys announced.

Munoz was 14 weeks pregnant with the couple's second child when her husband found her unconscious on their kitchen floor November 26. Though doctors had pronounced her brain dead and her family had said she did not want to have machines keep her body alive, officials at John Peter Smith Hospital in Fort Worth had said state law required them to maintain life-sustaining treatment for a pregnant patient.

Sunday's announcement came two days after a judge in Fort Worth ordered the hospital to remove any artificial means of life support from Munoz by 5 p.m. Monday. The hospital acknowledged Friday that Munoz, 33, had been brain dead since November 28 and that the fetus she carried was not viable. Her husband, Erick Munoz, had argued that sustaining her body artificially amounted to "the cruel and obscene mutilation of a deceased body" against her wishes and those of her family. Marlise Munoz didn't leave any written directives regarding end-of-life care, but her husband and other family members said she had told them she didn't want machines to keep her blood pumping.


Since there are a variety of opinions on this difficult ethical issue, we have included 2 commentaries.

Dr. David StevensCMDA CEO David Stevens, MD, MA (Ethics):"While the medical technology being applied to Mrs. Munoz’s body might be considered “organ support” for her, it was “life support” for her unborn child. At the time of her death the baby was a few days from reaching 24-weeks gestation when survival rates approach 50%. Every day of continued life support improved the odds of the baby’s survival.

"A few days ago, on February 9th, Robyn Benson had a premature baby boy. Just after Christmas she suffered a cerebral hemorrhage resulting in her own brain death. She was maintained on life support until her baby was delivered. The ventilator was disconnected the day after her child was born. According to reports, the baby is doing well in the NICU.

"I don’t have access to the medical records in either of these cases, but a CNN article on the Benson case makes an inadequate effort to ethically differentiate between her baby’s situation and Mrs. Munoz’s. First, they let you know that one child was wanted by its father but the other was not. The worth of a human being does not depend on whether it is wanted or not. Secondly, the Munoz lawyer’s reported that an incomplete ultrasound had shown the baby had hydrocephalus and possibly other malformations. We should recognize that disposing of the disabled is unethical and simply eugenics. Who decides when a person is disabled enough for elimination?

"CMDA does not have an official ethics statement dealing with this complex issue. Maybe we should. You can contribute to the discussion of what it should say by clicking on the comment link below."

Dr. Robert OrrClinical Ethicist and CMDA Trustee Robert D. Orr, MD, CM:“Marlise Munoz was dead, but her 14-week old fetus was alive. If Mom’s organs could be successfully perfused for another 12-14 weeks, her unborn baby could survive and be delivered by C-section. It is possible, though clinically very challenging. But should it be done?

“Marlise’s family did not want artificial support continued, and they were convinced she would not want it. The hospital believed Texas law prohibited removing life support from a pregnant woman. The legal issue was straightforward: Marlise was dead, therefore the support was not ‘life support’ for her, but ‘organ support’ for the benefit of the fetus. Continued support was legally optional.

“But what about the ethical dilemma? Who should decide? What factors should be considered? Some believe it is morally obligatory to do everything possible to prevent fetal death. Others believe that ‘doing everything’ is not always obligatory, making this comparable to high risk, high burden prenatal fetal surgery, i.e., optional, decided by her family based on their understanding of her wishes and values.

“Not all believers will agree. We will agree that we are stewards of our lives, our bodies and our resources. And we will likely agree it is immoral to intentionally end prenatal life for trivial reasons. The intention in continuation was to possibly benefit a second life. The intention in stopping was to discontinue ineffective and unwanted treatment. I personally believe continued support in this case was discretionary. And I believe we should not harshly judge the Munoz family’s decision.”


CMDA Ethics Statement on Vegetative State
Resources on End of Life Care


  1. I would love to hear some guidance and thoughts from CMDA on the ethics of COST in medicine. this is a very difficult ethical issue and I can see vaild arguements on both sides. However, one point that is not mentioned is cost. While I strongly believe in saving and protecting human lives, we are at a new era in techology where perhaps we can do more then we can afford. Having worked in NICUs I know the cost of saving some extremely young lives, that may or may not work. Working with geriatric patients I know the cost of "do everything" end of life care. It is hard for me to wrap my head around valuing life, and also understanding that we do NOT have unlimited resources in our world and that cost DOES have to be taken into consideration in what we do in medicine.
    I was fascinated by CMDAs lecture on perinatal hospice. I think this is a good idea and wonder if anyone is working on hospice care for NICU babies. There has to be a balance where we can still be compassionately caring for other human beings without overstepping the bounds of what we can afford.

  2. I agree with Megan. I had the same thought. Who was paying for her to be on a ventilator for 2 months? If individuals had to pay for the high cost technological means of playing God in sustaining life, more people would opt for Hospice. If this woman was in a natural environment in Africa, she and the child would have died the same day she was found unconscious. Just because we can sustain a body indefinitely doesn't mean we should, even for the sake of an unborn child. Chances are the child would have been very disabled. So who will pay for the lifelong care of a child that would not have lived in most developing countries. Would they consider a DNR for the child at birth? Not having had any children, and having worked for Hospice, I always believed that if I did have a child that was at risk, I would request that extraordinary measures not be taken at birth and the child allowed to die a natural death in my arms after birth. Would the government prevent me from doing this while at the same time, they allow millions to be aborted. Most likely, just like they prevent parents from refusing care in terminal illness for their children.

    I know there are many instances of families who have wonderful children rescued by medical science but is it natural and would they do it if they had to pay the costs directly? We do not have unlimited funds to pay for all these extraordinary death prolonging measures.

  3. Most Christian medical directive statements have a section specifically dealing with a pregnant woman. It begins with the statement something on the order of, "I believe that in a pregnancy you have two patients..." as a statement of belief that life begins at conception. The directive of Philippians 2:3-4 compels us to be more mindful of others. For those two reasons it is difficult to conclude not to continue treatment. If the patient were not pregnant I would side with Bob Orr. Because of the pregnancy, and because it does not appear that continued treatment was not unduly burdensome on Ms. Munoz, I side with Dave Stevens on this one.

  4. I think Dr. Orr misses the point of the Texas law. Like laws prohibiting capital punishment for pregnant women, it was clearly for the benefit of the baby (whether embryo or fetus) and not for the mother, since as soon as she ceased being pregnant, the law would no longer apply. The fact that Marlise Munoz was dead and her fetus on “organ support” is the scenario the law was enacted to address.
    It is particularly disturbing that her baby was provided support and then it was withdrawn just when he reached the stage of development where he would have had a chance of survival, although small, if he had been delivered, and had life support been continued for another week or two (I don’t know if he reached 23 weeks by the day he died or not), his chance of survival would have increased from 10% to over 25% at 23 weeks to over 50% at 24 weeks. Is that so much to ask? It seems like there was a rush to remove life support before the baby reached the magic “viability” mark. And why is “viability” defined as a 50% chance of survival? Is not the life of a baby who has only a 25% or 10% survival potential of the same value? Do we limit chemotherapy to people with cancer who have a minimal 50% expectation of recovery?
    I appreciate Dr. Lykke's comments on costs and would argue that cost, as well as beneficence, would be reasons to continue life support past 22, past 24, and up to 30 weeks or so if possible.

  5. I have been thinking about this a lot, and I think there is a Christian principal that deals with cost. It is called stewardship. I think this will be a future challenge for physicians- how do we be good stewards of valuing life, yet not over-running our bounds of what we can afford. I don't have great answers. I do like this quote from Oscar Wilde though "I am dying beyond my means."

  6. Great dialogue, David and Ron. Managing to address the issue so profoundly well, without demeaning the discussion around costs. I do think that a spouse's decision should be considered paramount, in recognition of the biblical unity. I also would introduce the concept of a child suffering for a parental mistake as a biblical concept that we haven't recognized in our Western culture. I agree with Dr Lyke's stewardship comments. It may be that we should have a public committee addressing such concepts like this en mass that doctors will have to live with. The funding decisions should be made by someone who is not treating the patient, but managing the resources as a fiduciary of the community resources. For this reason, public or non-profit health care organizations are much more apt to make better decisions than private organizations, whose profits may be protected, rather than minimized for the good of the patients.

  7. One of the considerations in this case, ethically and medically, is what happened to the fetus when the mother suffered the protracted hypoxemic event that resulted in her brain death. While a fetus is acclimated to a lower resting p02 than an air breathing person, they are not suited to sustain normal life and brain survival with the profound hypoxemia that must have occurred when the mother was so tragically affected. I strongly suspect that the fetus's brain was similarly impacted (like the mother's) and that the fetus was essentially brain dead. While we as neonatologists might have had the ability to sustain the physical life of the fetus some time within the 24+ week gestational age, it is far more likely than not that the fetus would have had no meaningful brain function ever. I cannot strongly oppose the decision that was made. I have been involved in cases where the mother had a massive stroke and was sustained for the sake of the fetus, resulting in a healthy little girl (after some intensive care). But the Munoz case is different and I think the difference justifies the decisions that were made.

  8. I believe that there are many of us who believe that governments/juries/courts/judges don’t always have the wisdom of Solomon, even in Texas – but there is a way to walk the fine line between obligation and autonomy, which is to have Texas (or other states) decide in these young life dilemmas to give adoption a chance. In all cases, trying to get the best understanding of the situation is the first step, and if the family is firm in their decision against life, then there should be a quick release of the particulars to the adoption agencies, and in the email era you should know, I suppose, in 24 hours whether there is one or more couples willing to take over the responsibilities and adopt. Recall the Down’s syndrome case with pyloric stenosis, where a low-risk “mandatory” surgery was refused – there were couples willing to adopt. And if there are cases of a brain dead mother due to intrathecal vincristine or cerebral hemorrhage, there may be couples willing to adopt. In this recent case in Texas, where (if I am reading it correctly, the mother was brain dead due to hypoxia), there would be some very real questions from the clinical presentation (and perhaps by ultrasound) about infant viability – even if the mother were kept on life support. Would anyone be willing to adopt? I don’t know. But I don’t think that it is wise to try to solve all of these by laws and courts.


    Medical Oncology