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Moynihan KM, Taylor LS, Siegel B, Nassar N, Lelkes E, Morrison W. "Death as the One Great Certainty": ethical implications of children with irreversible cardiorespiratory failure and dependence on extracorporeal membrane oxygenation. Front Pediatr 2024; 11:1325207. [PMID: 38274466 PMCID: PMC10808631 DOI: 10.3389/fped.2023.1325207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024] Open
Abstract
Introduction Advances in medical technology have led to both clinical and philosophical challenges in defining death. Highly publicized cases have occurred when families or communities challenge a determination of death by the irreversible cessation of neurologic function (brain death). Parallels can be drawn in cases where an irreversible cessation of cardiopulmonary function exists, in which cases patients are supported by extracorporeal cardiopulmonary support, such as extracorporeal membrane oxygenation (ECMO). Analysis Two cases and an ethical analysis are presented which compare and contrast contested neurologic determinations of death and refusal to accept the irreversibility of an imminent death by cardiopulmonary standards. Ambiguities in the Uniform Determination of Death Act are highlighted, as it can be clear, when supported by ECMO, that a patient could have suffered the irreversible cessation of cardiopulmonary function yet still be alive (e.g., responsive and interactive). Parallel challenges with communication with families around the limits of medical technology are discussed. Discussion Cases that lead to conflict around the removal of technology considered not clinically beneficial are likely to increase. Reframing our goals when death is inevitable is important for both families and the medical team. Building relationships and trust between all parties will help families and teams navigate these situations. All parties may require support for moral distress. Suggested approaches are discussed.
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Affiliation(s)
- Katie M. Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
- Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Lisa S. Taylor
- Office of Ethics, Boston Children’s Hospital, Boston, MA, United States
| | - Bryan Siegel
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Natasha Nassar
- Clinical and Population Translational Health, Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Efrat Lelkes
- Department of Pediatrics, MaineGeneral Medical Center, Augusta, ME, United States
| | - Wynne Morrison
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
- Divisions of Critical Care and Palliative Care, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
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Leśniewski K, Antoszewska B, Baczewska B. Attitudes of Polish Doctors towards Brain Death. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13729. [PMID: 36360608 PMCID: PMC9658485 DOI: 10.3390/ijerph192113729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/10/2022] [Accepted: 10/20/2022] [Indexed: 06/16/2023]
Abstract
Brain death has been one of the most controversial issues in the medical and bioethical debate globally for more than fifty years. There is no unanimous acceptance of the understanding of brain death, and a single set of neurological criteria for the determination of human death that is accepted worldwide has yet to be established. Physicians from different specialisations understand brain death differently. Therefore, research is needed to understand and typologically classify their points of views as regards brain death. In Poland, this research is particularly important, as the views of anaesthesiologists, neurologists and transplantologists, who fully accept and support brain death as being synonymous with biological human death, have dominated the scholarly debate on this issue. This study presents the opinions of Polish physicians with various medical specialisations in relation to brain death. Free-form interviews with 28 doctors were conducted. Participants expressed their personal views on brain death, while exhibiting at the same time various emotions. We discuss our findings in relation to the existing framework of knowledge and debate concerning brain death and the Polish legal regulation in force when the interviews were carried out. Although participants had different beliefs with regard to brain death, the research team managed to classify their statements and opinions into five attitudes, taking into account what for them were the most important, namely: the escapist-protective attitude, the scientistic-medical attitude, the accepting-critical attitude, the ignorant-agnostic attitude, and the ambiguous attitude.
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Affiliation(s)
- Krzysztof Leśniewski
- Department of Orthodox Theology, Faculty of Theology, The John Paul II Catholic University of Lublin, Al. Racławickie 14, 20-950 Lublin, Poland
| | - Beata Antoszewska
- Department of Special Needs Pedagogy and Resocialisation, Faculty of Social Sciences, The University of Warmia and Mazury in Olsztyn, Żołnierska 14, 10-561 Olsztyn, Poland
| | - Bożena Baczewska
- Department of Internal Medicine and Internal Medicine in Nursing, Faculty of Health Sciences, Medical University of Lublin, Chodźki 7, 20-093 Lublin, Poland
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Salazar L, Arora L, Botia M, Niño MA, Figueredo A, Alvarado J, Serrano N, Riaño C, Pizarro C. Somatic Support with Veno-venous ECMO in a Pregnant Woman with Brain Death: A Case Report. ASAIO J 2022; 68:e16-e18. [PMID: 33709988 DOI: 10.1097/mat.0000000000001411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Supporting homeostasis in a pregnant woman with brain death to achieve fetal viability is called somatic support. We present a case of young pregnant woman at 21 weeks' gestation who developed acute respiratory distress syndrome secondary to influenza A H2N3 infection requiring veno-venous extracorporeal membrane oxygenation (VV ECMO) support for refractory hypoxemia. The clinical course was complicated by intracranial hemorrhage and subsequent brain death. After multidisciplinary team discussion with her family, consensus was reached to continue somatic support with VV ECMO to enable fetal development to attain extrauterine viability. The challenging clinical, ethical, and legal concerns are discussed.
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Affiliation(s)
- Leonardo Salazar
- From the Department of Intensive Care, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Lovkesh Arora
- Department of Anesthesia & Critical Care, University of Iowa Hospitals & Clinics, Carver College of Medicine, Iowa City, IA
| | - Maria Botia
- From the Department of Intensive Care, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Maria Azucena Niño
- Department of Pediatrics, Universidad Industrial de Santander, Bucaramanga, Colombia
| | - Antonio Figueredo
- Department of Cardiac Surgery, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Jorge Alvarado
- Department of Pediatrics, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Norma Serrano
- Department of Medical Research, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Carlos Riaño
- Department of Obstetrics and Gynecology, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Camilo Pizarro
- From the Department of Intensive Care, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
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Malaiyandi D, James E, Peglar L, Karim N, Henkel N, Guilliams K. Neurocritical Care of the Pregnant Patient. Curr Treat Options Neurol 2021; 23:22. [PMID: 34177249 PMCID: PMC8214980 DOI: 10.1007/s11940-021-00676-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 02/07/2023]
Abstract
Purpose of review To summarize recent changes in management and emerging therapies for pregnant neurocritical care patients. Recent findings Diagnostic and treatment options for managing neurologic emergencies in pregnant patients have expanded with both greater understanding of the effects of imaging modalities and medications on pregnancy and application of standard treatments for non-pregnant patients to pregnant populations. Specifically, this includes cerebrovascular diseases (pregnancy-associated ischemic stroke, pregnancy-associated intracerebral hemorrhage, cerebral venous sinus thrombosis), post-maternal cardiac arrest care, seizures and status epilepticus, myasthenia gravis, and fetal somatic support in maternal death by neurologic criteria. Summary With the exception of direct abdominal computed tomography (CT), most imaging studies are reasonably safe in pregnancy. When emergent imaging is needed to prevent maternal morbidity or mortality, any CT sequence with or without contrast is appropriate to pursue. Though new safety data on antiplatelets, antihypertensives, thrombolytics, and antiepileptic drugs have increased options for disease management in pregnancy, unfractionated and low-molecular weight heparin remain the safest options for anticoagulation. Early studies on hypothermia, ketamine, and immunomodulating therapies in pregnancy are promising. In myasthenia gravis, new data on adjunct devices may allow more patients to undergo safe vaginal delivery, avoiding cesarean section and the associated risk of crisis. When difficult decisions regarding preterm delivery arise, recent outcome studies can help inform discussion. Lastly, when the feared complication of maternal death by neurologic criteria occurs, fetal somatic support may help to save at least one life.
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Affiliation(s)
- Deepa Malaiyandi
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA.,University of Toledo/ProMedica Neurosciences Center, 2130 W Central Ave, Ste. 201, Toledo, OH USA.,ProMedica Toledo Hospital, Toledo, OH USA
| | - Elysia James
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA.,ProMedica Toledo Hospital, Toledo, OH USA
| | - Lindsay Peglar
- Department of Neurology, Washington University, St. Louis, MO USA
| | - Nurose Karim
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA
| | - Nicholas Henkel
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA
| | - Kristin Guilliams
- Department of Neurology, Washington University, St. Louis, MO USA.,Department of Pediatrics, Washington University, St. Louis, MO USA
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Lott DT, Yeshi T, Norchung N, Dolma S, Tsering N, Jinpa N, Woser T, Dorjee K, Desel T, Fitch D, Finley AJ, Goldman R, Bernal AMO, Ragazzi R, Aroor K, Koger J, Francis A, Perlman DM, Wielgosz J, Bachhuber DRW, Tamdin T, Sadutshang TD, Dunne JD, Lutz A, Davidson RJ. No Detectable Electroencephalographic Activity After Clinical Declaration of Death Among Tibetan Buddhist Meditators in Apparent Tukdam, a Putative Postmortem Meditation State. Front Psychol 2021; 11:599190. [PMID: 33584435 PMCID: PMC7876463 DOI: 10.3389/fpsyg.2020.599190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/14/2020] [Indexed: 11/13/2022] Open
Abstract
Recent EEG studies on the early postmortem interval that suggest the persistence of electrophysiological coherence and connectivity in the brain of animals and humans reinforce the need for further investigation of the relationship between the brain's activity and the dying process. Neuroscience is now in a position to empirically evaluate the extended process of dying and, more specifically, to investigate the possibility of brain activity following the cessation of cardiac and respiratory function. Under the direction of the Center for Healthy Minds at the University of Wisconsin-Madison, research was conducted in India on a postmortem meditative state cultivated by some Tibetan Buddhist practitioners in which decomposition is putatively delayed. For all healthy baseline (HB) and postmortem (PM) subjects presented here, we collected resting state electroencephalographic data, mismatch negativity (MMN), and auditory brainstem response (ABR). In this study, we present HB data to demonstrate the feasibility of a sparse electrode EEG configuration to capture well-defined ERP waveforms from living subjects under very challenging field conditions. While living subjects displayed well-defined MMN and ABR responses, no recognizable EEG waveforms were discernable in any of the tukdam cases.
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Affiliation(s)
- Dylan T. Lott
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - Tenzin Yeshi
- Men-Tsee-Khang/TMAI, Upmuhal, Dharamshala, Himachal Pradesh, India
| | - N. Norchung
- Men-Tsee-Khang/TMAI, Upmuhal, Dharamshala, Himachal Pradesh, India
| | - Sonam Dolma
- Men-Tsee-Khang/TMAI, Upmuhal, Dharamshala, Himachal Pradesh, India
| | - Nyima Tsering
- Men-Tsee-Khang/TMAI, Upmuhal, Dharamshala, Himachal Pradesh, India
| | - Ngawang Jinpa
- Men-Tsee-Khang/TMAI, Upmuhal, Dharamshala, Himachal Pradesh, India
| | - Tenzin Woser
- Men-Tsee-Khang/TMAI, Upmuhal, Dharamshala, Himachal Pradesh, India
| | - Kunsang Dorjee
- Men-Tsee-Khang/TMAI, Upmuhal, Dharamshala, Himachal Pradesh, India
| | - Tenzin Desel
- Men-Tsee-Khang/TMAI, Upmuhal, Dharamshala, Himachal Pradesh, India
| | - Dan Fitch
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - Anna J. Finley
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - Robin Goldman
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | | | - Rachele Ragazzi
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - Karthik Aroor
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - John Koger
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - Andy Francis
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - David M. Perlman
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - Joseph Wielgosz
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - David R. W. Bachhuber
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - Tsewang Tamdin
- Men-Tsee-Khang/TMAI, Upmuhal, Dharamshala, Himachal Pradesh, India
| | | | - John D. Dunne
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
- Department of East Asian Languages and Literature, University of Wisconsin-Madison, Madison, WI, United States
| | - Antoine Lutz
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
- Lyon Neuroscience Research Centre, INSERM U1028, CNRS UMR5292, Lyon 1 University, Lyon, France
| | - Richard J. Davidson
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
- Departments of Psychology and Psychiatry, University of Wisconsin-Madison, Madison, WI, United States
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Katsuragi S, Tanaka H, Hasegawa J, Kurasaki A, Nakamura M, Kanayama N, Nakata M, Hayata E, Murakoshi T, Yoshimatsu J, Osato K, Tanaka K, Oda T, Sekizawa A, Shimaoka T, Ishiwata I, Takahashi J, Ikeda T. Perinatal outcome in case of maternal death for cerebrovascular acute disorders: a nationwide study in Japan. J Matern Fetal Neonatal Med 2020; 35:2429-2434. [PMID: 32674694 DOI: 10.1080/14767058.2020.1786511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The goal of this study is to find clues to improve perinatal outcomes in the case of cerebrovascular acute disorders during pregnancy. STUDY DESIGN We analyzed 35 cases of cerebrovascular diseases related to maternal deaths in Japan those that occurred during pregnancy and reported to the Committee of the Ministry of Health, Labor, and Welfare from 2010 to 2018. RESULTS Cerebrovascular acute disorders occurred at 34.6 ± 6.6 gestational weeks. There were seven intrauterine fetal deaths (IUFD), and eight cases showed neonatal asphyxia with umbilical arterial pH between 6.7 and 7.0 (asphyxia cases, n = 15). In two of eight newborns, brain hypothermia therapy was given, and all survived without neurological sequelae. Maternal dyspnea was significantly related to severe prolonged decelerations of the fetus (p < .05), and asphyxia cases (p < .005). Median time from maternal onset to delivery (OD time) was significantly longer in asphyxia cases than in the non-asphyxia cases (84 vs 29 min, p < .05). OD time over 30 min was significantly related to the antepartum occurrence, cervical dilatation <5 cm (p < .05), onset outside of the hospital (p < .001), and maternal transfer before delivery (p < .001). CONCLUSION More than 40% of cases experienced fetal asphyxia, and 20% ended in IUFD in maternal deaths related to cerebrovascular acute disorders. Maternal respiratory support and rapid delivery would be the keys to improve perinatal outcomes in case of cerebrovascular acute disorders during pregnancy.
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Affiliation(s)
- Shinji Katsuragi
- Department of Obstetrics and Gynecology, Sakakibara Heart Institute, Tokyo, Japan
| | - Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Junichi Hasegawa
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Akiko Kurasaki
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Masamitsu Nakamura
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Naohiro Kanayama
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University, Tokyo, Japan
| | - Eijiro Hayata
- Department of Obstetrics and Gynecology, Toho University, Tokyo, Japan
| | - Takeshi Murakoshi
- Division of Perinatology, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Jun Yoshimatsu
- Department of Perinatology and Gynecology, National Cerebral Cardiovascular Center, Osaka, Japan
| | - Kazuhiro Osato
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Kayo Tanaka
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Tomoaki Oda
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Akihiko Sekizawa
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Takako Shimaoka
- Department of Obstetrics and Gynecology, Sagamihara National Hospital, Kanagawa, Japan
| | - Isamu Ishiwata
- Ishiwata Obstetrics and Gynecology Hospital, Ibaraki, Japan
| | - Jun Takahashi
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
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Parent B, Gelb B, Latham S, Lewis A, Kimberly LL, Caplan AL. The ethics of testing and research of manufactured organs on brain-dead/recently deceased subjects. JOURNAL OF MEDICAL ETHICS 2020; 46:199-204. [PMID: 31563872 DOI: 10.1136/medethics-2019-105674] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/06/2019] [Accepted: 09/17/2019] [Indexed: 06/10/2023]
Abstract
Over 115 000 people are waiting for life-saving organ transplants, of whom a small fraction will receive transplants and many others will die while waiting. Existing efforts to expand the number of available organs, including increasing the number of registered donors and procuring organs in uncontrolled environments, are crucial but unlikely to address the shortage in the near future and will not improve donor/recipient compatibility or organ quality. If successful, organ bioengineering can solve the shortage and improve functional outcomes. Studying manufactured organs in animal models has produced valuable data, but is not sufficient to understand viability in humans. Before risking manufactured organ experimentation in living humans, study of bioengineered organs in recently deceased humans would facilitate evaluation of the function of engineered tissues and the complex interactions between the host and the transplanted tissue. Although such studies do not pose risk to human subjects, they pose unique ethical challenges concerning the previous wishes of the deceased, rights of surviving family members, effective operation and fair distribution of medical services, and public transparency. This article investigates the ethical, legal and social considerations in performing engineered organ research on the recently deceased.
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Affiliation(s)
- Brendan Parent
- Division of Medical Ethics, New York University School of Medicine, New York City, New York, USA
| | - Bruce Gelb
- Transplant Institute, New York University School of Medicine, New York City, New York, USA
| | - Stephen Latham
- Interdisciplinary Center for Bioethics, Yale University, New Haven, Connecticut, USA
| | - Ariane Lewis
- Division of Medical Ethics, New York University School of Medicine, New York City, New York, USA
| | - Laura L Kimberly
- Division of Medical Ethics, New York University School of Medicine, New York City, New York, USA
- Hansjörg Wyss Department of Plastic Surgery, NYU School of Medicine, New York City, New York, USA
| | - Arthur L Caplan
- Division of Medical Ethics, New York University School of Medicine, New York City, New York, USA
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Barr JJ. When Death Is Not the End: Continuing Somatic Care during Postmortem Pregnancy. LINACRE QUARTERLY 2019; 86:275-282. [PMID: 32431420 DOI: 10.1177/0024363919874955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Brain death during the second trimester of pregnancy creates a unique situation in which the mother is deceased, but life of the developing fetus still depends on somatic functions in the mother's body. In this article, I show that when a pregnant woman becomes brain dead during the second trimester, it is morally licit, though not morally obligatory, to continue somatic support while the fetus develops. The interventions on the mother's body are justified for the life of the fetus, especially in light of the unique mother-child dyad and the responsibilities the mother has for her child. However, this therapy is not frequently employed, and its success is unpredictable. In many cases, the expense and uncertain nature of the therapy may make it disproportionate. In such cases, somatic support of the mother's body may be discontinued. Summary When brain death is diagnosed during pregnancy, it is a challenging decision whether to use artificial ventilation and other heroic measures to support the developing fetus. This paper demonstrates that while these interventions are acceptable, they are not obligatory.
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Affiliation(s)
- Jennifer J Barr
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
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Čartolovni A, Habek D. Guidelines for the management of the social and ethical challenges in brain death during pregnancy. Int J Gynaecol Obstet 2019; 146:149-156. [DOI: 10.1002/ijgo.12871] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 11/20/2018] [Accepted: 05/23/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Anto Čartolovni
- Catholic University of Croatia Zagreb Croatia
- Faculty of Health SciencesUniversity of Hull Hull UK
| | - Dubravko Habek
- Catholic University of Croatia Zagreb Croatia
- Department of Obstetrics and GynecologyClinical Hospital “Sveti Duh” Zagreb Croatia
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