Brain death diagnosis for second Michigan teen raises questions

Detroit, Mich., Oct 29, 2019 / 17:36 pm

For the second time in a month, a family in Michigan is fighting to keep their teenage son on life support after a hospital has declared the boy brain dead and made plans to remove his life support systems.

Titus Jermaine Cromer Jr., 16, was rushed to Beaumont Hospital in Royal Oak after suffering cardiac arrest, according to local news reports. When he arrived, he could not breathe independently or regulate his own blood pressure. However, after receiving hydration, nutrition, and body temperature regulation, his family's lawyer says he is showing signs of improvement and can now breathe independently and regulate his own blood pressure.

Hospital officials, however, have diagnosed the teen as brain dead, after two doctors determined that he had suffered "irreversible cessation of all functions of the entire brain, including the brain stem."

The hospital made plans to remove his life support systems on Oct. 28, the Detroit Free Press reported.

The family challenged the decision and has asked for additional medical opinions on whether Cromer is actually brain dead.

"As a parent, if there's a million-to-one chance that he's going to get better, I'm going to take it," the family's lawyer said, according to the Detroit Free Press. "And I'm not going to get two opinions. I'm going to get 20. I'm going to fight for my boy until there's absolutely no hope at all. And then I'm going to fight some more."

Oakland County Circuit Judge Hala Jarbou ordered the hospital to continue life support until a Nov. 7 court hearing on the teen's health status.

The Detroit Free Press said the family's lawyer described them as "very much guided by their faith, and as Catholics, they believe that removing life support would be murder."

The case is similar to that of 14-year-old Bobby Reyes, who was rushed to C.S. Mott Children's Hospital in Michigan last month following a severe asthma attack. Repeat tests in the following days indicated that there was no blood flow or electrical activity in the boy's brain.

The hospital declared Reyes brain dead and made plans to remove him from life support. Reyes' family fought the decision but ultimately failed to receive relief from a court, due to a jurisdiction dispute. Reyes was removed from life support on Oct. 15.

The hospital said in a statement, "Continuing medical interventions was inappropriate after Bobby had suffered brain death and violates the professional integrity of Michigan Medicine's clinicians." Michigan law recognizes an individual as dead if they have undergone "irreversible cessation of all function of the entire brain, including the brain stem."

The two Michigan cases have drawn renewed attention to the diagnosis of brain death and sparked concerns over parental rights in cases where family members question a diagnosis.

The National Catholic Bioethics Center (NCBC) maintains that cases of improvement over the course of months or years generally indicate an incorrect diagnosis of brain death in the first place.

"Stories of people continuing on a ventilator for months or years after being declared brain dead typically indicate a failure to apply the tests and criteria for determination of brain death with proper attentiveness and rigor," said Fr. Tad Pacholczyk, director of education for the center, in a 2005 information sheet.

"In other words, somebody is likely to have cut some corners in carrying out the testing and diagnosis."

In Cromer's case, the family believes their teenage son has been misdiagnosed. Their lawyer cited his improvements in independent breathing and blood pressure regulation as "very strong indicia that he has not suffered brain death," according to the Detroit Free Press.

Medical criteria for diagnosing brain death, while controversial in some circles, have been accepted by most Catholic bioethicists, provided that diagnostic tests are carried out thoroughly and carefully.

In an Aug. 29, 2000 address to the international congress of the transplantation society, St. John Paul II stated that using as a criterion for death "the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem) … if rigorously applied, does not seem to conflict with the essential elements of a sound anthropology."

The NCBC has also stated repeatedly that "Health care workers can use these neurological criteria as the basis for arriving at 'moral certainty' that an individual has died."

The NCBC noted that determining death by these neurological criteria typically involves bedside testing to assess absence of response or reflexes, apnea testing to assess the absence of the ability to breath, and "possible confirmatory tests to further assess the absence of brain activity (for example, an EEG) or the absence of blood flow to the brain."

Similarly, the U.S. bishops' Ethical and Religious Directives for Catholic Health Care Services indicate that "the determination of death should be made by the physician or competent medical authority in accordance with responsible and commonly accepted scientific criteria."

And in 2008, the Pontifical Academy of Sciences stated that "brain death … 'is' death," and that "something essential distinguishes brain death from all other types of severe brain dysfunction that encompass alterations of consciousness (for example, coma, vegetative state, and minimally conscious state)."

"If the criteria for brain death are not met, the barrier between life and death is not crossed, no matter how severe and irreversible a brain injury may be," the academy added.

The Pontifical Academy of Sciences said that after brain death, "the ventilator and not the individual, artificially maintains the appearance of vitality of the body. Thus, in a condition of brain death, the so-called life of the parts of the body is 'artificial life' and not natural life. In essence, an artificial instrument has become the principal cause of such a non-natural 'life'. In this way, death is camouflaged or masked by the use of the artificial instrument."

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Still, some pro-life advocates question the medical criteria used for diagnosing brain death and argue that taking organs from individuals diagnosed as brain dead amounts to homicide. The NCBC rejects that stance as "irresponsible" and "in tension with Catholic teaching," countering that while a body may appear to be alive due to oxygenated blood being mechanically pumped through the body, thorough and rigorous testing can confirm that an individual is truly dead.

Dr. Alan Shwemon, former chief of the neurology department at Olive View-U.C.L.A. Medical Center, is an outspoken critic of the criteria used to diagnose brain death.

Shewmon had diagnosed some 200 patients as being brain dead throughout this career, according to the New Yorker. But he began to have doubts about the condition, which were intensified when he saw the case of a 13-year-old girl in Oakland who had been declared brain dead but began to show signs of improvement after being given tube feeding and hormone replacement.

Over the next four years, the girl was able to respond to simple motor commands and underwent puberty-related physical developments before dying of unrelated conditions, Shewmon said. His analysis of the situation led him to believe that the girl had not been brain dead, but was instead in a "minimally conscious state," with brain flow in the brain too low to be detected by imaging technology, yet sufficient to prevent the death of brain cells – a condition known as global ischemic penumbra.

"Her case challenges the claimed infallibility of diagnostic criteria for brain death and supports the hypothesis that global ischemic penumbra can mimic both clinical brain death as well as absent blood flow on radionuclide scans," Shewmon asserted in a December 2018 article.

Cromer's family is now seeking additional medical opinions and a long-term care facility that will accept their son.