Abstract
Dear Editor:
A 97-year-old woman was admitted to the hospital after traumatic head and facial injury following a syncopal episode. She was treated surgically with open reduction, internal fixation, and maxillomandibular fixation. She remained obtunded after the operation. The palliative care team was consulted to assist in determining goals of care.
The patient had appointed her nephew as her durable power of attorney for health affairs. Several decades prior to admission, the patient had paid a company to provide cryonic suspension after death. The family volunteered that, although they personally did not agree with cryogenics, the patient had paid over $100,000; they felt obligated to move forward with her wishes.
The company contract and directive to health care providers was riddled with many misspelled words that included inuured instead of injured and bod instead of body. These blatant errors in a legal document led the palliative medicine team to wonder if the company was legitimate. In addition, the medical treatments did not conform to contemporary standards of care of the dying. The document indicated that when the patient died, cardiopulmonary resuscitation (CPR) was to be initiated and continued for at least 15 minutes. If life was not restored, the document directed that heparin, streptokinase, and gentamicin be administered followed by another 15 minutes of CPR. The document then directed that the patient be placed on a heart-lung bypass machine until arrangements could be made to transport the individual to the cryonics facility.
The palliative care team contacted the cryonics organization to discuss the case. At the insistence of the facility, despite the recommendations of the health care team and family, the patient remained a full code. It was explained that the hospital could not honor the medical directives set forth in the contract because it was not the standard of medical care. There was also a question of revenue integrity, concerning how the organization would be paid. Unlike standard organ donor organization protocols where policies, procedures, and contracts ensure that costs are appropriately apportioned and paid, none of that existed with the cryonics organization.
The decision was made to transfer the patient to a facility closer to the cryonics company headquarters where the cryonics procedures could be fulfilled. During the two days it took to arrange transport, the patient's condition deteriorated. She was intubated and ventilated for airway protection. This required that the maxillomandibular fixation wiring be cut. The patient was then transported via critical care transport to the outside facility.
Ethical Challenges
The palliative care team faced several ethical challenges in response to the advance directives of the patient. First, the patient's directives seemed to violate the bedrock principle of medicine Primum non nocere (First, do no harm). Second, the patient's directives requested medical care outside the bounds of standard practice. Third, the ethical principles of beneficence and nonmaleficence were directed to be violated. In the best medical judgment of her physicians, the directed treatment would do no good, and only cause harm. From a palliative care perspective, pain and suffering were caused by the manipulation of the fixation wires and opening her mouth with the broken jaw and facial bones in order to intubate her. In addition, since palliative care includes care of the family—the directives were causing psychosocial and spiritual distress in the family.
In short, this case caused moral distress for the members of the palliative care team. In collectively treating thousands of patients and families, this was the first time where normative, moral ethics stumped the team. A literature review failed to provide any peer reviewed or scientifically based articles to support the process of cryonics. Further research revealed that approximately 300 patients have undergone cryonics suspension worldwide as of June 2015. This limits the odds of exposure for any medical professional. Unfortunately, these organizations are legally protected under the Uniform Anatomical Gift Act. Although what occurs after death has no bearing on the case while the patient is alive, it still is a pertinent point; it is illegal to desecrate a dead body.
Contemporary medical standards view the removal of the head from the body of a 97-year-old woman for cryopreservation after dying from head trauma as absurd. At best, cryopreservation hopes to restore life to an intact brain at the time of death; in this case, the brain was damaged to the point that it could not sustain awareness or life. It also seems clear that the treatment in preparation for this procedure caused needless pain and suffering for the patient and her family. It seems reasonable to speculate that when the patient signed a cryonics contract she was probably ignorant of the details and complexities of how she would die in order to be eternally preserved by profiteers.
Was this reasonable autonomy knowing how her life would really end? Doubtful! Should the palliative care team have withdrawn from the case on ethical grounds? Yet, the morphine administered probably eased some of the patient's pain. The purpose of reporting the case is that while it is rare, it will likely occur again.