X-Message-Number: 20005
Date: Fri, 6 Sep 2002 21:18:12 EDT
Subject: Agonal Hypoperfusion and Cryonics

In a message dated 9/6/02 2:01:49 AM Pacific Daylight Time, Brett Bellmore 

> "One of the problems that has delayed me signing up is that by the time of
>  cyropreservation, the brain has already been seriously damaged.  We (MD
>  intensivests) are exceptionally good at keeping the heart-lung machine
>  pumping.  What usually leads to ultimate demise is prolonged hypotension,
>  which kills the brain (and kidneys) long before death is admitted to.  
>  should be an avenue for direct escape from this doom to a cyropreserved
>  state, before the irreversible damage is acquired.  Obviously this will be 
>  huge social hurdle to cross.
>  James R Hughes, MD"
>  Ok, granted I'm not a physician, but aren't there treatments to prevent
>  brain damage from prolonged hypotension, such as inducing a coma with
>  barbituates? In fact, I'm pretty sure such things are part of Alcor's
>  protocol, at least *after* death is pronounced. Do we get better care after
>  being declared a corpse than before? I suppose given the hurdles of FDA
>  approval that's possible...

Dr. Hughes is correct in his concern about this issue. I have seen a number 
of slowly dying cryopatients who experience many hours in deep shock who lose 
pupillary and deep tendon reflexes hours before cardiopulmonary arrest. I 
have written at length on his topic on Cryonet and have even proposed the use 
of Cerebral Function monitors (spectral edge frequency EEG devices) to 
deterimne the degree of cerebral hemisphere (as opposed to brainstem 
perfusion) in such patients). I once owned such a monitor but never had a 
chance to use it on a patient dying in this way. The current Aspect BIS 
monitors with streaming hemispheric EEG would be ideal for this.

Steve Harris, M.D. is a cryonics involved physician who has had a wide range 
of medical experience, including cryonics cases and years of MICU work. He 
differs with me and Dr. Hughes on this matter stating that in his opinion as 
long as the brainstem is adequately perfused for respiratory effort to occur, 
then the cortices must be being perfused as well. Perhaps he is right. But, 
clinically, in a patient with failed peripheral perfusion (cold mottled 
limbs), 2-3 agonal respirations a minute, a barely palpable BP and 
midposition unresponsive pupils in the absence of liver failure, hypothermia 
or heavy sedation, I think there should be grave concern about cerebral 
cortical perfusion.

In the ICU this is a matter that need concern us little for the typical 
pre-need cryopatient. You simply turn off the pressors and stop fluid support 
as soon as the patient's condition becomes futile, or the patient's medical 
surrogate orders it. The same is true to withdrawal of ventilatory and/or 
renal support. This has been done routinely in the past.

The home hospice or inpatient hospice setting is more problematic. However, 
even there the nurses have developed mechanisms they are comfortable with 
from a medicolegal standpoint to terminate such drawn out situations. Often 
turning the patient or giving the patient a bed bath will deliver the coup de 
gras to a frankly agonal patient. Often there are standing orders for 
morphine before bathing as a prophylaxis against discomfort. If a caring 
hospice nursing team is advised of the potential problem the timing of such 
care can be arranged or family can intervene to deliver such care. And, it is 
important to point out that maintaining hygiene is an important part of 
preserving dignity and delivering good palliative medical care. If a 
profoundly agonal patient who is mechanically gasping and maintaining an 
agonal, bradycardic heart rhythm in the last few hours of life decompensates 
during bathing this is not wrong legally or morally, and it does not violate 
the law of double effect so long as s/he needed the care.

Most hospice nurses (double effect or not) are skilled at ending such 
situations if they are gruesome and disturbing to the family and the patient 
is actively dying and beyond recall. Simply elevating the head of the bed or 
erring on the side of caution (no pain) in giving morphine are often all that 
is needed. I've seen the situation handled this way countless times. 

Finally, most people don't die this way. As I've said before regarding 
cryonics you typically see a three way split in failure modes with about 
equal numbers in each group (if you include at need patients who do much 
better than members since they *all know* they are dying and preparations can 
be made). Of course, we all envision ourselves in Group I and never in the 
other two groups. Still, that's not a reason not to make arrangements.

Group I: The patient has a slow failure mode illness that has left his/her 
brain intact. They are typically dying of adenocarcinomas, are in the ICU for 
SIRS/sepsis, or have other disease which is slow and progressive. There is 
optimum time to prepare psychologically and professionally. Equipment and 
staff are fully deployed and "standing by."

Group II: This covers a wide range of failures modes from bad luck in 
logistics (no flights available over a holiday weekend) to willful stupidity. 
Sometimes the patient has an illness which results is serious injury to the 
CNS before death, sometimes there are delays to the start of cooling or CPS 
due to logistic or other problems. These people get cryopreserved often with 
astonishingly "good" responses to CPA perfusion, but they get a "substandard" 
job of it. 

Group III: These patients are for all intents and purposes the hopeless or 
nearly hopeless cases. They include long postmortem delays until discovery 
(days), cranial autopsy, accident, severe crushing or disruptive injuries to 
the CNS, and other cases where everything that can go wrong does. These also 
include patients with completed primary degenerative brain disease where MRI 
or CT shows loss of most cortical matter and heavy scarring and plaque 
formation in that brain tissue that is present on biopsy: end stage 
Alzheimer's would be an example of this.

I hope this answers Dr. Hughes' and Brett Bellmore's questions. In the ICU 
control over when death occurs is at the Intensivist's and family's 
discretion in futile (terminal) cases. In hospice, much can be done to affect 
timing and outcome within the scope of existing standards of practice and the 
law as it is currently enforced in most areas. And yes, some patients (50% - 
60%?) will die in ways that leave them little or no chance of recovery given 
our current understanding of the Universe. However, this is true of medicine 
in general, and two Intensivists especially should know that there are no 
guarantees in either medicine or cryonics.

You can always set up your own preconditions. If they are not met the money 
can and will go to whomever you designate. That's more than you can expect 
when you enter an ED or an ICU. Indeed, these days you are lucky to get out 
alive judging from what I'm seeing in medicine across the US.

Mike Darwin

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