X-Message-Number: 2944
Date: 27 Jul 94 17:54:07 EDT
From: Mike Darwin <>
Subject: SCI.CRYONICS BPI#13
Chapter 4 of STANDBY: END-STAGE CARE OF THE HUMAN
CRYOPRESERVATION PATIENT
by Michael G. Darwin with Charles Platt
Copyright 1994 by Michael G. Darwin. All rights reserved.
Dealing with the Patient's Health Care Providers
Technical sufficiency was the chief means by which the
Hippocratic Aesclepiads gained the confidence and friendship
of patients, but it was not the only one. Two of the later
writings of the Corpus Hippocraticum (On the Physician and
On Decorum) describe in minute detail the non-scientific
measures to be adopted by a doctor to gain that confidence.
His clothes must be decent and clean, and he should be
discreetly perfumed, "for all such things please a sick
man"; he must lead an honest and regular life, his manner
must be serious and humane; without stooping to be jocular
or failing to be just, he must avoid excessive austerity; he
must always be in control of himself. In the second of the
writings mentioned above, even more detailed advice is
given. The doctor must be "serious, artless, sharp in
encounters, ready to reply, stubborn in opposition, with
those of like mind quickwitted and affable, good tempered
towards all, silent in the face of disturbances, in the face
of silence ready to reason and endure, prepared for an
opportunity and quick to take it...setting out in effectual
language everything that been shown forth, graceful in
speech, strong in the reputation that these qualities
bring."
--From *Doctor and Patient* by Lain Entralgo
The medical staff caring for the patient can have a profound
effect upon the course of the standby and transport. Medical
staff can help us (or hinder us) in all of these crucial
areas:
1. Prompt pronouncement of legal death.
2. Minimizing the chance of a patient becoming a Coroner's
or Medical Examiner's case.
3. Assisting with the logistics of transport.
4. Ordering valuable laboratory studies to help determine
the patient's remaining time before legal death.
5. Documenting the patient's pre-cardiac arrest condition.
6. Helping to minimize discomfort for the patient
7. Supporting the patient's decision to be cryopreserved,
and dealing with family and friends.
At least five factors will affect the amount of support and
cooperation that we receive from the physician and other
medical staff. In order of importance:
1. The personality of the individual physician and the
personalities of other medical staff in the hospital or
nursing home where the patient is located.
2. The personality of the standby team leader, and the
personalities of other team members and cryonicists who are
involved in the case.
3. The degree of professionalism and the approach used by
the standby team in dealing with the medical and nursing
staff.
4. The policies of the institution caring for the patient,
and their approach to problem solving.
5. Local regulations and the general social climate
affecting the hospital or nursing home.
It may not be feasible or financially possible to alter some
of these factors, and even where some improvement is
possible, it will often be minimal. Bearing this in mind, we
will focus primarily on the factor which is most easily
under our control: the approach used by the standby team in
dealing with the medical and nursing staff.
First Contact
The first impression created by cryonics personnel will
inevitably set the tone for subsequent encounters. If
medical staff find themselbes confronted with a scruffy
looking, disorganized individual or with an inflexible
zealot, their worst suspicions will be confirmed and they
will probably dismiss the patient and/or the standby team as
"kooks" or "nuts" who should be ignored and avoided as much
as possible. A bad first impression can effectively limit or
cut off future communication. (This is true, also, when
dealing with family members who are not cryonicists. They
too are likely to be skeptical, and will be strongly
influenced by their first impressions.) It's very important
that the first personnel on the scene during a standby or in
preparation for a standby should be personable, well
groomed, knowledgeable, and well organized.
Preparing For Standby
Where a patient has been diagnosed with a terminal condition
weeks or months before the likely time of legal death, we
can assess the patient's environment and lay groundwork that
will increase our chances of performing the standby under
optimum conditions. Where possible, the leader of the
standby team should travel to the locations where legal
death will be pronounced and where standby and transport
will be carried out. The team leader should make
appointments to meet the medical and nursing staff who are
caring for the patient, as well as the principal
administrator of the hospital or nursing home. If the team
leader is traveling a long distance to prepare for the
standby, local staff must be made aware that they cannot
simply "cancel and reschedule" without causing a great deal
of inconvenience.
It is equally important for the team leader to keep all of
his or her appointments. Allow extra time for finding your
way around a strange city and dealing with local
transportation. Avoid scheduling appointments close
together, so that you don't have to cut a meeting short in
order to get to the next one. If you make a formal
presentation, expect a question-and-answer period which will
last half as long again as the presentation itself. Allow
additional time to talk one-on-one with people who have
special concerns.
In order to make a good first impression, you must project
an air of reliability and trustworthiness by keeping
appointments and being prompt and organized.
Dress and Grooming
It is no accident that mavericks and the mentally disordered
both tend to be poorly groomed and unconventionally dressed.
If you want to be taken seriously, you simply have to make
an impression as a serious, conventional person.
Always bear in mind that almost all medical staff will be
profoundly uneasy, very skeptical, and hypercritical when
they encounter cryonics advocates for the first time. They
will be primed and ready to find evidence confirming their
deeply held suspicions that cryonics people are full of
half-baked ideas. The best way to dress is at or above the
standard of the professionals whom you will be dealing with.
For most business and medical professionals the following
standards generally apply:
Dress for Males During Standby
Hair: short or if medium length, neatly styled.
Shirt: Oxford or Broadcloth in white, cream, blue, or muted
pastel color.
Jacket: Suit or sports coat of natural fiber, single
breasted, conservative in color. If on standby in the
hospital a short or full length white lab coat may be
substituted for the suit or sports coat.
Tie: conservative.
Pants: Dress slacks or pants of nonsynthetic material such
as wool or a woolblend. Permanent press cotton/polyester
blends are often acceptable in the summer months or in hot
climates.
Jewelry: minimal and conservative. Finger rings other than a
wedding band should not be worn (provision should be made
for safe-keeping of wedding bands during transport as they
may have to be removed so that you can scrub in, if you
assist with surgery).!
Earrings for males are discouraged and should be small and
discreet if worn.
Shoes: Good quality dress shoes. Tennis shoes, running
shoes, or sneakers are never acceptable.
Dress for Females During Standby
Hair: neatly and conservatively coifed.
Blouse: conservative white, cream, or pastel color.
Suit or skirt: conservative business-like attire.
Jewelry: minimal and conservative. Dangling ear-rings should
be avoided. Finger rings other than a wedding band should
not be worn (provision should be made for safe-keeping of
wedding bands during transport as they may have to be
removed so that you can scrub in, if you assist with
surgery).
Cosmetics: minimal. Avoid bright or shocking colors of
lipstick or nail polish.
Shoes: should match attire. High heels will create practical
problems during transport of the patient and should be
avoided.
During Transport
Males and females may wear scrub clothes (females may wear
scrub dresses if they prefer them to scrub pants/top). Every
team member should have a white, full-length lab coat to
serve as a cover gown and to hold writing utensils and
personal items. Shoes should be comfortable and soft-soled
so that they do not generate noise which could disturn
patients, particularly at night. Shoes should preferably be
white or black but this is not critical. Running shoes are a
practical choice and can decrease fatigue.
General Comments
Dress should always be appropriate to the situation. For
instance, it would be inappropriate to wear a lab coat when
you meet the patient's physician during a preliminary visit.
On the other hand, a lab coat is perfectly acceptable if the
patient is hospitalized, unstable, and the transport team
has been summoned on an emergent basis.
One member of the standby team should pack a small portable
iron or "pocket presser" to get wrinkles out of clothes
after they are unpacked. You can use this in conjunction
with a can of Wrinkle Free, which shouid be sprayed onto
clothes that are hung up on hangers.
Taking a few extra minutes to make yourself presentable is
almost always justified and and can give you a greater
feeling of confidence. You will inevitably feel at a
disadvantage if you meet a hospital administrator who is
immaculately dressed and groomed while you are wearing
rumpled clothes and have a 24-hour growth of beard. Your
embarrassment, and your loss of face, can seriously
interfere with getting the job done.
Establishing A Rapport With Health Care Providers
When you start preparing for an anticipated standby, you
should meet first with the patient's primary care physician.
This may be a family doctor or the "personal" physician that
has been assigned by a Health Maintenance Organization.
The primary care physician is the person who should be
responding to the patient's needs and the cryonics
organization's needs during standby and transport. This
physician should know the patient on a personal basis and
for this reason will be more important to you than a
hospital or nursing home administrator.
If the patient's physician can be convinced that there is
some rational basis for cryopreservation, you will have
obtained a powerful ally who is trusted both by the patient
and by the institution where the patient is being treated.
Generally, the smaller and less bureaucratic the
institution, the easier it will be for you to secure
cooperation. A free-standing nursing home or small
independent community hospital will usually be easier to
deal with than a large teaching institution or a nursing
home that is part of a large national chain.
The Primary Care Physician
Giving Information
When you meet the patient's physician you should be well
organized and businesslike in a nonthreatening manner. At
the meeting, you should have a checklist of items to be
covered, including:
1. The patient's choice of cryopreservation. Briefly
describe the patient's history of interest in cryonics and
offer a copy of the patient's Consent for Cryopreservation.
If cryonics has been a long-standing preference of the
patient, remember to mention this. If cryonics is a last-
minute decision, you should be ready to defend the patient's
ability to make a rational decision, but you should also be
willing to listen carefully to any objections that the
primary physician may express. If the physician is deeply
skeptical, you may consider asking for a psychiactric
evaluation of the patient to establish competency.
2. Principles of cryonics. Where appropriate, briefly
explain the principles of cryonics. Some physicians may have
little or no interest, while others will have an acute
curiosity. Do not use this discussion as an attempt to
proselytize or convert the physician. Arguments for
cryopreservation should be presented factually, without
"zeal."
3. Practical procedures of cryopreservation. Briefly and
simply explain the practical procedures of cryopreservation
with special emphasis on standby. You should be able to show
photographs of transport operations and of the equipment
employed, and you should give the physician a brochure or
simple handbook which covers these topics. If the physician
is willing to watch a videotape of a transport, this may be
very helpful.
4. Cooperation from the physician. Describe what you would
like from the physician, but be sure to offer reassurances
about limited liability. Try to anticipate the physician's
concerns, and deal with them during the course of your
presentation.
The five key things that will want from the physician are:
a) The physician should keep the standby team informed about
the patient's medical condition and prognosis. If the
physician sees problems developing or foresees an altered
time-course to legal death, the standby team must be
informed as soon as possible.
b) The physician should provide medical care which will help
to facilitate cryopreservation. For example, a helpful
physician might order a chest x-ray of a patient suffering
pneumonia, to get a clearer idea of when legal death is
likely to occur. (Such an x-ray might not normally be done
if the patient is elderly and treatment is being withheld.)
Another example would be to keep IV catheter(s) in the
patient past the normal time when they would be removed, so
that transport medications can be administered more easily.
c) If and only if the physician is very cooperative and
supportive, you may ask for laboratory tests to document the
patient's antemortem condition so that the efficacy of
transport procedures and the patient's post-arrest status
can be evaluated better. For example, you might ask the
physician to order a blood chemistry and CBC panel a day or
two before cardiac arrest is expected; and you could ask for
the same set of tests when the patient becomes agonal, so
that you have baseline values which will help to evaluate
the degree to which antemortem shock has contributed to
ischemic injury.
d) The physician should be willing to provide a prompt
pronouncement of legal death, either by coming personally or
by delegating the authority to registry nurses or other
qualified personnel.
e) The physician should help you to liaise with the
institution where the patient is being treated.
5. Duties of the standby team. Explain to the physician the
role of the standby team. Reassure the physician on the
following points:
a) Standby staff will take over the care of the patient as
soon as legal death is pronounced, but not before.
b) Standby staff will provide all personnel, equipment,
medications, and transportation required to carry out the
procedures which they wish to perform.
c) A licensed physician is medical director of the team and
is available for consultation at any time.
d) No invasive procedures (cut down, etc.) will be done in
the institution where the patient is being cared for.
e) A cooperating (local) mortician will handle the health
department paperwork and will facilitate shipping.
6. Reassurance regarding liability. Explain to the physician
that (s)he will not be liable for any eventualities
resulting from the standby. Offer to sign a hold-harmless
agreement. State that you understand that a physician's
first duty is to living patients, and make it clear that you
don't expect cooperation (for example, pronouncing death
promptly) if this will conflict with the physician's
obligations to other patients.
7. Establish contingency plans. What can be done if the
physician is unavailable? What will happen if the patient
experiences legal death sooner than expected? Solid plans
should be in place to deal with potential problems. The
details of such plans will of course vary from one situation
to another.
8. Filling in for the transport team. If legal death has
occurred before the transport team was able to reach the
patient, you must try to obtain as much help from the
physician as possible. Your strategy will vary depending on
the situation. If the patient is located a few minutes away
from the cryopreservation operating room, you may want to
ask only for CPR to be initiated by the hospital or nursing
home until the team arrives. If the patient is in a remote
location, you should ask the institution for limited CPR and
an abbreviated protocol of medication, and you should
request that the patient os packed in ice.
Some physicians and treating institutions will refuse to
perform any procedure related to cryonics. The most they
will do will be to place the patient in their refrigerated
morgue while they wait for a mortician to arrive. You can
try to obtain more cooperation, but if the institution
simply will not comply, you will have to respect its
policies. In this type of situation you may need to consider
sending in local cryonicists who are close by, or asking for
help from a local mortician.
Obtaining Information
While it's important to give information and reassurance to
the primary care physician, it's equally important to obtain
information that you need. Ask for a copy of the patient's
medical records as early as possible, so that the standby
team's consulting physician or medical director has a chance
to review them and plan accordingly. For example, if the
patient has HIV or some other infectious disease, special
precautions will be necessary. If the patient has a
pathology that could interfere with transport, this is also
important--for example, in the case of an elderly patient
who has atherosclerosis which would make femoral-femoral
bypass problematic or impossible.
The list of medical conditions which could complicate or
seriously impede transport is long and beyond the scope of
this guide. You will also wantg to know the physician's
plans for future care of the patient. How will intercurrent
medical emergencies be handled? For instance, if the patient
has end-stage HIV and develops an infection, will (s)he be
hospitalized?
If the patient dies unexpectedly, you should have some idea
of how the physician will want to proceed. Quite often, a
patient who is dying slowly from cancer or HIV may suffer a
completely unexpected cardiac arrest. In such a situation,
your prompt access to medical records may help to avoid
autopsy. How will this contingency be handled, and under
what conditions will the physician be unwilling to sign the
death certificate (necessitating an autopsy)?
Another topic on which you should quiz the physician is the
attitude and personality of the local coroner or medical
examiner. Is (s)he easy to deal with? What percentage of
deaths in the county are subjected to medicolegal autopsy?
Would the physician recommend relocating the patient in a
different county to to reduce chances of autopsy?
The physician may be able to offer similar advice about the
hospital or nursing home and the patient's home situation
and family dynamics.
Nursing Staff
Whether the patient is at home or in an institutional
setting, the nursing staff will be the people you will be
dealing with most. They are also the people who can make or
break an optimum transport. Nursing staff that are hostile
can greatly reduce access to the patient, seriously
compromise the flow of vital medical information, and make
it impossible for you to deploy necessary equipment.
On the other hand, cooperative nursing staff can make room
for transport equipment, provide blankets, coffee, and other
amenities for staff, free up a day-room or empty ward for
staff to sleep in, and provide advanced warning of
administrative problems. When the transport starts, a truly
cooperative nursing staff will often pitch in and provide
help without even being asked to do so.
Just as important, supportive nursing staff who are "on your
side" may be willing to look the other way when CPR is
started or meds are given in violation of the
administration's instructions.
Establishing a good rapport with nursing staff is contingent
on getting their respect. They don't need to believe in
cryopreservation; they only need to see that the standby
staff are sincere and competent, and the patient has a
strong desire for cryopreservation based on full
understanding of the facts. Most medical professionals
believe that the individual has a right to choose unusual
forms of medical care and postmortem disposition.
Nursing staff will require the same type of information that
you have supplied to the patient's physician. In fact, since
a nurse may have more sustained contact with the patient and
the standby team, (s)he will probably have more time and
inclination to ask questions. In an institutional setting,
your best option will be to give an in-service presentation
using slides or video.
Since nurses will be the ones who have to actually deal with
the standby staff, house the transport equipment, and
participate first-hand in facilitating removal of the
patient from the facility, you should discuss
cryopreservation and standby in more detail than during your
meetings with the patient's physician.
Additional material might include:
1. A good general introduction to the cryonics concept
including the underlying scientific and biomedical
evidence/hypothesis.
2. The mechanics of the cryopreservation process from start
to finish with special emphasis on transport. Here it is
appropriate to discuss specific procedures and equipment and
briefly touch on the needs of the standby team in order to
facilitate good care of the patient. Excruciating technical
detail is not necessary but sufficient detail should be
presented so that the staff understands what will happen.
3. As is the case with the physician, you should discuss
contingencies and how they will be handled. It's critical to
determine the limits of the nursing staff in terms of what
they will be permitted to do institutionally, and what they
will be willing to do as individuals. As was the case with
the physician, you should provide reassurance about
liability and (where appropriate) a hold-harmless.
You should mention that you understand how short-staffed and
overworked the nurses are. Make it clear that you do not
expect them to jeopardize the well-being of their "living"
patients in order to facilitate care of the cryonics
patient.
Problems to Avoid
Institutional Human Experimentation Committees
Since the 1980s, U.S. medical institutions have gradually
allowed greater autonomy and self-determination for
patients. There has also been increasing concern about
abuses of the relationship between patients and healthcare
providers, and in particular, between patients and
researchers.
The history of biomedical research is studded with instances
of gross abuse of patients. There have been shoddy or absent
procedures for establishing informed consent, coupled with
deliberate attempts to conceal important information. Recent
disclosures have documented abuses by Federal agencies and a
number of prestigious medical institutions which tested
radioactive materials on unsuspecting patients.
In order to prevent this type of abuse, many health-care
institutions have created a bureaucracy to deal with the
problem. The embodiment of this bureaucracy is the
Institutional Human Experimentation Committee (IHEC). This
committee usually consists of representatives from the
hospital administration, the medical staff, clergy, and one
or more professional biomedical ethicists.
Most institutions today will not allow an experimental
procedure to take place on their premises unless it has been
approved by the IHEC. Typically, an IHEC will take from 6
months to a year to approve a study involving human
subjects, and we can be virtu!ally certain that
cryopreservation will not be one of the "experimental
procedures" that an IHEC considers acceptable. And even if
it was, the reams of paperwork, long lead times, and lack of
participating medical staff at the institution would all
render the procedure impractical.
Therefore, we must make sure that cryopreservation is not
considered an experimental medical procedure by the hospital
or its IHEC. The standby team must present cryopreservation
as a nonmedical postmortem procedure which is akin to
embalming and involves no medical procedures. At the same
time, of course, the team will quietly try to obtain prompt
pronouncement of death, prompt CPR and cooling, and
treatment which will be compatible with cryopreservation.
The team should always emphasize that the patient will be
legally dead before cryopreservation procedures begin. If
the issue of IHEC involvement is ever raised, the team
should point out that IHEC permission is never normally
required for postmortem procedures such as embalming or
cremation.
In the long term, we may find that the cryonics is subjected
to review and control by IHECs whether we like it or not. In
the meantime, the standby team should be aware of the danger
and alert for any threat of IHEC involvement. The author has
had two experiences with IHECs both of which were very
unfavorable. In one case it was necessary to obtain a court
order to override the IHEC and obtain access to the patient.
Confrontations With Medical or Administrative Staff
Occasionally, the standby team will encounter irrational,
belligerent, or just plain mean-spirited medical, nursing,
or administrative staff. The first rule in such a situation
is to remain calm and resist the temptation to respond in
kind. Whenever possible, the cryonics organization
administration should be called in to resolve conflicts.
Since the standby staff will have to deal with hospital
personnel regardless, it's much better to keep the team on
the sidelines while conflicts are resolved. This way, the
team can honestly state that their only task is to care for
the patient. Any legal threats or harsh words should always
come from an attorney "back at headquarters," so that the
standby team members will not be held responsible.
The only situation where a team leader may resort to
hostility or legal threats is if the condition of the
patient is immediately threatened and there is not enough
time to refer the confrontation back to the cryonics
organization's administration.
Conflict with the Patient's Medical Care
There is often a delicate trade-off between medical care to
optimize the patient's current wellbeing, and care which
will optimize the subsequent cryopreservation. A classic
case of this occurs when a patient suffers an obliterative
primary brain disease such as an aggressive brain tumor. If
the patient is going to have any chance of recovering in the
future, legal death should come sooner rather than later, to
arrest the disease so that the patient can be placed in
cryopreservation. Clearly, however, this runs counter to
tranditional medical priorities.
In 1991, a computer programmer named Thomas Donaldson who
was suffering from a grade IV astrocytoma tried to obtain
judicial permission to be cryopreserved prior to legal
death. This challenge to the law against active euthanasia
and assisted suicide was unsuccessful.
Less obvious conflicts of interest between cryonics and
medical care also exist and in some ways are even more
troubling than the issue raised by active euthanasia. Should
a patient seek treatment which may extend the current
lifespan, but (if unsuccessfull) could degrade the quality
of subsequent cryopreservation? There are some neurosurgical
procedures, for example, which carry a risk of brain death
or massive irreversible brain injury. Another problem arises
when a patient has to choose whether to pay for medical care
today, or spend the money instead on cryopreservation, which
offers only a chance of extended life tomorrow.
These are real problems which real patients and cryonics
organizations have wrestled with in the past. Generally, we
should describe the pros and cons of a situation to the
patient as clearly and as calmly as possible, without
imposing our own judgment. A patient must be told if a
course of medical treatment is going to jeopardize
cryopreservation arrangements, but a patient must also be
allowed to make the final decision about any course of
medical treatment without pressure or coercion from cronics
personnel. Legally and morally, this is the only path to
follow.
In situations where standby personnel are being asked for
advice, they should tend to err on the side of keeping the
patient alive today. For further guidance, here is a short
case history based on an actual conflict that occurred
between a cryonics organization's medical director and
administration. Many details have been altered and this case
history has been fictionalized both to make it more relevant
to the discussion at hand and protect the privacy of the
institutions and individuals involved.
Rick is a 35 year-old patient with AIDS. His T cell count is
150 and he has been in reasonably good health except for a
bout with pneumocystis about 4 months ago. He is admitted to
the hospital on a Saturday evening with gram negative
sepsis, apparently secondary to a dental abscess. He is
shocky on admission with BP of 80/60 and a pulse of 140. His
temp is 39.5 C and he is in renal failure as a result of the
sepsis. He is a member of a cryonics organization, and their
standby team reaches his bedside within a few hours after
they are notified that Rick could "die anytime.".
One of Rick's physicians feels he should not be treated for
the sepsis. The other physician feels that antibiotics
should be started and, if necessary, Rick should be dialyzed
to get him through the sepsis-related renal failure.
Rick has had intact mentation prior to this hospitalization
but is disoriented and unable to make medical decisions now.
His lover, Bob, is Rick's medical power of attorney and is
asking the standby team leader what course of action to
pursue. The standby team leader is faced with a number of
difficult questions:
1. The hospital is cooperative now but will probably become
less so as time goes on, particularly come Monday when its
lawyers and administrators arrive at their desks.
2. Rick has very limited funds and he has just used up his
standby allotment flying the team and the equipment out to
his bedside.
3. Rick is not now demented, but faces a statistically
significant chance of suffering AIDS dementia or a brain
infection which could cause truly irreversible loss of
mentation regardless of how well his subsequent
cryopreservation goes.
4. The medical director of the standby team believes that
Rick has a treatable condition with at least a 50 percent
chance of recovery. It is impossible to say how much longer
he might survive with an acceptable quality of life, but one
to two years is not an unreasonable expectation, nor, on the
other hand, is death within 6 months.
It may seem attractive to withhold treatment from Rick and
"get his cryopreservation over with." If treatment is
withheld, Rick will very quickly reach cardiac arrest. The
standby team is ready, and the odds for a good transport are
favorable. Rick has limited money and may not be able to
afford another standby. Additionally, Rick's brain is now
certainly intact but may not be so in six months, a year, or
two years. Further, Rick's cryopreservation arrangements
themselves may be in jeopardy due his mounting medical bills
and the fact that a large part of his funding for
cryopreservation is in a revocable trust account.
What advice should the team leader offer? Clearly, the first
step is to review the situation with Rick's medical
surrogate and ask what Rick would want done. At the same
time, there must be a careful examination of Rick's
cryopreservation file and his durable power of attorney for
healthcare. If there is no direction from Rick, then
treatment should be given even though it offers a less
certain outcome in terms of cryopreservation.
The reasons for this course of action are as follows:
1. In the absence of clear direction to the contrary, our
first duty is to preserve a patient's life here and now, so
as long as there is a reasonable chance of recovery to an
acceptable quality of life (as is the case in this
situation).
2. From a legal standpoint, the patient's medical surrogate
and medical staff are obliged to act in Rick's best
interests using conservative criteria.
3. From a public relations standpoint, there could be grave
consequences if treatment is withheld and Rick's case
becomes a focus of media attention.
4. Buying time for Rick also buys more time to explore other
possibilities for funding any future standby and
facilitating a good cryopreservation in the future.
5. Rick will most likely be grateful for the added time if
the medical treatment works. In the absence of clear
directions to the contrary, we must presume that Rick would
want to stay alive here and now.
6. Improvements in medical care and in cryopreservation
continue to occur. Significant advances in treating HIV
and/or improvements in cryopreservation protocol may occur
in the time that Rick gains as a result of receiving medical
treatment.
Now let us consider another scenario:
Mary is a 42 year-old woman who has had metastatic breast
cancer for four years. She has been through two courses of
chemotherapy and one of radiation therapy. She has been
bedfast for nearly 5 weeks and is down to 70 pounds from 150
pounds 6 months before. Mary has been heavily sedated for
pain and has been unable to take solid food by mouth for
several days. She is enrolled in a home hospice program and
has resigned herself to dying because her underlying disease
cannot be treated and her current quality of life is
unacceptably low.
During the night Mary develops a fever of 39 C and appears
to have difficulty breathing. The hospice nurse determines
that Mary appears to have pneumonia. Some family members
want to start Mary on antibiotics while others say "no, it
is time for Mary to go." Mary's doctor advises against
antibiotics but is willing to administer them if her medical
surrogate insists. What should be done? Here the situation
is very different. Mary is clearly imminently terminal with
a quality of life that she finds unacceptable. Antibiotics
at this point would be inappropriate both ethically and
medically. Mary should be allowed to experience cardiac
arrest and enter cryopresrvation.
Other cases will be less easy to resolve than the examples
provided here. In general, however, the patient's well being
here and now (consistent with the patient's expressed
wishes) should be everyone's top priority, and this attitude
will tend to foster a good relationship between medical
personnel and the standby team. If the team attempts to
follow policies that are contrary to sound medical
treatment, this will usually result in antipathy or conflict
and may impair the team's subsequent ability to carry out
transport under good conditions.
Cooperation Versus Non-Interference
Throughout this chapter, and elsewhere in the guide, I have
used the term "cooperation" to describe the ideal
relationship between health-care staff and the standby team.
However, "cooperation" can sometimes carry implications that
go beyond its literal meaning. Some physicians, for
instance, may fear that by cooperating with a standby team,
they are to some extent giving their approval and may even
be seen as endorsing the concept of cryopreservation.
Bearing this in mind, instead of requesting cooperation, it
may be better to ask for non-interference. This term
accurately describes the needs of the standby team, and is
devoid of troubling implications.
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