END OF LIFE Soul and Body

1. END OF LIFE Soul and Body Deacon Patrick Bradley Director of Pastoral Care Cheyenne Regional Medical Center Cheyenne, Wyoming

2. I recommend that this set of slides be viewed while listening to the audio recording of the workshop. Deacon Pat The audio recording is available from Audio Visual Education Network. Go to the NACC website and click on 2008 Conference. Then go to Conference Materials; Conference recordings and photos; Order 2008 conference audio CDs and MP3s here. Or the order form is available at http://www.aven.com/conf.cfm/cid/1046

3. Ground Rules • There are no absolute answers. • The moment of death is in God’s hands. • I will try to have time for discussion at the end.

4. My Perspective • I am in an acute care facility. • My perspective is from the Emergency Department and the Intensive Care Unit. • I do not have a Hospice or Long Term Care perspective. • I have more questions than I have answers.

5. Issues to be covered • Brain Death • Ventilator Support • Nutrition and Hydration • GCS • Departure of the soul from the body

6. How Does Medicine Sustain Life? • Respiratory support • Cardiac support • Renal support • Nutritional support • Transfusion of blood products

7. Respiratory Support • Oxygen supplementation • Non-invasive ventilation • Full ventilation • Transplantation

8. Cardiac Support • Drugs • Intra-aortic balloon pumps • Left ventricular assist devices • Pacemakers • Transplantation

9. Renal Support • Dialysis • Transplant

10. Nutritional Support • Feeding Tubes • Nasogastric Tube (NG) • Percutaneous Endoscopic Gastrostomy (PEG) • Peripheral Parenteral Nutrition (PPN) • Total Parenteral Nutrition (TPN)

11. Transfusion of Blood Products • Red blood cells • White blood cells • Platelets • Coagulation products

12. Organs That Cannot Be Transplanted • Liver • Brain

13. All of these must be subject to the Benefit — Burden Test • Remember that the patient or their proxy makes the decision on Benefit — Burden.

14. Neurology of Brain Death • Unlike most organs and tissues, the body can sometimes live (with support) indefinitely after the brain dies. • “Brain needs the body, but the body doesn’t need the brain.”

15. What’s so important about the brain (seriously)? • Generally considered the organ of: • Thought • Memory • Personality • Emotion • The organ that makes us “human” • Or is it the soul that has those attributes and makes us human? (more later)

16. Central Nervous System • Unique organ system in that topology determines function and deficits • Brain • Spinal cord • The spinal cord is responsible for many reflexes we see in critically ill patients

17. Brain • Cortex • Thoughts, plans, emotions, memories, interaction with environment: “consciousness” • Brainstem • Eye movements, hearing reflexes, tongue/swallowing, facial pain, facial movements: “housekeeping”

18. Brain Death • Common for brainstem to survive and cortex to die or be severely damaged: “lights are on but no one’s home” • Brainstem reflexes • Turning head to voice • Following voices/faces with eyes • Moving mouth • Make sure enough time has passed, and no other factors involved • Drowning • Drugs • Etc.

19. A GCS of 5 or less requires the Organ Donor people be called. A porcelain doll has a GCS of 3!

20. Bedside Muscle tone Spontaneous movements Movements to command Reflexes Eye movements Pupil responses EEG Cerebral profusion Threat “Dolls Eyes” Grimacing/utterances Gag reflex “Cold Calorics” Clinical Tests for Brain Death

21. Three “Neurologic” Versions of Death – Different Jurisdictions: • Cortical Death • Cortical and Brainstem Death • Cortical, Brainstem and Bodily Death

22. A Brief Story

23. When Does The Soul Enter The Body? • Saturday’s speaker • Presume at time of conception. • No definitive answer

24. Soul Departs the Body • Ancient Jewish and Early Christian belief three days. • General agreement today – at time of death.

25. When Does the Body Die? • When the soul leaves the body. • No way to verify this. • When medical science says the body died. • Physical signs of death.

26. Thomas Aquinas (1225 – 1274) • At the time of death the soul separates from the body. • A separated soul can reflect on the intelligible without the need of the brain. • The embodied soul requires the ability of the brain to function in order to pursue higher spiritual goods.

27. Life SupportTo Disconnect or Not • Points we will cover • Medical futility • Moral responsibility • Impoverishment • Chance of recovery

28. Medical Futility • We can keep the body alive for an extra few days on life support. • The patient will die if we disconnect life support. • The patient will die regardless of what we do.

29. Moral Responsibility • Benefit or Burden? • Continued life vs Continued suffering. • Patient has the right to choose. • Patient decides how much benefit / burden.

30. Impoverishment • Impoverishment of the patient / family. • Impoverishment of the health care system.

31. Possibility of Recovery • The longer in PVS the lower the probability of recovery. • Do not resuscitate or full code?

32. What Do We Have To Do? • Francisco de Vitoria, O.P. (1492-1546) University of Salamanca says: • It is not necessary to sell off your patrimony to move to the Black Sea just because it is healthier there. • It is not necessary to eat only the most delicate foods just to live longer.

33. What Must We Do? • Is spending five days in ICU then dying the same as selling your patrimony and moving to the Black Sea? • Is there a parallel between eating only the most delicate foods and having a PEG Tube inserted?

34. Purpose of Life • Christian tradition says that the measure of all human activity is whether it leads to God. • Aquinas’ view was that the soul required the ability of the brain to function in order for the soul to pursue higher spiritual goods.

35. If the Body is Comatose and in a PVS Where is the Soul? • The soul is asleep for the cognitive functions of the brain are not working. • The soul is there and frustrated because the body cannot function and so it cannot pursue higher spiritual goods. i.e. move toward God • The soul is angry that we will not let it leave.

36. If The Soul Has Any Control • If the patient is comatose does the soul control things? • I’m going to die so I’ll quit breathing. • Vent • I’m going to die so I’ll stop my heart. • Pacemaker • I’m going to die so I’ll shut off my kidneys. • Dialysis

37. Could That Soul Be Angry? • With us? • With God? • Anger can be a sin. • Are we causing the soul to sin?

38. Could That Soul Be Glad? • This is penance for past sins. • I can join my suffering to that of Christ.

39. Discussion Ground Rules • There are no absolute answers • The moment of death is in God’s hands

40. Scenarios We have four. We don’t have to discuss them all.

41. Scenario 1 • 72 y/o male comes in for a routine procedure. • One of the main arteries to the brain is accidentally punctured. • He suffers a stroke in the brain stem. • He is now paralyzed from the neck down, unable to speak, unable to breathe on his own. • He is on a vent and can only move his eyes. • He is awake and alert and communicates with his eyes. • He communicates that he wishes to be taken off life support. • After 4 days there is no improvement. • He is now “locked in” to an essentially paralyzed body.

42. Scenario 2 • 45 Y/O male – MVA rollover • Respiratory arrest – intubated in the field • ICU on vent – chest tube • CT & MRI • no head injuries • Flail chest • Punctured lung

43. Scenario 3 • 45 Y/O male – MVA rollover • Respiratory arrest – intubated in the field • Without oxygen to brain for undetermined time • ICU on vent – chest tube • CT & MRI • head injuries • Flail chest • Punctured lung • Brain dead

44. Scenario 4 • 35 Y/O female – stroke victim • Otherwise healthy • ICU – IVs – feeding tube • CT & MRI – significant damage to cerebral cortex • GCS = 7

45. Thank You Deacon Patrick Bradley Director of Pastoral Care Cheyenne Regional Medical Center Cheyenne, Wyoming