Jahi McMath proves 'brain death' diagnosis is not irreversible

There have recently been fascinating developments in the Jahi McMath case. In December, 2013, physicians at Children’s Hospital, Oakland, declared Jahi dead by brain death criteria, following complications of tonsillectomy and sleep apnea surgery. Her hospitalization was marked by a struggle between hospital personnel, who sought to discontinue life support, and her parents, who rejected the diagnosis of brain death and believed she was alive and deserving of treatment. Several neurologists examined Jahi and testified that she met the criteria for brain death, which is supposed to be irreversible.

Jahi was spirited away in the middle of the night in early January to St Peter’s Hospital in New Jersey, where a tracheostomy and feeding tube were placed. She is currently residing in a private residence with round-the-clock nursing care in that state, which allows patients and family members to reject a diagnosis of death by neurological criteria on religious grounds. In recent weeks she has had an MRI and been examined by brain death expert, Calixto Machado, as well as others from Rutgers University. Now it appears that she has recovered some neurological function.  In a press conference in San Francisco, Jahi’s family’s lawyer, Chris Dolan, showed videos of what appeared to be Jahi moving her foot and hand at her mother’s command.  Dolan seeks to overturn the declaration of death that occurred last December. An article by Wesley Smith shows these videos and notes other recent developments.

D. Alan Shewon, Professor Emeritus of Neurology at UCLA, another world-class expert on brain death, has written the following about Jahi in a sworn declaration to the Court, in support of the reversal of the declaration of death. He has reviewed videos, her medical records from St Peter’s, her MRI and EEG, and discussed her with other examiners:

Jahi does not fulfill the criteria for brain death on several grounds. First and foremost, the videos and testimonies to me of several trustworthy witnesses of her motor responsiveness ….leave no doubt that Jahi can not only hear but understand simple verbal requests (“move your hand,” “move your foot,” even “move your thumb,”) and make appropriate motor responses…The recent video of her hand movement to command makes clear that the movement is not a spinal reflex that merely happened coincidentally after the verbal command…This alone, even if there is no additional evidence (which there is), proves she is not brain dead, not even comatose, but very severely disabled.                

In addition to videos showing voluntary movement, the MRI did not reveal destruction or liquefaction of the cerebral cortex, which a number of textbooks state occurs after brain death.  Instead, Jahi’s cerebral cortex is largely preserved.

Shewmon contrasts Jahi’s brain with MRIs of others who actually had chronic brain death and have undergone liquefaction. He states that Jahi’s MRI scan shows “vast areas of structurally preserved brain, particularly the cerebral cortex, basal ganglia and cerebellum. “However, Shewmon also notes widespread destruction of her brain stem, which accounts for her severe disability and need for a ventilator.

Of paramount importance is Shewmon’s statement that he has no doubt that Jahi fulfilled the criteria for brain death last December. But brain death is supposed to be irreversible, and by having voluntary movement now it is clear she no longer fulfills these criteria.  The significance of Jahi’s findings are that the clinical criteria for diagnosing brain death as death do not appear to be reliable.  Shewmon theorizes that the concept of the “ischemic penumbra” of Cicero Coimbra, a Brazilian neurologist, may be valid. This means that the brain damage from loss of blood flow can be temporary, and brain function potentially recoverable. But the reversible injury from ischemia, or loss of blood flow, makes it appear as if brain death has actually occurred. In fact at the American Academy of Neurology meeting in May, a paper was presented by Dr. Phil Defina et al, who is currently treating Jahi, in which they describe the recovery to a minimally conscious state of a woman who was formerly diagnosed with brain death by five neurologists.

These recent reports highlight the fact that the brain is a mysterious organ and there is much that we do not know about it. And that Jahi is not dead, but as Shewmon states, “she is an extremely disabled, but very much alive teenage girl.”

 Hat tip: a physician who prefers to remain anonymous

There have recently been fascinating developments in the Jahi McMath case. In December, 2013, physicians at Children’s Hospital, Oakland, declared Jahi dead by brain death criteria, following complications of tonsillectomy and sleep apnea surgery. Her hospitalization was marked by a struggle between hospital personnel, who sought to discontinue life support, and her parents, who rejected the diagnosis of brain death and believed she was alive and deserving of treatment. Several neurologists examined Jahi and testified that she met the criteria for brain death, which is supposed to be irreversible.

Jahi was spirited away in the middle of the night in early January to St Peter’s Hospital in New Jersey, where a tracheostomy and feeding tube were placed. She is currently residing in a private residence with round-the-clock nursing care in that state, which allows patients and family members to reject a diagnosis of death by neurological criteria on religious grounds. In recent weeks she has had an MRI and been examined by brain death expert, Calixto Machado, as well as others from Rutgers University. Now it appears that she has recovered some neurological function.  In a press conference in San Francisco, Jahi’s family’s lawyer, Chris Dolan, showed videos of what appeared to be Jahi moving her foot and hand at her mother’s command.  Dolan seeks to overturn the declaration of death that occurred last December. An article by Wesley Smith shows these videos and notes other recent developments.

D. Alan Shewon, Professor Emeritus of Neurology at UCLA, another world-class expert on brain death, has written the following about Jahi in a sworn declaration to the Court, in support of the reversal of the declaration of death. He has reviewed videos, her medical records from St Peter’s, her MRI and EEG, and discussed her with other examiners:

Jahi does not fulfill the criteria for brain death on several grounds. First and foremost, the videos and testimonies to me of several trustworthy witnesses of her motor responsiveness ….leave no doubt that Jahi can not only hear but understand simple verbal requests (“move your hand,” “move your foot,” even “move your thumb,”) and make appropriate motor responses…The recent video of her hand movement to command makes clear that the movement is not a spinal reflex that merely happened coincidentally after the verbal command…This alone, even if there is no additional evidence (which there is), proves she is not brain dead, not even comatose, but very severely disabled.                

In addition to videos showing voluntary movement, the MRI did not reveal destruction or liquefaction of the cerebral cortex, which a number of textbooks state occurs after brain death.  Instead, Jahi’s cerebral cortex is largely preserved.

Shewmon contrasts Jahi’s brain with MRIs of others who actually had chronic brain death and have undergone liquefaction. He states that Jahi’s MRI scan shows “vast areas of structurally preserved brain, particularly the cerebral cortex, basal ganglia and cerebellum. “However, Shewmon also notes widespread destruction of her brain stem, which accounts for her severe disability and need for a ventilator.

Of paramount importance is Shewmon’s statement that he has no doubt that Jahi fulfilled the criteria for brain death last December. But brain death is supposed to be irreversible, and by having voluntary movement now it is clear she no longer fulfills these criteria.  The significance of Jahi’s findings are that the clinical criteria for diagnosing brain death as death do not appear to be reliable.  Shewmon theorizes that the concept of the “ischemic penumbra” of Cicero Coimbra, a Brazilian neurologist, may be valid. This means that the brain damage from loss of blood flow can be temporary, and brain function potentially recoverable. But the reversible injury from ischemia, or loss of blood flow, makes it appear as if brain death has actually occurred. In fact at the American Academy of Neurology meeting in May, a paper was presented by Dr. Phil Defina et al, who is currently treating Jahi, in which they describe the recovery to a minimally conscious state of a woman who was formerly diagnosed with brain death by five neurologists.

These recent reports highlight the fact that the brain is a mysterious organ and there is much that we do not know about it. And that Jahi is not dead, but as Shewmon states, “she is an extremely disabled, but very much alive teenage girl.”

 Hat tip: a physician who prefers to remain anonymous