Tag: advance directives

16 May

Judge: Brain Dead Toddler May Not Remain on Supportive Measures Indefinitely

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On Friday May 13th, 2016, U.S. District Judge Kimberly J. Mueller denied a family’s request to keep their brain dead toddler on supportive measures indefinitely.  The judge did, however, grant a one-week extension to the order restraining Kaiser Permanente Roseville Medical Center (Kaiser Permanente) from taking the boy off a ventilator.

In early April, two-year-old Israel Stinson suffered an asthma attack, depriving his brain of oxygen for more than forty minutes. After a second attack, and after suffering a cardiac arrest, Israel was placed on a ventilator and declared brain dead.  IsraelStinsonFamily-IsraelAndMomJoneeFonseca_810_500_55_s_c1When Kaiser Permanente staff moved to take Israel off the ventilator in accordance with California Health and Safety Code § 1254.4(a), his parents filed an ex parte application with the court to block the staff from disconnecting mechanical support.  Israel’s mother argued that it is on the basis of religious grounds, constitutional rights to privacy, and due process as his mother, that she is objecting to the removal of the ventilator.  In a heartbreaking video posted recently by Life Legal Defense Foundation, Jonee Fonseca can be seen tickling her little boy and saying “Israel, you have to stop fooling everybody” and “I know you’re going to come out of this, baby.”  And therein lies the second tragedy.  In the days and weeks following Israel’s placement on a ventilator, the boy has been declared brain dead by no fewer than three physicians at Kaiser Permanente.  According to the Uniform Determination of Death Act, brain death is defined by either: (i) irreversible cessation of circulatory and respiratory functions, or (ii) irreversible cessation of all functions of the entire brain, including the brain stem.  There is no recovery from brain death.  Arthur Caplan, head of the Division of Medical Ethics at New York University, and David Magnus, Professor in Medicine and Biomedical Ethics at Stanford University spoke bluntly about brain death in Time Magazine:

Concepts matter in medicine… Brain death is death. It has nothing to do with being in a coma. It does not refer to a permanent vegetative state. It does not refer to being severely brain damaged.

Caplan and Magnus would like to see the phrases “brain dead” and “life support” stricken from the conversations that take place between hospitals and families as i) the use of “brain dead” gives the impression that the person is not really dead and ii) “removing life-support” sounds a lot like termination of care for a living person. While acknowledging that a brain death diagnosis can be “a devastatingly hard thing to accept”, they argue strongly that such language confuses families and fundamentally lays the groundwork for cases such as this one, and that of Jahi McMath and Marlise Munoz, discussed in a previous blog.

Complicating matters is the assertion by one doctor that there may be hope for little Israel. In a court declaration, Dr. Paul Byrne, a pediatric neonatologist, stated that the toddler “may achieve even complete or nearly complete neurological recovery if he is given proper treatment soon”. Dr. Byrne is a former president of the Catholic Medical Association and current president of a faith-based group called Life Guardian Foundation. According to their website, Life Guardian Foundation is an organization dedicated to the belief that a brain death diagnosis is one promoted by physicians “for the sole purpose of organ transplantation and human medical experimentation”.

Israel’s parents will use the one week extension to take the case to the 9th Circuit U.S. Court of Appeals. They also intend to use the one week reprieve to continue their desperate search for a medical facility in New Jersey that might accommodate the family and agree to take over the boy’s “care”.  New Jersey is one of only two states in the United States with a law allowing religious objection to a declaration of death on the basis of neurological criteria.  Jahi McMath, for example, lies today in a bed in a New Jersey rental apartment with 24-hour nursing care, as she has for the past two years, while her parents await a ruling on their recent lawsuit to have her death certificate revoked.

Kaiser Permanente is complying with the order to leave Israel on a ventilator until Friday May 20th.  A GoFundMe page set up by Fonseca has raised more than $15,300 towards the costs of Israel’s care and transfer.

Jennifer Hartman


06 May

Brain Death: Turmoil at the Intersection of Law and Medicine

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In Roseville, California, Jonee Fonseca and Nate Stinson await a decision by a federal judge with respect to the fate of their little son.  On April 2nd 2016, two year old Israel Stinson suffered an asthma attack, depriving his brain of oxygen for more than forty minutes.  He was seen in the E.R., admitted to hospital, suffered a second attack, lapsed into a coma, and was placed on a ventilator.  Days later, he was declared brain dead by doctors at Kaiser Permanente Center in Sacramento (Kaiser Permanente).  According to the Uniform Determination of Death Act, an individual is dead when he or she “has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem.”


California Health and Safety Code § 1254.4(a), mandates that “after a reasonably brief period of accommodation”, a hospital may shut down the cardiopulmonary equipment that keeps the heart of a brain dead patient beating.  However, when Kaiser Permanente moved to take Israel off the ventilator, his parents filed an ex parte application with the court to block the medical center from disconnecting this supportive measure.  Israel’s mother argued that it is on the basis of religious grounds that she is objecting to the removal of the ventilator; “We won’t give up. God won’t give up. Who is a doctor to go against God?” The ex parte application further seeks an order compelling placement of a tracheostomy tube and gastric feeding tube so that the toddler can be provided respiratory support and nutrition.  Ultimately, the parents hope to have Israel transferred to a medical facility in New Jersey.  Why New Jersey? Unlike other states, the New Jersey Declaration of Death Act provides that “the death of an individual shall not be declared upon the basis of neurological criteria when … such a declaration would violate the personal religious beliefs of the individual.”  Such religious beliefs subscribe to the principle that the heart is the sole indicator of death, even if that heart is artificially supported by mechanical means.  On April 30th, the United States District Court issued a temporary restraining order preventing Kaiser Permanente from removing Israel’s ventilator. On May 2nd, an extension to that order was granted; supportive measures must be maintained until May 11th, at which time another hearing will be held.

If any of the facts of this case seem tragically familiar, it is because they echo the case of young Jahi McMath. You may recall Jahi, the 13 year old girl whose complications after a routine tonsillectomy rendered her brain dead in a California hospital in 2014.  Jahi’s parents would not accept the declaration of brain death by their daughter’s hospital, fought to have mechanical ventilation continued, and successfully won the right to have her body transferred to a facility that agreed to sustain supportive measures (ventilator, tracheostomy and gastric feeding tube). To this day, Jahi remains in a hospital bed in New Jersey.

Kaiser Permanente has indicated that they will comply with the decision of the federal judge next week.

Jennifer Hartman


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