Thursday, 6 April 2017

Jahi McMath update

It's about that time again, folks: time to revisit the tragic story of Jahi McMath.  In case you're new here and don't know Jahi's story, you can read about it here, here, here, here, and here.  I even wrote a stupid FAQ here.  The short short version of the story is that a 13-year-old girl in California underwent a rather extensive three-part surgery for sleep apnoea and suffered cardiac arrest and brain death back in December, 2013.  She was declared brain dead after multiple separate brain death evaluations by multiple different people as well as by Dr. Paul Fisher, the court-appointed second opinion expert, and multiple ancillary tests confirmed the diagnosis.  Her mother, Nailah Winkfield, refused to accept the diagnosis, so she had her transferred to another hospital in New Jersey (St. Peter's University Hospital) where she had a tracheostomy and feeding tube placed.  She stayed at that facility for 8 months until she was discharged to her mother's care, and has been sustained on somatic support in an apartment in New Jersey since August 2014.

Got all that?  Good, let's move on.

In the intervening 2 1/2 years, we've had sporadic "updates" from the family (and anti-brain death quack Dr. Paul Byrne) claiming that Jahi is alive because she no longer meets the criteria for brain death.  The "proof" for her resurrection has been, shall we say, lacking.  One of the pieces of evidence was a video of Jahi supposedly moving her foot to command, and another was a video of her moving her arm to command.

My last update was over a year ago in March 2016, but it was just a couple of vague pictures of Jahi, still with her eyes closed.  More recently than that in October 2016 a video was posted of Jahi supposedly breathing over the ventilator, again in response to verbal commands.

So what are we to take away from all of this?  What does this all mean?

The short answer: Nothing.

As usual, the "evidence" is meaningless.  How do I know this?  Because it is no longer merely implausible, it is quite literally impossible.

Thanks to Professor Thaddeus Mason Pope's Medical Futility Blog, we now have access to some information that has up until now been mere educated guesses.  A case management statement (whatever the hell that is) was submitted by Jahi's surgeon, Dr. Frederick Rosen, which contains the statements of two experts on brain death, Drs. Thomas Nakagawa and Sanford Schneider.  For a bit of background, Dr. Nakagawa is the division chief of critical care medicine and the director of the paediatric intensive care unit at Johns Hopkins All Children's Hospital in St. Petersburg, Florida, and he has over 25 years of clinical experience in paediatric critical care.  Dr. Schneider is a clinical professor of neurology at the College of Medicine, University of California, Irvine and has been in paediatric neurology practice for 48 years.

These two guys know their shit - THEY ARE EXPERTS.  Both doctors reviewed all available records, starting with her original hospitalisation in California, all the way through the end of her hospitalisation in New Jersey and the release to her mother.  In their statements they disclose some very interesting, and very revealing information.

Dr. Nakagawa describes the several EEGs that were done as ancillary brain death tests (note than an EEG is not a definitive test for brain death).  On December 12th there was no brain activity, and the technician noted that her right arm and left leg were both moving during the EEG.  They also tried auditory and painful stimuli during the test as well as shining a light in her eye, but there was no brain activity in response to anything.  Another EEG was performed on December 17th, and again there was no response to painful stimuli, light touch, or sound.  Yet another EEG was done on December 23rd, which was exactly the same.  This is very important information, because it means that her movements are in fact spinal movements, not caused by brain activity.  Also keep in mind there was no response to sound.  This will come into play a little later.

Nakagawa also goes over Jahi's brain flow scan on December 23, 2013 (page 33) which showed a complete absence of blood flow to the brain, which Dr. Fisher calls "beyond definitive".  Brain tissue cannot survive more than a few minutes without blood, and this was 13 days after her anoxic event and cardiac arrest.  Thirteen days is more than enough time for the brain to die.

He also describes Jahi's clinical exam during her 8-month hospitalisation in New Jersey, and at no time was her examination ever not consistent with brain death.  She never had any purposeful movement, she never opened her eyes, she never had any cough, gag, or pupillary reflex, and she never had any spontaneous breathing.

Drs. Nakagawa and Schneider both talk about the other ancillary tests that were done on September 26, 2014, including MRI, brainstem auditory evoked potentials, upper extremity somatosensory evoked potentials, visual evoked potentials, and EEG.  None of these are accepted ancillary tests for brain death, but they still revealed something very interesting: they were still consistent with brain death.  Additionally, on page 46 of the document Schneider states that the somatosensory evoked potentials demonstrated some integrity of the spinal cord up to the level of C5, but there was no function above this.
It is a medical impossibility that J. McMath is moving in response to verbal commands.  The brain stem auditory evoked potentials test performed at University Hospital on September 26, 2014 . . . demonstrates that as a result of J. McMath's brain death she has no auditory pathways; there were no evoked potentials to maximum aural stimulation.  This test result establishes to a reasonable degree of medical certainty that J. McMath cannot respond to verbal commands because she has no cerebral mechanism to hear sound.
In plain English, the videos of Jahi moving in response to her mother's voice are nothing more than spinal reflex movements, because Jahi CAN NOT HEAR and her brain CAN NOT CAUSE MOVEMENTS because it is dead.  It is now plainly obvious that they simply caught Jahi at a time when her hand and foot were twitching, and they took a video of it while Nailah told her to move.  I don't know if this was deliberately deceptive on Nailah's part, but I suspect it was not.  I believe that she honestly believes Jahi can hear her.  However, she can not.  It is 100% impossible.

In summary, Nakagawa and Schneider exhaustively evaluated everything that had been done to and for Jahi from her surgery up until her release to her mother on August 25, 2014 (there was no evidence that Jahi had been re-evaluated for brain death since that day), and all of the brain death evaluations that were done in California were deemed completely valid.  There was no evidence that anything was awry in any way.  They also both stated, quite definitively, that nothing that had been done since her declaration of death -- no subsequent tests, no exams done at St. Peter's University Hospital, no nothing -- could . . . well, I'll let Dr. Nakagawa sum it up:
There is nothing in McMath's medical records from Saint Peter's University Hospital that would cause a reputable expert in pediatric or adult brain death to question or reconsider the accepted brain death assessments of Dr. Robin Shanahan, Dr. Robert Heidersbach, and Dr. Paul Fisher.
He makes the same statement regarding additional tests she had done in September of 2014, none of which are accepted tests for brain death.  Dr. Schneider then says this, which Nakagawa also averred:
There is absolutely no medical possibility that J. McMath has recovered, or will someday recover, from death.
It seems I may have said something very similar many, many times.

So there you have it.  That's about as definitive as it gets.  Comments, as always, are welcome.  But please keep them respectful.

114 comments:

  1. I don't think there is anything that will stop Mrs. Winkfield from trying to get Jahi's death certificate overturned. If she can do that, she can move the body back to California and get Medical benefits there for care. Then if the family can win a malpractice lawsuit, they can get millions in compensation. With a DC, the limit is $250,000. Chump change, according to the uncle. There is video released by nailah that supposedly demonstrates Jahi coloring. There is a marker placed between her thumb and forefinger, with the tip of the marker on a piece of paper that has squiggles of different colors on it. I watched the video maybe three times, because I thought I missed it the first time. Nope. No movement whatsoever, yet everyone one the Jahi Facebook pages got all excited that this was somehow demonstrative of her healing. It's just so damn sad that people believe a brain dead person can heal. There is going to have to be some actual medical evidence to get a death certificate overturned, and that's just not going to happen. I can't help but wonder if the videos are supposed to get public opinion swayed in favor of the family, but I don't know what purpose that will serve.

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  2. One thing this whole story has done is to convince me to make absolutely sure that my family knows I don't want to linger on "life support". Not that I'm going anywhere soon, but forget the jumper cables and let me go. If I've got usable parts at that point, let somebody else use them.

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    1. ...right there with you...

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    2. I agree. I won't be using them again.

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    3. Totally agree. If there's something that can be used again, take it and make someone healthy. Just make sure I don't fog the mirror when they light the fire.

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    4. "greater love hath no man but that he lay down his life for another"

      I don't see how that could fail to include organ donation.

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    5. I agree with the other comments!! My wishes are verbally known to my family AND all legal documents have been completed/filed to accomplish this in accordance with my wishes. I specifically told my daughter, when the doctor says it's over, she'd better pull the plug fast without any second thoughts.

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  3. Jahi's family fought very hard to keep the contents of these medical records out of the court documents made public. The defendants in the medical malpractice suit just recently won the right to include them with their expert testimony.

    The judge agreed with the defense's argument that by attempting to try their case in the "court of public opinion" by releasing selected and biased declarations, Jahi's family had waived any right to her medical privacy.

    Doc didn't mention that Dr. Nakagawa was the lead author of the revised brain death determination criteria for infants and children which was updated in 2011.

    Also, in the last paragraph of Dr. Schneider's testimony he had some interesting things to say about Dr. Alan Shewmon's thoughts regarding brain death. His was the expert opinion on which the family based their belief that Jahi was no longer brain dead.

    Alan Shewmon.one of the brain death experts had to say about Alan Shewmon.

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    1. Oops, while editing I forgot to delete the last sentence.

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    2. Alan shewmon does not recognize brain death, while still admitting that a brain dead patient will never recover from being brain dead.

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  4. Thanks for taking the time to keep us posted on this case.

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  5. Do you have a link to the video?

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  6. she's not just mostly dead, she's go through her pockets and look for loose change dead.

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  7. OK Doc, so you said :

    "Nakagawa also goes over Jahi's brain flow scan on December 23, 2013 (page 33) which showed a complete absence of blood flow to the brain, which Dr. Fisher calls "beyond definitive". Brain tissue cannot survive more than a few minutes without blood, and this was 13 days after her anoxic event and cardiac arrest. Thirteen days is more than enough time for the brain to die."

    So if her brain is literally dead meat inside her skull, how is she not literally rotting away from the inside out? How does she manage to not look like the crypt keeper after all this time? Life support measures can only sustain life where there's actual living tissue, correct? Nobody can live without a brain. But in those videos she doesn't look "dead". I know she is -- no pupillary reflex, no purposeful movement, no auditory pathways. But she looks like she's in a coma.

    I watched the video. If I were her mom & I called her name & her hand moved, then I called her name again it moved AGAIN & she opened her fingers & dropped what she'd been holding, you could NEVER convince me my daughter can't hear. That, coupled with the fact that she looks like a coma patient, would certainly keep me believing that my child was still alive.

    Are there other videos of her hands randomly moving when she's alone & can't be responding to someone's voice? And why does she still look like she's asleep rather than like a corpse? Why isn't her skin deteriorating, her hair falling out? No judge in America can get away with an order to remove her from life support after have seen that video. It's tragic, but I can see why her parents refuse to accept that Jahi's dead.

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    1. I address this question in the FAQ. http://www.docbastard.net/2014/01/jahi-mcmath-faq.html

      In short, organs do not need a brain to function.

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    2. Also theres a reason you often hear people say "it just looks like they are sleeping." Its not like we all look like we just saw the girl from the Ring. And theyve done quite a bit to dress up the body via makeup lighting editing angles of photos and photoshop. They might make a good living prepping bodies for an open casket funeral.

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    3. RC

      Not sure exactly what you are looking for as far as an answer. Doc does a great job in the link to explain things.

      I also have worked with PICU families for 30 years (Doc I am old enough to remember when Pocus started) and during that time have seen families struggle to understand the concept of brain death or dying. I have evened helped families get another opinion or deal guidance from the ethics committee and yes I have cared for a few that went to court. Yet all of those families finally came to understand. Jahi' s family was used and is now allowing themselves to be used for financial gain. Remember Jahi was right as the repeal vote was happening related to California tough malpractice protections. Jahi's body appears to look ok because it is receiving oxygen and nutrients. The body decays once oxygen is stopped from perfusing tissue.

      These results as noted by the true experts indicated that she truly is dead.

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    4. Dear all, sorry for the typing mistakes. Darn autocorrect on the phone. PICU and helped receive guidance from the ethics committee

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    5. The last update I heard said she had begun menstruating--is that somehow consistent with "death"? Does that mean she could conceive?

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    6. Yes, there have been other cases of long-term somatic support after brain death where the patient has undergone puberty. Other than her brain, her organs are all functioning.

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    7. Story from an ex nurse is that the body was decaying in the crotch, and the mother claimed it was her period.

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  8. I have been continually horrified by this story since its beginning. I always had the impression from Jahi's family's accounts that she had basically "bled out". This obviously painted the hospital in the worst possible light. I mean, who lets a kid bleed to death in their ICU, right? Now that we get some actual facts, instead of lay persons interpretations, it sounds as if she aspirated some blood - probably clots. That makes a whole lot more sense. For someone to bleed out from their oropharynx in an ICU would require many, many errors by many people. However, aspirated clot and the ensuing airway disaster that that could cause, is a tragic, but more understandable scenario. I have pulled some gross things from people's vocal cords during codes, but if you got clots past the cords it would be very difficult to get them out.

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    1. keep in mind grandma said, on TV that she had taken it upon herself to suction the surgery site, and then handed off the wand for jahi to do her own suction, all of her own accord.

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    2. Hi Ken.
      Would that make granny culpable for Jahi's death?

      Would it be negligent homicide?
      Could it possibly even be Murder given she should have known better and would have known or suspected the consequences given she was not qualified and neither was Jahi?

      If so could we see mamanails suing granny?

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    3. I doubt any lawyer would take that lawsuit, since there is nothing substantial to be gained by it; and I also don't see anyone being so cold hearted as to actually file charges against Granny; but it does put CHO in the position that they, now that the records have been unsealed, can say "we told them to do this, and they chose to do that, instead. we are not liable for what they did."

      which some versions of the story have it that CHO would really rather not have had the family there at all at that point in the procedure. some versions also have it that Jahi was not supposed to be speaking and that the family was posting on social media that she was talking and laughing. there were even unsubstantiated rumors that they has smuggled in solid food and fed it to her.

      it will take a full investigation to determine if the family did anything that caused the bleed; and there were suspicions that the circus was partly to give time for any evidence to disappear. it is a horribly convoluted case, once you start looking for liability.

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    4. Word is that they fed the girl a McDouble right after surgery, against doctor's orders. They really have no leg to stand on.

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    5. as I said, that word is unsubstantiated.

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  9. Thank you for the update... this case has sickened me from the beginning. As an ICU nurse, I would like to know what her lactic acid levels are...

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  10. This whole situation just makes me think if my opinion of Typhoid Mary. Now i know it sounds unrelated but hear me out. I assume we all know who Typhoid Mary is. What most people dont realize is all the things she did to avoid the authorities as her reign of terror continued. Shed be a cook for a family, theyd get sick shed quit move and change her name and start over. She did that 6 times. The first time she was confronted with the possibility she might be causing outbreaks it was understandable she thought they were being ridiclous- a carrier whose unaffected by typhoid was unheard of! Yet youd think shed have connected the dots enough after that happened after the first couple breakouts. They finally tracked her down and arrested her and she stayed in quarantine for the rest of her life. Apparently while in quarantine shed offer food to the people who came to visit her! At a certain point claiming ignorance isnt a viable excuse you are being malicious. Jahis family after so many denials and such and despite all the proof and the fact their daughter has been lying there for THREE YEARS should be a sign that its not going to get better. Claiming ignorance at a certain point isnt acceptable. Theyve long since surpassed that point and are giving out malicious misinformation.

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  11. Doc, I do understand that Jahi is dead, and will never become less so. However, I still don't understand one small aspect: if there has been no blood flow to the brain for three years, why isn't necrosis in the brain poisoning her body?

    Cheerio
    Softship

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    1. In the case of the 4 year old who was kept on somatic support for 20 years after brain death it was found on autopsy that his brain had calcified.

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    2. Don't forget Terri Shiavo either. While she was in a persistent vegetative state, the shenanigans remind me of Jahi's.

      http://theness.com/neurologicablog/index.php/schiavo-and-the-persistent-vegetative-state/

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  12. I'm being serious here. It's a real question. Although morbid. So, if you took your hand to the top of her head and shook it back and forth would you hear liquid brain sloshing around? Kind of like a coconut? Why isn't her liquified brain coming out her ears or nose?
    I ask this because after my first brain surgery to remove a brain tumor in my pons fossa, I ended up with a significant cerebral spinal fluid leak. If drained out my nose like a faucet, I coughed up what went into my lungs... I was put on a CSF drain and after a emergency involving the drain malfunctioning and leaking every single bit of my spinal fluid out into my bed. The next day, another brain surgery to bone wax my brain and I've been leak free since but not without cognitive problems, due to the damage that was done because my brain sat on my skull and damaged it.

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    1. Jahi's brain has an intact sure (brain lining) and a working ventricular system so the system is closed and there is way for a leak to occur. In your case, it was the surgery that caused a hole and a leak.The bone wax was used to plug the whole. Different types of brain injuries.

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    2. Thank you for your answer. I don't know why I hadn't thought of the obvious dura involved in my case and hers. But still doesn't exactly explain if you shook her head, would it sound like a coconut? I'm morbid, or that comes across that way but I swear, I'm just curious.

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    3. it's okay, you have healthcare and emergency response people here. morbid curiosity is normal for us.

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    4. not, I know it seems weird however the brain is not really the same as a fake egg with candy inside. While her brain has decreased in size proven by MRI done by the family it is not the same as a water filled balloon.

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  13. How can the state of NJ still continue to pay for this child's care if she is brain dead? You know the family is not paying for it. At what point does the state say 'okay, enough is enough. If you think she is still alive mom, YOU pay for her medical care.' I know that's ugly to say, but people are denied everyday of medical care and they are ALIVE, so why is a dead person getting it?? Can't anyone come to their senses and force this family to let go?

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    1. This is what really bothers me is that New Jersey taxpayers are footing this bill. Court records show she is receiving Medicaid. Honestly not paying and having her heart stop would not be a bad thing. However the family would just show up at some hospital demanding care and then that hospital suffers the financial loss.

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    2. They are milking the system! They moved her all the way to New Jersey because NJ has a law that lets people in these situations be considered "alive" due to religious beliefs. It's a crock.

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    3. I totally agree!!! Why does the state keep paying for this?

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  14. As someone who lost his child years ago and his mother recently I definitely understand that dealing with death is a painful thing. It feels unreal and as if a part of you died along with your loved one. So I understand the parents of Jahi, however this girl is dead and at first I thought they would eventually let her go after they grieved and gave themselves extra time but it has been 3 years now and going by the mom behavior she's either in serious denial that she needs psychological help or she's profiting. Eventually even with the machines Jahi body will be the one that says enough is enough and her mom wont be able to stop whatever happens. I too saw that she was bloated (very bloated) and starting to feel as if her body is finally starting to give away. What the mom is doing is not only disgusting but it's dishonorable to her daughter who passed. I honestly do want to know when the state going to stop this, are we looking at another 3 years from now the mom is still keeping Jahi on life support? Bring in some medical experts again and order them to reevaluate her to see if her brain is giving away and her body is filling up with fluids. Most of all her supporters are sick in the head. I believe in God and I also believe in miracles, but it's clear he called this young lady home awhile ago. P

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    1. Thank you for saying this eloquently and much more tact than I'll ever be able to. Because, truly - enough is enough. Get with the program and become a parent of an angel kid (whoa-whoa I am as well) no one wants to join but in my case was given no warning, no say, and no control over my own daughter dying yet here you are unable to cope. I get it (sort of) I wish my daughter were still here but she's not. And hugging and talking to a dead body is just prolonging the grief period. It's time someone evaluate momma and get her the help she needs.
      I'm sorry for your loss.

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    2. "You are" meaning Mom Nails. Not you, you. And I forgot to acknowledge both your losses. My prayers are with you.

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    3. Thank you for your reply and trust me it was times I wrote and wasn't so pleasant to the mother on her Facebook and she banned me from posting. I know it hurts but she's taking it too far and her grief is going to be even worst to the point she probably end up in a mental institution. Also thank you for the prayers, still grieving over my mom whom I lost to cancer less than a month ago. She's pain free now and watching over her family. No more pain which helps me move forward.

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  15. I have a question, Is it true that Medicaid is funding Jahi care? and if so, can the state step in and ask them to stop funding unless proof is provided that Jahi is indeed alive? Because overall her body been legally turned over to her mother.

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    1. and the state declared her dead*

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    2. New Jersey has a statute that allows families to reject a brain death diagnosis. However, one of the legislators who drafted the exception said it was only meant to apply to people who were declared dead by neurological criteria in New Jersey. Jahi has yet to undergo a complete brain death exam including an apnea test since being transferred. The NJ lawmaker said the statute was never meant to apply to patients who were already declared dead in another state as in Jahi's case.

      It appears that her family was able to circumvent that rule by establishing residency and acquiring a NJ doctor who was willing to submit Medicaid eligibility paperwork stating that Jahi was a living but brain damaged patient.

      In response to a question regarding the legality of such a move Professor Pope conjectured that Medicaid simply approved her eligibility based on the NJ doctor's paperwork. I doubt there is a mechanism in place to question such things.

      As the court case slowly moves toward the discovery phase the defendants will have an opportunity to pursue an independent medical exam which will include a thorough brain death evaluation.

      In fact, that was supposed to happen by April 27th but due to the family's motion to bifurcate the trial that deadline has been pushed back indefinitely. If that exam verifies that she meets brain death criteria it's anyone's guess what might happen afterward.

      I suspect at that point Jahi's mother might try to invoke the brain death exemption since they have already established NJ residency. It's certainly an unprecedented situation.

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  16. I have a question. How come Jahis body isn't all bent up from not moving? Arms, legs, feet. I have seen people that weren't brain dead and there hands are all contracted, some in fetal position.

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    1. For the exact reason that she is brain dead so the body sends no signals. The patients with contractures are receiving signals albit bad signals but still signals. Brain dead people Re generally flaccid because the brain sends no signals

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  17. The state is not funding Jahi's care.
    The only way mamanails could move Jahi to New Jersey was to have the coroner file a death certificate which then allowed mamanails to take custody of the body and do what she pretty much wanted with it which was move her up north to a state where somebody can be claimed to be alive even when they are dead on religious grounds which is what mamanails did.

    They tried and as far as i know failed, to get the death certificate overturned.
    If she had succeeded then Jaho would be declared alive again and would then be moved back down south and the state would then become liable for Jahi's care plus there would be million dollar liability and compensation.

    I am pretty sure that mamanails and chums have refused to allow independent doctors to perform any tests that would conclusively prove Jahi is still dead.
    These include apnoea tests (claiming it would harm her further) brain scans and anything else remotely unfavorable to the story they are spinning.

    This does not smack of a parent in denial, it smacks of a parent seeking a chitload of money, fame, book and movie deals.
    If it was denial of the facts Jahi is dead then she would or should be allowing tests to be done that would prove her daughter was alive albeit profoundly and permanently disabled, probably requiring full life support until her body eventually gave up.

    Her main problem is that to gain custody of Jahi she had to admit Jahi was dead and get a coroners death certificate which made Jahi legally and permanently dead.

    No hospital or medical insurance provider will pay for care of a corpse.
    All that is keeping Jahi out of her well deserved and long overdue grave is donations and possibly pro bono work by sundry carers and doctors (doctors who are using Jahi to purport a theory and to get fame/infamy)

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    1. Court documents filed by the family indicate that she is receiving state Medicaid in New Jersey

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    2. @tania,


      A very minor point from California, where Jahi started.

      You say, "do what she pretty much wanted with it which was move her up north..." I feel like I'm fighting the Civil War again.

      New Jersey is somewhat "north" of California, but what it really is is 3000 miles EAST. It is not really "up north." Nor would returning her to California constitute taking her "down south," although California is somewhat south of NJ. What it is overwhelmingly, however, is WEST. You're looking, I think, for "back" east and "out" west.

      Not everything in the US is "up north" or "down south." Even if Jahi had been moved from California to Seattle, due north of Oakland, no one in California would say that she had gone "up north." Over here on the other side of the Rockies we see geography somewhat differently.

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    3. well, considering California, which is the southern end of the western US, considers themselves part of the pacific northwest, I can see that opinion. but it is true that their current residence in Jersey appears to e a more northern climate than Oakland, and part of the family complaints have been of being cold, even though you are right that Jersey is "back east" the north/south move seems to be the more significant one.

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    4. I'm a Brit so here everything is pretty much north or south from wherever your location is.

      Currently i am in the midlands but i used to live down south in North Devon which is technically southwest.
      I used the term up north as in A) i am crap at US geography although i can find Texas, Florida, California and Alaska.

      B)Everywhere else is either up north, down south, east(ish) or west(ish)

      C) America is way too big, has way too many states and distance is measured in hours not miles.

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    5. case in point: California is 12 hours from top to bottom, assuming you don't mind getting assessed for velocity tax.

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  18. medicaid fraud anyone?
    I wonder, if she is claiming for medicaid, is she claiming for a brain damaged daughter or is she claiming for a dead daughter?

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    1. she is claiming for a living but disabled daughter.

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    2. Given Jahi has a death certificate signed by a coroner does this mean mamanails is committing fraud?
      To get custody of Jahi's body she had to admit and accept Jahi was dead.

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    3. my opinion would be that she is. there is still a possibility she believes the state of California and CHO wants to kill her baby; some delusions can be incredibly persistent, and she has a very vocal "support group" promoting that delusion.

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    4. The death certificate was signed, but never filed. I don't know if that makes a legal difference.

      New Jersey had the facts when they admitted Jahi to Medicaid, including the facts about the death certificate. It's hard to argue fraud in that case.

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    5. I don't think New Jersey Medicaid was aware of her status in CA at the time her application was processed. Jahi spent the first 8 months in the PICU at St. Peter's Hospital when they moved her to New Jersey. Even though doctors there agreed she met the criteria for brain death they never performed an apnea test so she has yet to be officially diagnosed as brain dead in New Jersey.

      The family found a Christian fundamentalist doctor, Alieta Eck, to treat her once she left St. Peter's. This doctor signed off on the application with diagnosis code 348.1, anoxic brain damage. She spent so many months in the PICU because no long term care facility would accept her which is why she ended up in an apartment.

      http://thaddeuspope.com/images/Spears_v_Rosen_07-17-15_Opp_to_demurrer_.pdf

      Scroll down to the attachments to view the eligibility documents.



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    6. I would also be curious if the family members are getting paid by the government to take care of Jahi. ie: elderly/disabled patients that have family members being paid to care for their loved ones.

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  19. This is so tragic. If Jahi has any siblings they are the real victims. All the attention they should be getting is directed to a brain dead child. How very sad.

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    1. Agreed. This is not a healthy situation for them to be in by any stretch of the imagination.

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    2. and yes, there are siblings. well, step siblings. and yes, they are acting out in response to the neglect.

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    3. There are three half-siblings, all younger.

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    4. She also has an older sister. I don't know if she's a half-sister but it doesn't really matter. She was shortchanged by their mother too.

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    5. I seem to recall all the siblings had different last names. I can only hope they have been taken in by the respective dads' families and are hopefully living a more normal life.

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    6. I saw a photo of a younger relative kissing the corpse. If that doesn't lead to years of counseling I don't know what will.
      I just wanted to mention that the Schivo fiasco convinced my mother to write a living will. Unfortunately it was used less that a year later.
      I also want to thank the good doctor for keeping us informed.

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  20. Haven't been here for a while so let me weigh in with my opinion
    Reading the pleadings and the information there is no question that the diagnosis of brain death in the patient in 2013 was correct.
    If it was purely a medical question the whole case should have stopped there.

    But it didn't and so there is a legal question and that essentially becomes -is the diagnosis of brain death still correct. Now we presume so - but the fact is we don't know so. The expert statement "there is absolutely no possibility she will recover" is consistent with what we know- but is an opinion and is challengeable because we do not have a lot of experience with testing patients who have had long term somatic survival. For those medical people out there gnashing your teeth at that statement answer the question "how many times have brain death criteria been applied to someone who has survived somatically for more than a year?" I'd be surprised if the number is in double figures.

    My interpretation of that is that they should not only perform those tests again but should supplement them with an fMRI and a PET scan (which is after all the best current test at cerebral metabolism. Not because I think they will show activity but because I don't know what they will show and neither do the defendant experts.

    The case is not simply about Jahi McMth, nor is it a simple medical issue. For all the commentators who decry the family, that's all well and good, have at it. And no I don't think Jahi McMAth will ever wake up.

    But whether or not they intended it, her lawyers and family have raised a couple of legitimate questions where medicine does not have good answers but does have new technology. This will come up again. I think they should proceed with resting.
    Cory Franklin M.D.

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    1. and the problem is getting a test subject in circumstances where everybody is willing to use them for a test subject. I'm not sure I would want to be the test subject for that; and that would be a case where you would need to have someone who would say "okay, my loved one is brain dead, so we are going to spend the next few years studying how their body carries on under somatic support"

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    2. I have a question for Dr. Franklin. You suggest that Jahi have an fMRI and Pet scan done to supplement the brain death exam. I realize the dead salmon study I link to was done back in 2009 as kind of a lark but since then has there been more reliable research done regarding how useful fMRI would be as an ancillary test when it comes to diagnosing brain death?

      I have read where it's been used to predict the chances for recovery in PVS and minimally conscious patients and perhaps to determine whether someone was misdiagnosed as the former when they were actually the latter but how can someone who is thought to be brain dead "participate". I don't understand how that could work and given the chances of a false positive couldn't that give desperate families even more of an incentive to continue futile care?

      https://www.wired.com/2009/09/fmrisalmon/

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    3. Complex question there and I had to read the Wired article.
      Actually the Wired article sort of supports was I am saying. Yes, the dead salmon showed brain activity. But you know what that did? It told us something we would not have known- about fMRI scanning, namely that there are false positives when we correlate clinically. Good info to know.
      In the McMath case the legal proceedings have given us a unique opportunity - to actually see what these scans show in someone with prolonged somatic survival. As the Wired article states it will tell us more about the brain (and more about the tests).
      Remember, and this is important, brain death is an artificial clinical construct we created. It is a clinical situation with a number of variants in terms of movement (spinal), blood pressure and heart rate control, endocrine function, and somatic survival. Exactly what is going on with the brain in each of these cases? And what does it tell us about future cases. I always hear neuro experts say "Well,in brain death you can see this or you can see that." that's fine - but WHY can you see this or that?
      All of our brain death criteria were formulated decades ago before most of today's high-tech imaging.
      Let me make two points - First the routine diagnosis of brain death should not change as of today. Absent some new information - gained from cases like this - we should not apply the new techniques routinely. That may be a path for the future but not today, except in special cases - and what ever anyone says this has become a special case (prolonged somatic survival is reported but rare - as the neuro people would say - "you can see it").
      Second, yes this kind thing could always give families false hope. But remember most patients with brain death die somatically in a very short period of time, so it is not an issue for them. In mot other cases my experience has been that families do not want to prolong the situation - in this case the McMath's are again an exception. Most of the cases that make the papers are.
      It is just as likely that the information we get for new advanced imaging in brain death will solidify the question rather than leave doubt. I don't know.
      I doubt the advanced testing in Jahi's case will be dispositive in resolving the legal dispute. But it may indeed give us valuable clinical information for the future. It's hard for me to argue against that.
      thanks for asking
      Cory

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    4. I appreciate the thoughtful answer. I agree that advanced testing will probably not settle anything legally or emotionally in the case of Jahi's mother. I doubt anything short of McMath's heart stopping will convince her mom but legally, from what I understand, fMRI studies aren't even admissible as a lie detection method because the results can be too variable.

      I'm curious whether there would still be brain structure left after all this time on somatic support.

      Terri Schiavo's autopsy revealed an atrophied brain and the child who survived for twenty years on organ support had a calcified brain. Are you aware of any other post mortem brain studies done on people who were long term PVS patients?

      Determining possible function would be something else entirely.



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    5. I'm going to refer you to this citation.
      http://www.cmq.org.uk/CMQ/1995/neuropath_tony_bland.html
      A long time ago I wrote a piece on the legal problem of Tony Bland, who was a victim of the Hillsborough football disaster.
      This discusses his brain postmortem and that of Karen Quinlan.
      It speaks for more sophisticated imaging in coma patients.
      Cory

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    6. Dr. Franklin - unfortunately those case studies don't really apply here. Both Quinlan and Bland were PVS patients so never would (or could) have had a negative brain flow study. Jahi had a flow study done *2 weeks* after her anoxic event, which showed no blood flow to the brain. The extent of injury to her brain vs. either Quinlan or Bland is not comparable.

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    7. Thanks for the reference Dr. Franklin, it was an interesting comparison. I found it compelling that the author still believed:

      "Our lack of knowledge should not, however, deter us from making decisions about the futility or wisdom of various medical interventions. We can only make judgements based on our current state of knowledge. I have no difficulty accepting that a diagnosis of brain stem death equates with a statement that there is no likelihood of recovery and so all further treatment is futile."

      I agree with DocB that the cases aren't comparable to Jahi McMath but I did specifically ask Dr. Franklin about post mortem studies in PVS patients.

      So far, I don't think any of the "experts" on the McMath side have alleged that Jahi is in a PVS. Dr. Calixto believes she inhabits some new, unnamed category of alternate consciousness but even he didn't suggest she is in a PVS or a minimally conscious state.

      It's also interesting that both Quinlan and Bland lost significant body mass while Jahi still seems to retain hers. Shouldn't she also suffer from cachexia?

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    8. Doc Bastard:
      I think you are missing the bigger point. Trust me I am well aware that neither of those patients were brain dead.
      But the principle in Bland and Schiavo applies here.
      That is - to learn more about the brain in traumatic, anoxic, and degenerative situations, when there is long-term somatic survival we should be doing more imaging, not less.
      The issue I am addressing is not whether JAhi is PVS- the issue is what is going on in the central nervous system in a patient who was declared brain dead more than three years ago, yet survives somatically.
      This is isn't a routine diagnostic issue, nor is it a management issue for our purposes. What the courts decide here is something completely different, and to a certain extent divorced from medicine.
      I'm sorry if I did not make that clear.
      Cory

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    9. I apologise, I didn't get your point. That makes sense.

      It bears repeating, however, that at autopsy the Japanese brain death patient who "survived" somatically for 20 years had no discernible neural tissue remaining where his brain used to be, and that Jahi's brain was oxygen-deprived for nearly 2 weeks. I would be interested in at least seeing a CT scan of Jahi's head, though I can't see anyone justifying doing an unnecessary test on a dead patient. That would amount to treating her as a curiosity and doing tests on her just because her heart should have stopped by now but hasn't. That is ethically borderline at best.

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    10. except for the fact I wouldn't want to waste usable organs, I would say they could do a study of that nature on me.
      Mrs Ken and I already have an agreement that brain dead is dead, though.

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    11. I'm agreeing (from a lay point of view) with Dr. Franklin here. The argument "it can't happen because it has never happened, except that we've never been in a position to actually look" strikes me as circular. ("We declared her dead and the dead cannot rise so let's not look to closely to see whether we were wrong...") It is quite likely that the conventional wisdom ("it can't happen") is correct, but a persistent refusal to check up on it looks to me like ... there might be some doubt. In exactly the same way that the family's reluctance to permit further tests looks like they're afraid they don't want the answer.

      We're in unknown territory. "The issue is what is going on in the central nervous system in a patient who was declared brain dead more than three years ago, yet survives somatically." I don't see that finding out is ethically borderline any more than any number of investigative inquiries are. An autopsy for example cannot help the dead person, but autopsies are done in the hope of helping the living. I don't see anything wrong with that, especially since we're talking here about non-invasive tests which cannot possibly harm the patient.

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    12. my interpretation of the scenario is that it requires a person who is brain dead, but maintained on somatic support.

      the common cause of this is a family member who insists the patient is not dead, in which case, they will be resistant to any testing which might defeat their denial.

      this leaves only a person who is brain dead, whose relative knows they are brain dead, but is interested in seeing what changes happen in their body over time. - or in other words, wants to turn them into a bizarre medical experiment. I don't have any problems with a person doing that - but the odds of getting the right person are quite slim.

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  22. Last night I finally followed momma Nails Facebook and found the latest picture and oh my geez is she swollen. Horribly swollen.

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    1. How did you do that? Looks like her account is private. The Nailah Nailah account?

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    2. I think she means the FB that is in support of her remaining on life support. That is public. Jahi's face does look swollen.

      I also want to point out that it's not just Jahi's siblings who are likely being shunted to one side. Her stepfather also has at least one child (featured in a wedding day photo) and I can't imagine she's happy that her father has devoted this much time and attention to her dead stepsister.

      Or maybe she's good with it but I would be surprised if it were the case.

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    3. What I have noticed over the months is that back in Oct. of 2015 a hairdresser showed a photograph of braids that she put into Jahi's hair. The angle of the shot was from the top of the head. Jahi looked shrunken and skinny with obvious necrosis on her lip area. Then months later her mother put up a photo that looked "retouched" to me. It looked like the early photos of Jahi where she look fuller in the face. I am assuming the hairdresser had no motive to retouch any photos. But to me, the proportions of Jahi's face in the photos of this past year do not look correct. It looks to me like they had to "add" hair - it is just a black blur now, the face looks elongated, like they used imagery from an older photo and melded it with part of a new photo. The face look eerie out of proportion. How does one go from having necrosis on the lips and very thin, thin hair and waxy complexion to looking like she did 3 years ago? Not being medically trained, I am asking if this is possible?

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    4. I think you would want to be more photographically trained to address that topic.

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    5. Ken, I am photographically trained. Have worked in the graphics/photo arena since the 1980's. That is why I brought it up. Look closely at her FB page photo and look at the hair in comparison to last year. Looks like they took a photoshop tool and just filled in the areas. Also put a ruler to the face of the photos of today and the photos of 2-3 years ago. Something doesn't look right and especially after seeing the hairdresser's photo of a year ago. Just my opinion.

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    6. Anon april 13 2:37 i believe this was touched on in a previous blog post, dor at least it was discussed in the comment section. Somebody on the internet was able to undo all the photoshop and reveal the actual photo underneath revealing the horrible state shes in.

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    7. you missed the implication. that being that her appearance has more to do with photo manipulation than medicine.

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    8. Ken, thanks. After I posted I realized your tongue in cheek and laughed at myself for being too serious and not understanding your intent.
      And thanks Connor. I don't subscribe to all of the blogs would have been interesting to see because I know what we see on the FB page is not current nor accurate.

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  23. Perhaps Jahi is temporarily dead for tax purposes?



    Zaphod Beeblebrox: Did you talk to the big noiseboy?

    Ford Prefect: Hotblack? Yeah, I sort of spoke to him.

    Zaphod Beeblebrox: What did he say?

    Ford Prefect: Nothing much. He's, um...

    Zaphod Beeblebrox: Yeah?

    Ford Prefect: He's spending a year dead for tax reasons.

    Hitchhikers Guide to the Galaxy

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  24. I am surprised that her blood deprived brain has not developed gangrene. How has she avoided sepsis?

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    1. Jahi's body is young and is receiving nutrients, hormones, antibiotics, etc.,as well as oxygen. Her body can go on like this for years, as long as her pressure sores are not allowed to get infected. Unless her NJ Medicaid funding ends and her mother accepts that she's dead, they can stay there for years.

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  25. This is somewhat analogous to the Teresa Schiavo case, where a young woman was kept on a feeding tube for many years.

    Teresa was not brain dead, and no one on either side contended that she was. She seemed to be conscious to some extent, and to react to her family (though it looks as though those reactions were random). But there was a famous (on the internet) video of Teresa following a balloon with her eyes.

    Then comes the autopsy, and we learn that the part of the brain which processes vision was missing in Teresa. It had died, it was just not there. She was blind not because there was something wrong with her eyes, but because her brain was not there to process visual input.

    Jahi's situation as to hearing is apparently the same. "The brain stem auditory evoked potentials test performed at University Hospital on September 26, 2014 . . . demonstrates that as a result of J. McMath's brain death she has no auditory pathways; there were no evoked potentials to maximum aural stimulation. "

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    1. It's interesting to note that to this day the Schiavo family does not accept the autopsy results. I lived in Southampton, Pa and the Schiavo family is from that area. I followed the case closely.
      The government involvement in that case was scary.

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    2. Yet they have posted the autopsy report on their website.

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    3. I remember reading about the father saying don't let anyone tell you she was blind. This was in response to the autopsy. It's strange that they posted it as the results pretty much disproved everything her supporters were saying... Then again that entire farce was strange LOL

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    4. http://www.washingtontimes.com/news/2014/jan/16/schindler-my-sister-terri-schiavo-was-alive-like-j/

      Sigh...

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  26. If/when she's proven brain dead once and for all (in court) two for sure things will happen: it is going to take a hella chunk off MomNails settlement to pay back its tax payers. (Even if she loses-there will be some sort of money involved) and two, Mom Nails will forever be the victim here. For the remainder of her life, expect to hear in one way or another (books or movies) how MomNails was oh so forced to "kill" i.e.: let her daughter actually die. Die die like 6 feet under die.

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  27. Someone needs some research money and a "willing" patient to watch the metabolic/organic breakdown of the not so dead, for the cases like Jahi.

    I have kids, I get it, how far are you willing to fight to keep your kid a"live"..
    But, the counselor in me says, the mother isn't mourning, and is seeing what she wants to see and is stuck in denial and bargaining of the grief process.. And when the time comes this fight will have hurt more than helped..

    In California death laws state, the body is the next of kin property.. Once they issued that death certificate that body belongs to the family and they have every right to do as they please for lack of better terminology, please don't be a smartass and say necrophilia..
    I don't get how they did the transition from death to on a flight with all life support still intact, once she was declared the hospital didn't remove the tubes and vent? I suppose the restraining order kept them in place because the hospital was not allowed to touch her..
    From Schrödinger's cat to Frankenstein, this needs to be study to advance medicine.. She is both alive and dead, but neither alive or dead... Without being allowed to do more studies on her we can tell you from a study of her brain three years ago she is dead kept "alive" by machines and medicines, however, she should have had some form of breakdown and her heart by studies should have stopped and disallowed her body to continue being kept artificially alive by somatic support..
    So was she almost all the way dead is the question, can death be more or less than we originally thought of by medical standards that can be considered outdated..
    I'm going to make a fallacy argument, BMI is based off a military young white male, fast forward 50 years and we come to find out minorities and females have different body structures and they don't always fit in the parameters of the original BMI..
    In the case of brain death- I get, it's black and white, what if there is a very small gray.. We just don't what the gray is..
    My belief is death is the greatest equalizer.. If the docs said hey Cali you can live forever but you will have to be rolled like a log, someone will have to pump meds in to you, you will never see, hear, speak or feel again, how about our new live forever garden.. My simple question is why are you afraid of death.. My answer is just as simple- No, those regrets and fears are for the living, they don't get to pluck me in a garden of the undead because they fear death, they don't get to make their regret someone else's burden.. Living on a machine will not make me be me, and it will not fix regrets or bring comfort, if I die mine will not stop loving me, so forcing me to be alive so you mine can continue to love me, is not justification..

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    1. My family had to remove a very young uncle off life support, 23 years old.. Was shot execution style in a home burglary.
      This was back in 81, they did the tests, showed no blood flow to the brain, showed shadowing of the brain from the swelling of the brain crushing parts of his brain.. The docs told us, he was brain dead, however, if we did keep him "alive" he would forever be on machines.. My uncle was a true native, hunting fishing, outdoorsy in every aspect.. Even in doubt of the docs, maybe he would be in a vegetative state, would it be what he wanted.. They gave us three days to say our goodbyes, because even in grief we couldn't force him in to "living" via life support even in doubt of the doctors- there is a chance he would be vegetative, that's not who he was or how he lived..
      I still love him, I still miss him, we still visit the cemetery he is buried next to his brother in, I still talk to them.

      On work Saturday my guys were discussing life support, they started using "pull the plug", my call receiver had a horrified look.. I stop my guys banter and said- keep it fkn PC, it's called removing life support, the loved one on life support isn't a laptop or computer you just pull the cord out of the wall, and sometimes when you do remove somatic care the body still "lives" after for a short time.. Don't be callous, you never know who has experienced this, as I glance over to my near tears call receiver..
      Apparently a buddy of theirs went on a oxy/meth binger, and had a stroke and heart attack, they had him on life support for a week and decided to remove it and the guy is still breathing on his own, they said it would take three days for shut down, they removed it Wednesday and it was Saturday when we talked..

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    2. Motel Styx: we'll keep the respirator on for you.

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    3. I believe some of your questions have been answered in the comments and FAQ of this blog.

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  28. not sure why but i am always disappointed when you right about this poor young girl. her family is disturbed but I just don't care

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  30. Why is it that she keeps on "living" when Mirranda Grace Lawson, who was only 2, did not?

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    1. there are many possible factors that could make the difference. the best a person could do is speculate; but overall, it is very unusual for a brain dead person to be undead for as long as Jahi has. as has been said multiple times over the past three years, there are a huge number of things that can go wrong.

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  31. Mirranda's parents were successful in preventing the hospital from discontinuing somatic support but they were unable to compel them to perform a tracheostomy and insert a feeding tube. The same was true in the Aden Hailu case. Mirranda survived for 6 months and Hailu about 9 months.

    In the well publicized cases of brain death disputes since Jahi it seems what the long term survivors had in common was the tracheostomies and feeding tubes. None of them recovered brain function but their physical conditions remained stable longer.

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  32. Hi Doc. I hope you are OK as it has been a long time since your last post.
    If you are having some well deserved vacation time, may it be filled with fun and frolics.

    Keep up the good work.

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