Case 11
So full of life and laughter only 48 hour ago, Mr. Ahmed now lay in the ICU of the local community hospital after suffering a massive heart attack. While CPR was successful in securing a heartbeat, there was only marginal brain activity, and he could breathe only with the assistance of a ventilator. The well–liked, energetic patriarch of a large Shiite Muslim Arab–American family, Mr. Ahmed was known as a generous family man and a community leader. Indeed, while several of Mr. Ahmed's adult children were flying in from out–of–state, friends came to the hospital to lend emotional support to the family. Mrs. Ahmed remained silen as her son Tony spoke with the doctor, Linda Hopkins, MD. Dr. Hopkins's suggested that the family begin to think about withdrawing ventilator support. Tony's reaction was strongly negative. Even though Dr. Hopkins explained to him that his father would not regain consciousness, Tony insisted that every effort be made to keep his father alive. When Mr. Ahmed's other children arrived at the hospital, Tony filled them in on his conversation with Dr. Hopkins. Meanwhile, Nurse Janet Simpson, RN, attempted to talk with Mrs. Ahmed about what she thought her husband would have wanted for himself in this circumstance. Because they never spoke to one another about such things, Mrs. Ahmed felt uncomfortable speculating. Concerned that his mother was too distressed to talk, Tony broke into the discussion. He reiterated that the family wanted everything done to save their patriarch.
Anxious to diffuse the emotionally charged circumstance, Nurse Simpson recommended that the family sit in a conference room to talk with Dr. Hopkins and the staff Imam from pastoral care. While they were waiting for Dr. Hopkins and the Imam, Janet listened to the family talk about Mr. Ahmed and their family. Tony used to help his father with the family business, a neighborhood grocery store. However, he and his father often disagreed about business decisions. Tony had always been critical, for example, of the amount of money his father spent sponsoring local youth athletic teams, providing uniforms, refreshments, and trophies. These differences of business philosophy led Tony to take a job out of state several years ago. The daughters, however, still lived close to Mr. and Mrs. Ahmed and still helped keep the books for the store. In fact, the youngest daughter, Rita, was at the store with her children, decorating the store window for the holidays, when Mr. Ahmed suffered his heart attack.
Dr. Hopkins arrived, and the Imam shortly after. The Imam explained to Dr. Hopkins and Nurse Simpson that for Shiite Muslims cessation of brain activity is not considered death. Instead, he explained, they believe that death means cessation of cardiac function. The Imam then helped the family to understand that because Mr. Ahmed's brain activity would likely soon cease, from the standpoint of the medical staff, he would then be dead, even though, in all likelihood, his heart and lungs would still function. After a long pause in the conversation, Nurse Simpson asked the family to imagine what Mr. Ahmed might say if he were sitting among them. "He would say that we should keep trying," said Rita. Other family members nodded.
As time passed, brain activity waned until Mr. Ahmed was brain dead. Dr. Hopkins spoke with the family about Mr. Ahmed's condition. 'We're sorry that there isn't anything more we can do. We think that we should turn off the ventilator and let nature take its course." The family appeared shocked at Dr. Hopkins's suggestion and Tony responded angrily, "How can you say that you've done everything you could? I'm not going to let you give up on him as long as he's still alive." Later, Nurse Simpson reminded Dr. Hopkins about what the Imam had said regarding the Shiite beliefs about death. "That's fine," she said, "but by 'death' we mean brain death, and that's the law."
After a day and a half, Dr. Hopkins was growing impatient. She felt that allowing a brain dead patient to remain breathing on a ventilator was permissible for a brief time if it would allow out–of–town family time to get to the hospital to say goodbye. However, Mr. Ahmed's family had been present for over a day, and was still insistent upon doing everything to keep him alive. Worried that she had alienated the family, Dr. Hopkins asked Nurse Simpson if she could try and talk to the family.