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On Being a Doctor |

The Man with No Heart

Ari Mosenkis, MD
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From University of Pennsylvania School of Medicine, Philadelphia, PA 19104.


Requests for Single Reprints: Ari Mosenkis, MD, University of Pennsylvania School of Medicine, 415 Curie Boulevard—700 CRB, Philadelphia, PA 19104; e-mail, mosenkis@hotmail.com.


Ann Intern Med. 2005;143(12):915. doi:10.7326/0003-4819-143-12-200512200-00011
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As I was en route to the parking lot on a cold autumn night, my pager started beeping. I was a new renal fellow on call, and this was an all-too-familiar, yet still unnerving, occurrence. The number to call back was one I didn't recognize: the OR. When I returned the call, I learned that a heart transplant had failed with disastrous complications. The patient was hypotensive and grossly volume overloaded. The transplant team was requesting intraoperative dialysis.

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A Straw Man with No Heart
Posted on January 2, 2006
David Goldblatt
University of Rochester (NY; emeritus)
Conflict of Interest: None Declared

TO THE EDITOR: Dr. Mosenkis (1) tells the harrowing story of a man whose newly transplanted heart ceased to function. An extracorporeal membrane oxygenation device (ECMO) provided circulation and oxygenation. The patient awoke from operative anesthesia as a "man with no heart" and remained that way until a second, successful transplant could be performed. "Figuratively," the author says, his courageous patient "did have a heart all along."

Unfortunately, Dr. Mosenkis digresses to a flawed discussion of definitions of death. He states that many persons debate "brainstem death or cardiovascular death. According to proponents of [a brainstem] definition, a person is considered dead when the brainstem dies, even though the most vital of the brainstem functions, breathing, is easily and effectively replicated by a machine." He poses a rhetorical question: might not his patient, by analogy, be considered dead because his "heart and circulatory functions," the traditional criteria by which death is judged to have occurred, ceased for two days, even though his circulation was maintained artificially? Dr. Mosenkis sensibly dismisses the idea: the patient was awake and "by any definition . . . was alive."

In the United Kingdom and some other countries, death is legally defined as irreversible loss of all brainstem functions. Ancillary tests of higher brain function are not required for the diagnosis of brainstem death, "because death of the brainstem is regarded as equating with death." (2) Although "bedside clinical criteria for determining [whole] brain death and brainstem death are identical,"(2) the whole brain definition used in the United States has theoretical and practical advantages. (3) In either way of defining death by cerebral criteria, there must be unresponsive coma without confounding anesthesia, other drug effect, or hypothermia; absence of brainstem reflexes; and apnea. (2-4)

The lost function most relevant to diagnosing death is not breathing or heartbeat; it is consciousness. Irreversible coma is always the diagnostic sine qua non. By limiting his consideration of definitions of death to two functions for which machines can compensate, and bringing his patient into the discussion, Dr. Mosenkis made his man with no heart into a straw man"”a bit of wizardry that even L. Frank Baum did not imagine. David Goldblatt, MD University of Rochester School of Medicine and Dentistry Rochester, NY 14642

Correspondence to 232 East Lake Road, Penn Yan, NY 14527; dgoldblattmd@verizon.net

References 1. Mosenkis A. On Being a Doctor. The Man with No Heart. Ann Intern Med. 2005;143:915. 2. Swash M, Beresford R. Brain death still-unresolved issues worldwide. Neurology 2002;58:9-10. 3. Bernat JL. Ethical Issues in Neurology, Second Edition. Boston: Butterworth-Heinemann 2002:251-252. 4. Wijdicks EFM. Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria Neurology 2002;58:20-25

Conflict of Interest:

None declared

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