Case report

A 3 year old Jewish girl was being investigated by a paediatric neurologist at another hospital because of unsteadiness, intermittent tremors, and facial weakness. Magnetic resonance imaging, performed under general anaesthesia, showed a large, right sided, temporal mass extending into the midbrain. The scan was performed as a day case and the child returned home to await urgent neurosurgical referral. The procedure had been undertaken without event, but some hours later the girl suddenly became unresponsive and was taken to her local hospital by emergency ambulance. She was found to have a reduced level of consciousness, posturing consistent with a decorticate state, and unequal pupils. The girl was treated with dexamethasone and mannitol and was referred to our institution for further management. She was assessed by our transport team and was intubated before being transferred to the paediatric intensive care unit.

On arrival at this hospital, the patient was taken to theatre for emergency debulking of the tumour. At craniotomy her intracranial pressure was grossly raised and although some tumour tissue was resected, the procedure had to be abandoned after 7 litres of blood had been lost. The tumour cavity was packed with surgical swabs and the skin was closed. When she returned to the intensive care unit, the child was bradycardic, hypertensive, and had a fixed and dilated right pupil. The parents were told that the prognosis was hopeless and that their daughter had been brought back to the intensive care unit to die. Some hours later, both pupils became fixed and dilated. Formal brain stem testing was performed the next day and the child was certified to be brain stem dead.

The intensive care team advocated withdrawal of care, in line with the recent Royal College of Paediatrics and Child Health guidelines.1 However, this was in conflict with the family's wishes. They had consulted their rabbi, who insisted that Jewish law would not allow treatment to be withdrawn. Under Jewish law the child was still alive, and to withdraw or withhold care would be tantamount to murder.

Medical and religious interpretations

Brain stem death has been accepted as death of the individual in the United Kingdom since 1976, when the royal colleges published criteria for making a diagnosis of what was then called brain death.2 The Royal College of Paediatrics and Child Health and the Department of Health have accepted the criteria as being applicable to term infants and children over 2 months of age. Such is the degree of consensus on the issue that supporting legislation has not been required.

As Jewish law is hundreds if not thousands of years old, it does not deal with the issue of a brain stem dead patient on a ventilator. However, the definition of the moment of death is addressed. In one source, physical decapitation of an animal is said to determine death even if there is some degree of subsequent movement, provided that it is “pirchus be'alma,” or like the “severed tail of a lizard that twitches spasmodically.”3 Another source states that in the case of an individual trapped under a fallen building, absence of breathing may determine death even if cessation of the heartbeat is not established.4 Progressive Jews, who accept brain stem death as a valid determinant of death within the Jewish tradition, argue that it is physiologically equivalent to decapitation—that destruction of the brain stem means inability to breathe spontaneously and that movement of the heart as it beats falls into the category of “pirchus.”5

The arguments against the latter view are that brain stem death is not the equivalent of anatomical decapitation and that the coordinated beating of the heart and maintenance of circulation cannot be characterised as “pirchus” since it is no different to the beating of the heart in a normal individual. In support of this view, there are also sources which state that death has occurred only when there is neither breathing nor cardiac pulsation.6 7 Since this is not the case in a brain stem dead patient on a ventilator, these patients are not considered dead. This is the majority view in the orthodox tradition, 8 9 and it is summed up below by the former chief rabbi of the United Kingdom and expert on Jewish medical ethics, Lord Jakobovits.

So long as the heart still functions and the blood circulates, death has not yet set in. But this does not mean that a lingering life, especially when experiencing great pain, must be prolonged at all costs and in all circumstances. While one may not actively cause or hasten the onset of death, and one may therefore never withhold normal and natural means to sustain life—such as food,drink, blood, or oxygen (or air)—one need not artificially prolong life … by administering antibiotics … to suppress infection. Thus, one may allow nature to take its course by withholding such treatment. On the responsibility for making such decisions … affecting life and death, it should be emphasised that these should, wherever possible, be left to disinterested parties, preferably including experts, including moral specialists such as experienced rabbinic authorities.

The practice of maintaining brain stem dead patients on mechanical ventilation until they become asystolic has largely ceased in the United Kingdom as a result of the clear guidelines of the royal colleges. However, published data show that even if supportive care is continued, asystole occurs within days of brain stem death.10

Our care plan

After discussion with the rabbinical authorities, a plan of care was agreed in line with Lord Jakobovits's recommendations. No action was taken to hasten cessation of the heart beat. Ventilation and intravenous fluids were continued. There was, however, limitation of care to allow the heart to stop beating as soon as possible within the limits proposed by Jewish law. Invasive and non-invasive monitoring were stopped and antibiotic treatment was withdrawn. There was to be no resuscitation in the event of an arrhythmia, no endotracheal suction, and no renal support. Asystole occurred four days after the child had been declared brain stem dead.

Conclusion

The aim of intensive care should be to treat the family, not just the patient. Thus, we suggest that when an orthodox Jew is declared brain stem dead while on mechanical ventilation, a death certificate should not be issued. In these unusual circumstances it is more important to respect the cultural traditions of the family than to free a bed in the intensive care unit. Asystole will occur within a few days. It should be possible to reach a compromise with the religious authorities about the level of active care that is required under Jewish law while permitting sufficient limitation of care to allow asystole to occur as rapidly as possible. However alien the belief system of Jewish law is to staff on the intensive care unit and however difficult it is for them to continue supportive treatment, the families concerned should not be asked to become “accessories to murder.”