Friday, December 18, 2009

Cheating Death: A Book Lost in Definitions


"Death is not a single event, but a process that may be interrupted, even reversed. And here's the exciting part – at any point during this process, the course of what seems inevitable can be changed. That is precisely what we are going to explore in this book: the possibility of cheating death."
These are the words of Dr. Sanjay Gupta, a practicing neurosurgeon, the chief medical correspondent to CNN, an almost Surgeon General, and now author of the book Cheating Death. Cheating Death is, in Dr. Gupta's own words, a "medical thriller". This is an apt description considering the dramatic prose that the author infuses into this book. Dr. Gupta lavishly uses inspirational and exceptional real life stories to make his point that medical science is blurring the distinction between life and death. His tale weaves the science of hypothermia protocols, CPR resuscitation techniques, hibernation and suspended animation research, near death experiences, and fetal surgeon into a gripping argument that if you and your physician “fight” hard enough, and don’t “give up”, you can overcome practically everything, even death [insert collective GeriPal groan here].

I completely understand that I am not the intended audience of this book. I also understand that this book is intentionally sensationalistic, as most mass journalism is today. However, even if I resign myself to read this book as a piece of modern infotainment, I am still unable to get past its biggest flaw – the complete lack of consistency when using the term “death”.

Dr. Gupta does an excellent job near the beginning of the book describing death as not as an event, but a process. He views it as an "ongoing chain of events that might be reversed with the right intervention". This sounds like a similar definition to those described by some in the palliative care field when discussing DNR status with patients ("If you were to die, would you like us to try to resuscitate you"). It is also similar to the description of death used by the character Miracle Max in the Princess Bride when describing a seemingly lifeless body in front of him:
"It just so happens that your friend here is only MOSTLY dead. There's a big difference between mostly dead and all dead. Mostly dead is slightly alive."
Dr. Gupta however seems to jump in and out of the process of death definition throughout the book. His anecdotal accounts of people who "cheat death" range from people who were "dead", "clinically dead", "virtually dead", "nearly frozen to death", and "returned from the dead". Sometimes he uses these various terms interchangeably when discussing the same patient. Even when he describes death as a cascade of physiologic and metabolic events, he hedges by saying that these are steps "toward death".

This lack of clarity or consistency comes to a climax in the chapter titled "What Lies Beneath". Dr. Gupta seemingly confuses "brain death", coma, and persistent vegetative state, something that I find unforgivable in a book written by a neurosurgeon. His main example was that of Mark Ragucci:
"You won't find a better example than Ragucci. His doctors might have given up, but he can tell the story today because one doctor didn't – and because something inside Ragucci was able to bounce back, something that gave him the strength to cheat death: brain death."
Mark Ragucci was never declared brain dead. He was placed in a medically induced coma for refractory seizures and suffered severe brain injury from strokes, but at no point in time was he declared brain dead (Dr. Gupta’s definition does seem to change later in the chapter when he states that Mark was “nearly brain dead”). Am I reading too much into this considering the lack of clarity of this chapter? I would say no. The publishers own synopsis of the book makes clear where the book stands on the concept of brain death:
Extended cardiac arrest, "brain death," not breathing for over an hour-all these conditions used to be considered inevitably fatal, but they no longer are.
When discussing the diagnoses of "brain death, vegetative state, and minimally conscious state” Dr. Gupta goes on to say that "a patient may improve or decline from one state to another". Really? Declaring someone dead by brain death criteria does take some expertise, and there have been some misdiagnoses reported, but to make a statement that patients who meet the criteria for brain death can improve and "cheat death" is reckless and harmful. There is a great deal of misinformation about brain death in the lay public and in the media. Dr. Gupta's use of the term "brain death" only worsens this confusion.

I will say, in defense of Dr. Gupta, attempting to define death is an incredibly complex task, as seen by the great deal of literature attempting to discern what death actually means. The "process" definition of death as used in this book, one in which someone can go in and out of death by having physicians who "don't give up", is lacking one critical concept - permanence. Once someone is dead they remain dead. The "irreversible" nature of death may depend on someone's cultural and spiritual beliefs. For some death may not be rooted in science or physical laws; death may only mean that the soul, or metaphysical spirit, no longer animates the body. However, from a medico-legal and clinical aspect, permanence is integral to any societal criteria of death. Death certificates, clinical trial outcome data, practical needs of family members, and organ donations rely on the irreversible nature of death.

Dr. Gupta put in a tremendous amount of work to search for the most extraordinary and sensational cases in order to make his story dramatic. Yet, in doing so, he loses sight that everyday stories do a better job in describing the fine line between life and death. Dr. Gupta may do well by heeding author Mitchell Stephens warning:
"When journalists confine themselves to the search for the violent or the miraculous, not only do they paint a grotesque face on the world, but they deprive their audiences of the opportunity to examine subtler occurrences with larger consequences".

10 comments:

Dan Matlock said...

great summary Eric

Jan Henderson said...

Thanks, Eric. I could tell this wasn't a book for me as soon as I got it home from the library.

I wanted to share this end-of-life decision from a NYT op-ed today: http://www.nytimes.com/2009/12/19/opinion/19sat4.html?th&emc=th

"Which means that now is the time for a hard decision. According to the vet, there are no signs of disease, other than the disease of age — nothing to force our hand. When Tavish died, four years ago, his liver was failing, and there was no choice but to sit on the floor and hold him while the vet inserted the final needle. It’s somehow not surprising that Darcy raises the matter of our responsibility in its purest form.

"I’ve known too many owners who waited far too long to put their dogs to sleep, and I’ve always hated the sentimentality and the selfishness in their hesitation. Last week, watching Darcy out in the sun, it felt as though I was trying to decide just when most of the life — the good life, that is — inside her has been used up. Is it conscionable to wait until it’s plainly gone? Or is it better to err on the side of saying goodbye while she’s still discernibly Darcy, while she seems, as she nearly always does, to be without pain?"

ken covinsky said...

Fascinating review. I did not read the book, and based on this review probably won't. I did see parts of the related special hosted by Dr. Gupta on CNN. Some of the stories of survival were certainly inspiring.

That said, the stories tended towards the sensationalistic, particularly the contention that one can "cheat death" if one just tries hard enough.

It does sounds like the book creates some confusion around the issue of brain death. I dont recall this being an issue on the CNN special, though I could have missed this. The components I saw on CNN convey the sense that medical technology can now save some people on the brink of death, who probably would not have survived in the past. That is all fine, and there is nothing wrong per se with conveying this or describing these interesting stories. The problem is that these cases are vastly different from most of the patients in ICUs, in whom aggressive of medical care decisions will need to be made. Most of the stories I saw portrayed on CNN apply to generally well, high functional status people who have a catastrophic event.

In some ways, these issues reminds me of a NEJM paper that described CPR as portrayed on television--which was wildly optimistic in terms of outcomes and survival (http://content.nejm.org/cgi/content/abstract/334/24/1578). There was nothing wrong per se with each of these TV shows---it is certainly there purview to be dramatic. However, collectively, these shows were probably damaging to the public by creating an untrue sense of the outcomes of CPR.

I don't really have a problem with Dr. Gupta choosing to write a book about dramatic cases. These cases are not typical, and the book may not create a correct image about what medical care can offer to most people. It is important that this be made clear to the public.

Perhaps one of the problems is that Dr. Gupta's responsibilities as CNN's chief medical correspondent is different than his responsibility as an author. I am not sure how these roles should be balanced. I am not sure an author has a responsibility to present a balanced perspective. However, in his CNN role, objectivity and balance are important. While it is certainly fine to present compelling human interest stories, they should be presented in proper perspective. Perhaps the CNN coverage needed to take a different perspective from that of the book.

ElderLaw said...

This reminds me of that old rumor that if you check the box on the back of your driver's license to be an organ donor, the EMTs won't try as hard to save you. Very responsible, Dr. Gupta. Not.

Mike said...

Thank you, thank you, thank you for writing this criticism. It has been extraordinarily frustrating these last few months since "Cheating Death" has been published to see so little criticism of Gupta's obvious misinformaton concerning brain death. His co-author (ghost writer?) Caleb Hellerman in the Amazon reviews, and whoever supervises the CNN comments pages, have actively obfuscated and stonewalled criticism. Comments critical of Dr. Gupta are cencored on CNN. BTW, there are only 3 critical views with low votes to the 9 praising reviews on Amazon. It would be worth your time to post there.

I can add two things. This isn't something new for Gupta. He's been misinforming about brain death for years, and has been criticized for it before. See Truog RD. Brain death – too flawed to endure, too ingrained to abandon. Journal of Law, Medicine, and Ethics 2007; 35(2):273-281. For those that doubt the criticism is justified, see the white paper from the President's Counsel on Bioethics from this year: http://www.bioethics.gov/reports/death/index.html
The current professional discussion about brain death is about improving the definition of death and the protocol for determining irreversible upper brain function, not about a supposed failure of brain death.

The other thing is that I've come to believe that Gupta's motivation for doing it is right there in the book. Against any evidence he actually does believe that a surgeon could reverse brain death, and that brain death is just a variation on vegetative state. The surgeon as god, in other words. You're not dead until Sanjay Gupta says you're dead. In interviews promoting the book he claims that he has personally seen the charts of patients who were declared brain dead but survived. This is deceitful in that he has not published anything about this in the peer reviewed liturature. In other words, he's delusional. He prefers his own subjective misunderstanding of brain death to the objective consensus understanding because it serves him better. Its more sensational.

firman said...

I'm really disagree that "You're not dead until Sanjay Gupta says you're dead" . cos I'm not a "MD" . I just believe that it's same other perspective that human kind think "I'm a God".

Jerry said...

So, would any of his peers (physicians, surgeons, neurosurgeons) consider this book an example of malpractice?

A question for laypeople, or for non-physicians, might be - what purpose or benefit is served with this book?

Personally, I see the book as yet another example of how members of the corporate media act to protect or advance their own material interests.

Gupta sure couldn't pull off this deceit if he was a blogger.

Eric Widera said...

Thanks for the comments. I actually thought this book had some potential. Dr. Gupta does have a good writing style that is very accessible to the general public (something that is very hard for doctors to do). He also does a good job of presenting his case that the medical profession is making great strides in prolonging lives of those critically ill.

What is lacking though is any relevance to what occurs in the day to day work in a medical ICU or in working with patients who are chronically ill. As a neurosurgeon Dr. Gupta may not have a lot of experience with this population, but in writing this book he should at least acknowledge that most people now a days die of chronic progressive diseases rather than falling through the ice in a Scandinavian glacier.

Mike - I am not knowledgeable about Dr. Gupta's previous work to know whether his blurring of "brain death" and PVS is a common theme. I would like for him to set the record straight though considering that he is the chief medical correspondent to CNN (or at least move over to Fox News)

soulfulsilkee said...

Hi,
Thanks for writing the review of the book. When I saw the title "cheating" death, I knew the book wasn't for me.

I have a terminal degenerative brain disease and I consider death a process not to be feared but as a part of life.

Also there is life then there is just hanging on in limbo between life and death. When I get to that point of limbo, my personal option is to go ahead and cross on over to the other side.

Dying is teaching me so much about living.

Anonymous said...

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