Table of Contents

END-STAGE CARE OF THE HUMAN CRYOPRESERVATION PATIENT
CHAPTER 4: Dealing with the Patients Health Care Providers

by Michael G. Darwin

Copyright 1994 by Michael G. Darwin. All rights reserved.

Alcor Disclaimer: This manual was written in 1994 by former Alcor president, Mike Darwin, for his own cryonics service company, BioPreservation, Inc., which ceased operation in 1999.  The opinions and procedures in this manual are not necessarily those of the Alcor Life Extension Foundation.  The manual is reproduced here for its educational value in explaining the many challenges of implementing cryonics in practical settings.

Technical sufficiency was the chief means by which the Hippocratic Aesclepiads gained the confidence and friendship of patients, but it was not the only one. Two of the later writings of the Corpus Hippocraticum (On the Physician and On Decorum) describe in minute detail the non-scientific measures to be adopted by a doctor to gain that confidence. His clothes must be decent and clean, and he should be discreetly perfumed, “for all such things please a sick man”; he must lead an honest and regular life, his manner must be serious and humane; without stooping to be jocular or failing to be just, he must avoid excessive austerity; he must always be in control of himself. In the second of the writings mentioned above, even more detailed advice is given. The doctor must be “serious, artless, sharp in encounters, ready to reply, stubborn in opposition, with those of like mind quickwitted and affable, good tempered towards all, silent in the face of disturbances, in the face of silence ready to reason and endure, prepared for an opportunity and quick to take it…setting out in effectual language everything that been shown forth, graceful in speech, strong in the reputation that these qualities bring.” — From Doctor and Patient by Lain Entralgo

The medical staff caring for the patient can have a profound effect upon the course of the standby and transport. Medical staff can help us (or hinder us) in all of these crucial areas:

1. Prompt pronouncement of legal death. 2. Minimizing the chance of a patient becoming a Coroner’s or Medical Examiner’s case. 3. Assisting with the logistics of transport. 4. Ordering valuable laboratory studies to help determine the patient’s remaining time before legal death. 5. Documenting the patient’s pre-cardiac arrest condition. 6. Helping to minimize discomfort for the patient 7. Supporting the patient’s decision to be cryopreserved, and dealing with family and friends.

At least five factors will affect the amount of support and cooperation that we receive from the physician and other medical staff. In order of importance:

1. The personality of the individual physician and the personalities of other medical staff in the hospital or nursing home where the patient is located. 2. The personality of the standby team leader, and the personalities of other team members and cryonicists who are involved in the case.

3. The degree of professionalism and the approach used by the standby team in dealing with the medical and nursing staff.

4. The policies of the institution caring for the patient, and their approach to problem solving.

5. Local regulations and the general social climate affecting the hospital or nursing home.

It may not be feasible or financially possible to alter some of these factors, and even where some improvement is possible, it will often be minimal. Bearing this in mind, we will focus primarily on the factor which is most easily under our control: the approach used by the standby team in dealing with the medical and nursing staff.

First Contact

The first impression created by cryonics personnel will inevitably set the tone for subsequent encounters. If medical staff find themselves confronted with a scruffy looking, disorganized individual or with an inflexible zealot, their worst suspicions will be confirmed and they will probably dismiss the patient and/or the standby team as “kooks” or “nuts” who should be ignored and avoided as much as possible. A bad first impression can effectively limit or cut off future communication. (This is true, also, when dealing with family members who are not cryonicists. They too are likely to be skeptical, and will be strongly influenced by their first impressions.) It’s very important that the first personnel on the scene during a standby or in preparation for a standby should be personable, well groomed, knowledgeable, and well organized.

Preparing For Standby

Where a patient has been diagnosed with a terminal condition weeks or months before the likely time of legal death, we can assess the patient’s environment and lay groundwork that will increase our chances of performing the standby under optimum conditions. Where possible, the leader of the standby team should travel to the locations where legal death will be pronounced and where standby and transport will be carried out. The team leader should make appointments to meet the medical and nursing staff who are caring for the patient, as well as the principal administrator of the hospital or nursing home. If the team leader is traveling a long distance to prepare for the standby, local staff must be made aware that they cannot simply “cancel and reschedule” without causing a great deal of inconvenience.

It is equally important for the team leader to keep all of his or her appointments. Allow extra time for finding your way around a strange city and dealing with local transportation. Avoid scheduling appointments close together, so that you don’t have to cut a meeting short in order to get to the next one. If you make a formal presentation, expect a question-and-answer period which will last half as long again as the presentation itself. Allow additional time to talk one-on-one with people who have special concerns.

In order to make a good first impression, you must project an air of reliability and trustworthiness by keeping appointments and being prompt and organized.

Dress and Grooming

It is no accident that mavericks and the mentally disordered both tend to be poorly groomed and unconventionally dressed. If you want to be taken seriously, you simply have to make an impression as a serious, conventional person. Always bear in mind that almost all medical staff will be profoundly uneasy, very skeptical, and hypercritical when they encounter cryonics advocates for the first time. They will be primed and ready to find evidence confirming their deeply held suspicions that cryonics people are full of half-baked ideas. The best way to dress is at or above the standard of the professionals whom you will be dealing with. For most business and medical professionals the following standards generally apply:

Dress for Males During Standby

Hair: short or if medium length, neatly styled. Shirt: Oxford or Broadcloth in white, cream, blue, or muted pastel color. Jacket: Suit or sports coat of natural fiber, single breasted, conservative in color. If on standby in the hospital a short or full length white lab coat may be substituted for the suit or sports coat. Tie: conservative. Pants: Dress slacks or pants of nonsynthetic material such as wool or a wool blend. Permanent press cotton/polyester blends are often acceptable in the summer months or in hot climates. Jewelry: minimal and conservative. Finger rings other than a wedding band should not be worn (provision should be made for safe-keeping of wedding bands during transport as they may have to be removed so that you can scrub in, if you assist with surgery).!Earrings for males are discouraged and should be small and discreet if worn. Shoes: Good quality dress shoes. Tennis shoes, running shoes, or sneakers are never acceptable.

Dress for Females During Standby

Hair: neatly and conservatively coifed. Blouse: conservative white, cream, or pastel color. Suit or skirt: conservative business-like attire. Jewelry: minimal and conservative. Dangling ear-rings should be avoided. Finger rings other than a wedding band should not be worn (provision should be made for safe-keeping of wedding bands during transport as they may have to be removed so that you can scrub in, if you assist with surgery). Cosmetics: minimal. Avoid bright or shocking colors of lipstick or nail polish. Shoes: should match attire. High heels will create practical problems during transport of the patient and should be avoided.

During Transport

Males and females may wear scrub clothes (females may wear scrub dresses if they prefer them to scrub pants/top). Every team member should have a white, full-length lab coat to serve as a cover gown and to hold writing utensils and personal items. Shoes should be comfortable and soft-soled so that they do not generate noise which could disturb patients, particularly at night. Shoes should preferably be white or black but this is not critical. Running shoes are a practical choice and can decrease fatigue.

General Comments

Dress should always be appropriate to the situation. For instance, it would be inappropriate to wear a lab coat when you meet the patient’s physician during a preliminary visit. On the other hand, a lab coat is perfectly acceptable if the patient is hospitalized, unstable, and the transport team has been summoned on an emergent basis.

One member of the standby team should pack a small portable iron or “pocket presser” to get wrinkles out of clothes after they are unpacked. You can use this in conjunction with a can of Wrinkle Free, which should be sprayed onto clothes that are hung up on hangers.

Taking a few extra minutes to make yourself presentable is almost always justified and and can give you a greater feeling of confidence. You will inevitably feel at a disadvantage if you meet a hospital administrator who is immaculately dressed and groomed while you are wearing rumpled clothes and have a 24-hour growth of beard. Your embarrassment, and your loss of face, can seriously interfere with getting the job done.

Establishing A Rapport With Health Care Providers

When you start preparing for an anticipated standby, you should meet first with the patient’s primary care physician. This may be a family doctor or the “personal” physician that has been assigned by a Health Maintenance Organization. The primary care physician is the person who should be responding to the patient’s needs and the cryonics organization’s needs during standby and transport. This physician should know the patient on a personal basis and for this reason will be more important to you than a hospital or nursing home administrator.

If the patient’s physician can be convinced that there is some rational basis for cryopreservation, you will have obtained a powerful ally who is trusted both by the patient and by the institution where the patient is being treated. Generally, the smaller and less bureaucratic the institution, the easier it will be for you to secure cooperation. A free-standing nursing home or small independent community hospital will usually be easier to deal with than a large teaching institution or a nursing home that is part of a large national chain.

The Primary Care Physician

Giving Information

When you meet the patient’s physician you should be well organized and businesslike in a nonthreatening manner. At the meeting, you should have a checklist of items to be covered, including:

1. The patient’s choice of cryopreservation. Briefly describe the patient’s history of interest in cryonics and offer a copy of the patient’s Consent for Cryopreservation. If cryonics has been a long-standing preference of the patient, remember to mention this. If cryonics is a last-minute decision, you should be ready to defend the patient’s ability to make a rational decision, but you should also be willing to listen carefully to any objections that the primary physician may express. If the physician is deeply skeptical, you may consider asking for a psychiatric evaluation of the patient to establish competency.

2. Principles of cryonics. Where appropriate, briefly explain the principles of cryonics. Some physicians may have little or no interest, while others will have an acute curiosity. Do not use this discussion as an attempt to proselytize or convert the physician. Arguments for cryopreservation should be presented factually, without “zeal.”

3. Practical procedures of cryopreservation. Briefly and simply explain the practical procedures of cryopreservation with special emphasis on standby. You should be able to show photographs of transport operations and of the equipment employed, and you should give the physician a brochure or simple handbook which covers these topics. If the physician is willing to watch a videotape of a transport, this may be very helpful.

4. Cooperation from the physician. Describe what you would like from the physician, but be sure to offer reassurances about limited liability. Try to anticipate the physician’s concerns, and deal with them during the course of your presentation.

The five key things that will want from the physician are:

a) The physician should keep the standby team informed about the patient’s medical condition and prognosis. If the physician sees problems developing or foresees an altered time-course to legal death, the standby team must be informed as soon as possible. b) The physician should provide medical care which will help to facilitate cryopreservation. For example, a helpful physician might order a chest x-ray of a patient suffering pneumonia, to get a clearer idea of when legal death is likely to occur. (Such an x-ray might not normally be done if the patient is elderly and treatment is being withheld.) Another example would be to keep IV catheter(s) in the patient past the normal time when they would be removed, so that transport medications can be administered more easily.

c) If and only if the physician is very cooperative and supportive, you may ask for laboratory tests to document the patient’s antemortem condition so that the efficacy of transport procedures and the patient’s post-arrest status can be evaluated better. For example, you might ask the physician to order a blood chemistry and CBC panel a day or two before cardiac arrest is expected; and you could ask for the same set of tests when the patient becomes agonal, so that you have baseline values which will help to evaluate the degree to which antemortem shock has contributed to ischemic injury. d) The physician should be willing to provide a prompt pronouncement of legal death, either by coming personally or by delegating the authority to registry nurses or other qualified personnel.

e) The physician should help you to liaise with the institution where the patient is being treated.

5. Duties of the standby team. Explain to the physician the role of the standby team. Reassure the physician on the following points:

a) Standby staff will take over the care of the patient as soon as legal death is pronounced, but not before.

b) Standby staff will provide all personnel, equipment, medications, and transportation required to carry out the procedures which they wish to perform.

c) A licensed physician is medical director of the team and is available for consultation at any time.

d) No invasive procedures (cut down, etc.) will be done in the institution where the patient is being cared for.

e) A cooperating (local) mortician will handle the health department paperwork and will facilitate shipping.

6. Reassurance regarding liability. Explain to the physician that (s)he will not be liable for any eventualities resulting from the standby. Offer to sign a hold-harmless agreement. State that you understand that a physician’s first duty is to living patients, and make it clear that you don’t expect cooperation (for example, pronouncing death promptly) if this will conflict with the physician’s obligations to other patients.

7. Establish contingency plans. What can be done if the physician is unavailable? What will happen if the patient experiences legal death sooner than expected? Solid plans should be in place to deal with potential problems. The details of such plans will of course vary from one situation to another.

8. Filling in for the transport team. If legal death has occurred before the transport team was able to reach the patient, you must try to obtain as much help from the physician as possible. Your strategy will vary depending on the situation. If the patient is located a few minutes away from the cryopreservation operating room, you may want to ask only for CPR to be initiated by the hospital or nursing home until the team arrives. If the patient is in a remote location, you should ask the institution for limited CPR and an abbreviated protocol of medication, and you should request that the patient os packed in ice. Some physicians and treating institutions will refuse to perform any procedure related to cryonics. The most they will do will be to place the patient in their refrigerated morgue while they wait for a mortician to arrive. You can try to obtain more cooperation, but if the institution simply will not comply, you will have to respect its policies. In this type of situation you may need to consider sending in local cryonicists who are close by, or asking for help from a local mortician.

Obtaining Information

While it’s important to give information and reassurance to the primary care physician, it’s equally important to obtain information that you need. Ask for a copy of the patient’s medical records as early as possible, so that the standby team’s consulting physician or medical director has a chance to review them and plan accordingly. For example, if the patient has HIV or some other infectious disease, special precautions will be necessary. If the patient has a pathology that could interfere with transport, this is also important–for example, in the case of an elderly patient who has atherosclerosis which would make femoral-femoral bypass problematic or impossible. The list of medical conditions which could complicate or seriously impede transport is long and beyond the scope of this guide. You will also want to know the physician’s plans for future care of the patient. How will intercurrent medical emergencies be handled? For instance, if the patient has end-stage HIV and develops an infection, will (s)he be hospitalized? If the patient dies unexpectedly, you should have some idea of how the physician will want to proceed. Quite often, a patient who is dying slowly from cancer or HIV may suffer a completely unexpected cardiac arrest. In such a situation, your prompt access to medical records may help to avoid autopsy. How will this contingency be handled, and under what conditions will the physician be unwilling to sign the death certificate (necessitating an autopsy)?

Another topic on which you should quiz the physician is the attitude and personality of the local coroner or medical examiner. Is (s)he easy to deal with? What percentage of deaths in the county are subjected to medicolegal autopsy? Would the physician recommend relocating the patient in a different county to reduce chances of autopsy? The physician may be able to offer similar advice about the hospital or nursing home and the patient’s home situation and family dynamics.

Nursing Staff

Whether the patient is at home or in an institutional setting, the nursing staff will be the people you will be dealing with most. They are also the people who can make or break an optimum transport. Nursing staff that are hostile can greatly reduce access to the patient, seriously compromise the flow of vital medical information, and make it impossible for you to deploy necessary equipment. On the other hand, cooperative nursing staff can make room for transport equipment, provide blankets, coffee, and other amenities for staff, free up a day-room or empty ward for staff to sleep in, and provide advanced warning of administrative problems. When the transport starts, a truly cooperative nursing staff will often pitch in and provide help without even being asked to do so.

Just as important, supportive nursing staff who are “on your side” may be willing to look the other way when CPR is started or meds are given in violation of the administration’s instructions. Establishing a good rapport with nursing staff is contingent on getting their respect. They don’t need to believe in cryopreservation; they only need to see that the standby staff are sincere and competent, and the patient has a strong desire for cryopreservation based on full understanding of the facts. Most medical professionals believe that the individual has a right to choose unusual forms of medical care and postmortem disposition.

Nursing staff will require the same type of information that you have supplied to the patient’s physician. In fact, since a nurse may have more sustained contact with the patient and the standby team, (s)he will probably have more time and inclination to ask questions. In an institutional setting, your best option will be to give an in-service presentation using slides or video.

Since nurses will be the ones who have to actually deal with the standby staff, house the transport equipment, and participate first-hand in facilitating removal of the patient from the facility, you should discuss cryopreservation and standby in more detail than during your meetings with the patient’s physician.

Additional material might include:

1. A good general introduction to the cryonics concept including the underlying scientific and biomedical evidence/hypothesis.

2. The mechanics of the cryopreservation process from start to finish with special emphasis on transport. Here it is appropriate to discuss specific procedures and equipment and briefly touch on the needs of the standby team in order to facilitate good care of the patient. Excruciating technical detail is not necessary but sufficient detail should be presented so that the staff understands what will happen.

3. As is the case with the physician, you should discuss contingencies and how they will be handled. It’s critical to determine the limits of the nursing staff in terms of what they will be permitted to do institutionally, and what they will be willing to do as individuals. As was the case with the physician, you should provide reassurance about liability and (where appropriate) a hold-harmless.

You should mention that you understand how short-staffed and overworked the nurses are. Make it clear that you do not expect them to jeopardize the well-being of their “living” patients in order to facilitate care of the cryonics patient.

Problems to Avoid

Institutional Human Experimentation Committees

Since the 1980s, U.S. medical institutions have gradually allowed greater autonomy and self-determination for patients. There has also been increasing concern about abuses of the relationship between patients and healthcare providers, and in particular, between patients and researchers.

The history of biomedical research is studded with instances of gross abuse of patients. There have been shoddy or absent procedures for establishing informed consent, coupled with deliberate attempts to conceal important information. Recent disclosures have documented abuses by Federal agencies and a number of prestigious medical institutions which tested radioactive materials on unsuspecting patients. In order to prevent this type of abuse, many health-care institutions have created a bureaucracy to deal with the problem. The embodiment of this bureaucracy is the Institutional Human Experimentation Committee (IHEC). This committee usually consists of representatives from the hospital administration, the medical staff, clergy, and one or more professional biomedical ethicists.

Most institutions today will not allow an experimental procedure to take place on their premises unless it has been approved by the IHEC. Typically, an IHEC will take from 6 months to a year to approve a study involving human subjects, and we can be virtu!ally certain that cryopreservation will not be one of the “experimental procedures” that an IHEC considers acceptable. And even if it was, the reams of paperwork, long lead times, and lack of participating medical staff at the institution would all render the procedure impractical.

Therefore, we must make sure that cryopreservation is not considered an experimental medical procedure by the hospital or its IHEC. The standby team must present cryopreservation as a nonmedical postmortem procedure which is akin to embalming and involves no medical procedures. At the same time, of course, the team will quietly try to obtain prompt pronouncement of death, prompt CPR and cooling, and treatment which will be compatible with cryopreservation.

The team should always emphasize that the patient will be legally dead before cryopreservation procedures begin. If the issue of IHEC involvement is ever raised, the team should point out that IHEC permission is never normally required for postmortem procedures such as embalming or cremation. In the long term, we may find that the cryonics is subjected to review and control by IHECs whether we like it or not. In the meantime, the standby team should be aware of the danger and alert for any threat of IHEC involvement. The author has had two experiences with IHECs both of which were very unfavorable. In one case it was necessary to obtain a court order to override the IHEC and obtain access to the patient.

Confrontations With Medical or Administrative Staff

Occasionally, the standby team will encounter irrational, belligerent, or just plain mean-spirited medical, nursing, or administrative staff. The first rule in such a situation is to remain calm and resist the temptation to respond in kind. Whenever possible, the cryonics organization administration should be called in to resolve conflicts. Since the standby staff will have to deal with hospital personnel regardless, it’s much better to keep the team on the sidelines while conflicts are resolved. This way, the team can honestly state that their only task is to care for the patient. Any legal threats or harsh words should always come from an attorney “back at headquarters,” so that the standby team members will not be held responsible.

The only situation where a team leader may resort to hostility or legal threats is if the condition of the patient is immediately threatened and there is not enough time to refer the confrontation back to the cryonics organization’s administration.

Conflict with the Patient’s Medical Care

There is often a delicate trade-off between medical care to optimize the patient’s current wellbeing, and care which will optimize the subsequent cryopreservation. A classic case of this occurs when a patient suffers an obliterative primary brain disease such as an aggressive brain tumor. If the patient is going to have any chance of recovering in the future, legal death should come sooner rather than later, to arrest the disease so that the patient can be placed in cryopreservation. Clearly, however, this runs counter to traditional medical priorities. In 1991, a computer programmer named Thomas Donaldson who was suffering from a grade IV astrocytoma tried to obtain judicial permission to be cryopreserved prior to legal death. This challenge to the law against active euthanasia and assisted suicide was unsuccessful. Less obvious conflicts of interest between cryonics and medical care also exist and in some ways are even more troubling than the issue raised by active euthanasia. Should a patient seek treatment which may extend the current lifespan, but (if unsuccessful) could degrade the quality of subsequent cryopreservation? There are some neurosurgical procedures, for example, which carry a risk of brain death or massive irreversible brain injury. Another problem arises when a patient has to choose whether to pay for medical care today, or spend the money instead on cryopreservation, which offers only a chance of extended life tomorrow.

These are real problems which real patients and cryonics organizations have wrestled with in the past. Generally, we should describe the pros and cons of a situation to the patient as clearly and as calmly as possible, without imposing our own judgment. A patient must be told if a course of medical treatment is going to jeopardize cryopreservation arrangements, but a patient must also be allowed to make the final decision about any course of medical treatment without pressure or coercion from cryonics personnel. Legally and morally, this is the only path to follow. In situations where standby personnel are being asked for advice, they should tend to err on the side of keeping the patient alive today. For further guidance, here is a short case history based on an actual conflict that occurred between a cryonics organization’s medical director and administration. Many details have been altered and this case history has been fictionalized both to make it more relevant to the discussion at hand and protect the privacy of the institutions and individuals involved.

Rick is a 35 year-old patient with AIDS. His T cell count is 150 and he has been in reasonably good health except for a bout with pneumocystis about 4 months ago. He is admitted to the hospital on a Saturday evening with gram negative sepsis, apparently secondary to a dental abscess. He is shocky on admission with BP of 80/60 and a pulse of 140. His temp is 39.5 C and he is in renal failure as a result of the sepsis. He is a member of a cryonics organization, and their standby team reaches his bedside within a few hours after they are notified that Rick could “die anytime.”. One of Rick’s physicians feels he should not be treated for the sepsis. The other physician feels that antibiotics should be started and, if necessary, Rick should be dialyzed to get him through the sepsis-related renal failure. Rick has had intact mentation prior to this hospitalization but is disoriented and unable to make medical decisions now. His lover, Bob, is Rick’s medical power of attorney and is asking the standby team leader what course of action to pursue. The standby team leader is faced with a number of difficult questions:

1. The hospital is cooperative now but will probably become less so as time goes on, particularly come Monday when its lawyers and administrators arrive at their desks.

2. Rick has very limited funds and he has just used up his standby allotment flying the team and the equipment out to his bedside.

3. Rick is not now demented, but faces a statistically significant chance of suffering AIDS dementia or a brain infection which could cause truly irreversible loss of mentation regardless of how well his subsequent cryopreservation goes.

4. The medical director of the standby team believes that Rick has a treatable condition with at least a 50 percent chance of recovery. It is impossible to say how much longer he might survive with an acceptable quality of life, but one to two years is not an unreasonable expectation, nor, on the other hand, is death within 6 months.

It may seem attractive to withhold treatment from Rick and “get his cryopreservation over with.” If treatment is withheld, Rick will very quickly reach cardiac arrest. The standby team is ready, and the odds for a good transport are favorable. Rick has limited money and may not be able to afford another standby. Additionally, Rick’s brain is now certainly intact but may not be so in six months, a year, or two years. Further, Rick’s cryopreservation arrangements themselves may be in jeopardy due his mounting medical bills and the fact that a large part of his funding for cryopreservation is in a revocable trust account.

What advice should the team leader offer? Clearly, the first step is to review the situation with Rick’s medical surrogate and ask what Rick would want done. At the same time, there must be a careful examination of Rick’s cryopreservation file and his durable power of attorney for healthcare. If there is no direction from Rick, then treatment should be given even though it offers a less certain outcome in terms of cryopreservation.

The reasons for this course of action are as follows:

1. In the absence of clear direction to the contrary, our first duty is to preserve a patient’s life here and now, so as long as there is a reasonable chance of recovery to an acceptable quality of life (as is the case in this situation). 2. From a legal standpoint, the patient’s medical surrogate and medical staff are obliged to act in Rick’s best interests using conservative criteria.

3. From a public relations standpoint, there could be grave consequences if treatment is withheld and Rick’s case becomes a focus of media attention.

4. Buying time for Rick also buys more time to explore other possibilities for funding any future standby and facilitating a good cryopreservation in the future.

5. Rick will most likely be grateful for the added time if the medical treatment works. In the absence of clear directions to the contrary, we must presume that Rick would want to stay alive here and now. 6. Improvements in medical care and in cryopreservation continue to occur. Significant advances in treating HIV and/or improvements in cryopreservation protocol may occur in the time that Rick gains as a result of receiving medical treatment.

Now let us consider another scenario:

Mary is a 42 year-old woman who has had metastatic breast cancer for four years. She has been through two courses of chemotherapy and one of radiation therapy. She has been bedfast for nearly 5 weeks and is down to 70 pounds from 150 pounds 6 months before. Mary has been heavily sedated for pain and has been unable to take solid food by mouth for several days. She is enrolled in a home hospice program and has resigned herself to dying because her underlying disease cannot be treated and her current quality of life is unacceptably low.

During the night Mary develops a fever of 39 C and appears to have difficulty breathing. The hospice nurse determines that Mary appears to have pneumonia. Some family members want to start Mary on antibiotics while others say “no, it is time for Mary to go.” Mary’s doctor advises against antibiotics but is willing to administer them if her medical surrogate insists. What should be done? Here the situation is very different. Mary is clearly imminently terminal with a quality of life that she finds unacceptable. Antibiotics at this point would be inappropriate both ethically and medically. Mary should be allowed to experience cardiac arrest and enter cryopresrvation.

Other cases will be less easy to resolve than the examples provided here. In general, however, the patient’s well being here and now (consistent with the patient’s expressed wishes) should be everyone’s top priority, and this attitude will tend to foster a good relationship between medical personnel and the standby team. If the team attempts to follow policies that are contrary to sound medical treatment, this will usually result in antipathy or conflict and may impair the team’s subsequent ability to carry out transport under good conditions.

Cooperation Versus Non-Interference

Throughout this chapter, and elsewhere in the guide, I have used the term “cooperation” to describe the ideal relationship between health-care staff and the standby team. However, “cooperation” can sometimes carry implications that go beyond its literal meaning. Some physicians, for instance, may fear that by cooperating with a standby team, they are to some extent giving their approval and may even be seen as endorsing the concept of cryopreservation. Bearing this in mind, instead of requesting cooperation, it may be better to ask for non-interference. This term accurately describes the needs of the standby team, and is devoid of troubling implications.

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