Edition: U.S. / Global

Focus Shifts To Decisions Made at End Of Girl's Life

Published: February 24, 2003


The medical examiner will conduct an autopsy Monday to determine exactly what caused the death of the girl, Jésica Santillán, 17. Ms. Santillán, who had undergone a second heart-lung transplant Thursday after medical mistakes two weeks ago, died Saturday after doctors declared her brain dead and removed her from life support.

Her case drew attention as an alarming example of a medical mistake at an elite institution, Duke University Hospital, and for her story as an illegal immigrant from Mexico who probably would have died without a transplant.

Ms. Santillán's death has intensified acrimony between her supporters and Duke University Hospital. One crucial point of disagreement is the circumstances under which life support was discontinued.

Hospital officials initially said Ms. Santillán was taken off the respirator ''without protest,'' but lawyers for her family disputed that. Duke, they said, told the family it did not need consent once brain death, meaning an irreversible lack of brain activity, was established.

In an interview tonight, Dr. Karen Frush, one of two doctors who determined that Ms. Santillán was brain dead, described a harrowing conversation with family members -- conveyed through three interpreters provided by the hospital -- who refused to believe she was dead and felt Duke had killed their child.

Dr. Frush said that once they were told Ms. Santillán was dead, her parents asked for a second opinion but were told that second opinions could be used only to evaluate treatment options, not to question a determination of death.

''I told them we were very sorry, but Jésica had died,'' Dr. Frush said. ''They did say they did not believe that, but I had to tell them the truth. She was dead.''

Legal medical experts say that once a person is declared brain dead physicians can end all treatment, including life support. Arthur Caplan, a professor of bioethics at the University of Pennsylvania who has studied the issue, said he was unaware of any state in which that is not the case.

''Whether it is cardiac or pulmonary or brain death, doctors have no obligation to treat once death is pronounced,'' Professor Caplan said.

Edward E. Hollowell, a longtime health care lawyer in Raleigh, N.C., and member of the American College of Legal Medicine, agreed. In North Carolina, ''if there is a determination of brain death, life support can be withheld,'' Mr. Hollowell said. ''That determination is the trigger point.''

The public, the experts said, sometimes confuses brain death with conditions like coma, in which a patient is unconscious with an unknown prognosis but brain activity continues, and permanent vegetative state, in which damage to the cerebral cortex leads to a deep, coma-like state.

Lawyers for Ms. Santillán's family said they would pore over her medical records and request more tests after the autopsy. They declined to say what legal course they would pursue but ''we are reviewing everything that was done,'' said one of the lawyers, Frank Cassiano.

Ms. Santillán's family declined to donate any of her healthy organs, said Richard A. Puff, a Duke hospital spokesman. But Renee McCormick, a family friend and spokeswoman for the foundation that had raised money for Ms. Santillán's treatment, said family members had been told that her organs had been damaged by her ordeal and were not usable.

Ms. Santillán's family members appeared briefly at a church service today in nearby Louisburg, where they live, and are making arrangements for a funeral, possibly in Mexico, where they are from. Ms. McCormick said the family had received a condolence call from President Vicente Fox of Mexico.

Ms. Santillán suffered from restrictive cardiomyopathy, a condition characterized by an enlarged and weakened heart and malfunctioning lungs.

In a Feb. 7 operation, doctors gave Ms. Santillán a heart-lung transplant with organs of the wrong blood type. Ms. Santillán has Type O blood; the organs were Type A, and her body rejected them, sending her into a coma-like state.

Ms. Santillán developed complications, including swelling of the brain and kidney failure, after a second transplant operation on Thursday. Duke acknowledged the mistake and said it had adopted new procedures.