What may have caused an Argentine baby to be mistakenly declared dead?
This post has been updated. See the note below for details.
The stunning case of a baby who was declared dead only to be found whimpering in the morgue nearly 12 hours later has riveted Argentina. The family said it planned to sue the hospital where the infant, named Luz Milagros, or Miracle Light, was born and later struggled for her life in intensive care.
[Updated, 11:30 a.m. April 16: To understand how a baby might be declared dead then found alive, The Times turned to Yao Sun, director of neonatal clinical programs at UC San Francisco's Benioff Children's Hospital.]
How could a baby mistakenly be declared dead?
Obviously it’s extremely rare, and that’s why this story has fascinated people. What it sounds like to me -- gleaning what I can from what I’ve read -- is that at the time the baby was born, the baby did not have many of the clinical signs of life. As far as I can tell, this was a pretty premature infant.
So I would guess that the baby was not breathing, was limp, was most likely blue and could have had such a slow heart rate that when they listened they didn’t hear it. We will frequently attempt to resuscitate a baby like that, but there are certain circumstances in which we would not attempt it.
How would a baby like that have survived?
My understanding is that the baby was transferred to a cooled area of the morgue rather quickly. Here I’m hypothesizing, but that may have allowed the baby to survive by cooling the metabolic rate so much that the organs of the body don’t need as much oxygen and nutrients. You’d normally expect that if the heart rate was that low, the baby would have died relatively quickly.
Even though the patient is dying, it doesn’t mean that they may not, on occasion, have something like a gasp or movement. In the end stages of dying, the brain stem can still occasionally fire primitive reflexes which can result in a gasp. That’s not truly breathing effort, but a primitive breathing reflex.
I would expect that this baby is going to be at extremely high risk for having a lot of problems. The risks for mortality and long-term poor neurological outcomes are extremely high. [As of Friday, doctors said the baby had suffered cardiopulmonary failure and an infection. She was in critical condition.]
How do you make the decision whether to try to resuscitate a baby?
We consider several factors. Gestational age is one of them. Some neonatologists will attempt to resuscitate essentially any live-born infant no matter their gestational age -- but that’s not the most common. For most neonatologists, 23 to 24 weeks of gestational age is seen as viable.
All of those things play into the physical condition of the baby and its expected long-term survival and outcome. We also do prenatal counseling with the parents to determine how aggressive of a resuscitation, if any, they would like us to attempt to perform.
What are some of the possible downsides of trying to resuscitate a baby in that state?
Medical care for an infant like that would likely necessitate doing things that most people would feel are painful. It could include intubation, artificial ventilation, blood draws. … All of those things would cause a baby pain, though certainly we would try to ameliorate the pain with sedation and drugs.
Another aspect is that in this period, for a 24-week infant, the chances of surviving are considered to be about 50%. There’s a very high risk of complications and other problems, including infections and bleeding into the brain. It’s an emotional roller coaster for the parents to go through something like this and not have the baby survive after all this happens.
Out of the survivors, a fairly high percentage of them have long-term neuro-developmental problems -- not what anyone would hope to be the quality of life for their children. It’s an ethical dilemma and an area of legal controversy that neonatologists have to deal with continually.
One way of thinking about this is, if chances of survival are low and the chances of long-term survival with good neurological outcomes are minuscule, instead of putting the baby and the family through all the pain, what we should be doing is providing comfort care to allow a peaceful dying process and let the parents spend time with their infants in a loving environment.
The other perspective is, there are people who feel that life at any cost is worthwhile. We as neonatologists counsel parents about the probabilities and the risks so we can come together to a group decision about what might be reasonable for their baby.
This story has been seen as a tale of a hospital making a terrible mistake. Do you see it differently, as perhaps something other than that?
A story of malpractice? Yes, I do. We see babies who are born prematurely who have a very low heart rate, not breathing, and we either give them comfort care or we resuscitate.
I’ve talked to other doctors who have initially given comfort care [believing a baby will likely die] and then in the first few minutes, even as long as an hour of life, the baby has done a lot better than they’ve expected and they’ve proceeded to resuscitate. This is always done after talking to the parents; most of the time in comfort care, the parents are actually holding the baby.
I haven’t heard of a circumstance where the clinicians have actually declared the infant dead, but I can imagine that happening. Obviously that would be extremely rare.
The story, on the face of it, sounds like a horrible story, and it really is a horrible story. But the decision-making at the time of birth may have been very much the norm for that clinical situation.
It seems like one of the big differences in how a doctor might see this is, is that your understanding of life and death is not as black and white.
The easy answer is that is true. It’s not quite so black and white. The harder answer is there are different approaches to what is considered death. I think that everyone would agree that if all your organ systems have failed, you have no bodily function, that that is death.
But the question then comes up, how long do you have to wait before you decide there are no bodily functions? Is it five minutes? Is it 10 minutes? Is it 30 minutes? Or think about organ donation. In order to donate an organ in viable condition, you have to support that person after they’ve “died.”
Is that person dead because we’ve declared them medically dead? Or are they alive because we’re keeping them alive in order to donate their organs? It’s not totally black and white in the way we think about death.
-- Emily Alpert in Los Angeles
Photo: Fabian Veron and Analia Bouret, parents of a premature baby who had been declared dead and was found alive 12 hours later in the morgue, speak at Perrando de Resistencia Hospital in Argentina on Wednesday. Credit: Agence France-Presse / Getty Images