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When Technology Complicates Management:
The Case of Jahi McMath
Dr. Vincent F. Maher
Dr. George V. Priovolos
Ms. Elisabeth J, Maher
ABSTRACT
In December 2013, a thirteen year old girl underwent elective surgery to correct a sleep
apnea condition. The surgery was completed without incident. In the post anesthesia care
unit, the girl awakened, talked and laughed with her mother and grandmother. She was
later transferred to a surgical unit for routine post-operative care. At some point she
coughed. The coughing triggered post operative hemorrhaging that quickly devolved into
a medical emergency during which time frame she became anoxic and sustained severe
brain damage. She was transferred to a critical care unit. Within days, she was diagnosed
as brain dead. Her family refused to accept this diagnosis. They refused to remove her
from life support or to permit others to do so. Court interventions, news and social medial
exposure ensued. Fingers were pointed. What should have been a difficult but
straightforward medical decision became a management, ethical and legal fiasco. This
paper tackles the issue of technology as a hindrance to rather than a facilitator of
management in a healthcare environment. It also examines collateral issues thereof
including organizational behavior and contemporaneous and post-event institutional
marketing.
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When Technology Complicates Management:
The Case of Jahi McMath
Dr. Vincent F. Maher
Dr. George V. Priovolos
Ms. Elisabeth J, Maher
Most would agree that decisions of any sort made without an understanding of the
context and/or impact of the decision are ill-advised at the least and foolhardy at the
worst. This is true regardless of the environment in which the decision is made.
We
would suggest that ill advised and/or foolhardy are terms that barely scratch the surface in
the context of the difficulty of clinical decision-making in a health care environment.
Clinical decisionmaking is different from non-healthcare or even of nonclinical
healthcare environments.
The problem in a clinical healthcare environment is
particularly compounded because, more often than not, a specific, individual person is
going to reap the impact of the decision and, due to the nature of the clinical health care
environment, there is a cascade effect on administrators, providers and payers on the one
hand and clients or patients and families on the other end. Such a clinical decision is
difficult when dealing with adults: it is compounded when a child is involved: it is
complicated when the decision that must be made is perceived to be the fault of an
involved party or when technology obfuscates the issues.
Background
In November 2013, a thirteen year old female who was suffering from sleep apnea agreed,
through her parents, to undergo surgery to correct this condition. Presumably, other
nonsurgical methods commonly used to correct this situation had been attempted and
failed.
The surgery can be as minor as a tonsillectomy or it can get quite involved.
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Surgery for sleep apnea can range from the simple to the complex. In the simplest
iteration, surgery involves a tonsillectomy – removal of the tonsils. A fairly straight
forward procedure in children, it becomes more complicated in the case of teens and
adults because problematic intraoperative and post-operative bleeding can occur with
greater frequency. The procedure to correct sleep apnea can become more complex as
one checks items on the a la carte menu that include uveloplasty, paletoplasty,
adenoidectomy, uvelectomy, phararyngopaletoplasty and so on. In lay terms, we’re
talking about reconstruction of the soft tissues of the posterior mouth and airway.
In this case the more extensive multisite surgery, described above, was anticipated by her
surgeons and was the procedure they performed. Further, based on media reports and
court filings, it was reported that Miss McMath came through the surgery in a satisfactory
fashion and was transferred for routine monitoring in the post anesthesia care unit
(PACU). It was reported that she was responsive and interacting with her mother and
grandmother and was even asking for an ice popsicle. Following her stay in the PACU,
she was then transferred to a routine post operative bed for overnight monitoring as
previously planned due to the anticipated extent of surgery.
There, something went wrong.
Jahi’s grandmother, described in various media outlets as a veteran nurse, is reported to
have noticed that Jahi was bleeding from the mouth and nose. Whether at this time she
had been asleep or awake or awake and talking has not been reported. Whatever it is that
started the problem, she began to hemorrhage. Rescue efforts ensued. It has not been
reported by whom these efforts were performed or for how long they were carried out.
Some sources have stated that, regardless of the cause of the bleeding or of what may or
may not have constituted a proper staff response, the grandmother attempted to suction
the blood from Jahi’s mouth. Jahi was without oxygen for some time and, although
“successfully resuscitated,” she was transferred to a critical care unit in extremely critical
condition. Some days later, a neurologist concluded, based on the period of anoxia and of
neurological testing, she was brain dead.
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Defining Death
Death is a process as different parts of the body stop functioning at slightly different
times. The time of death is when the brain stops functioning. Once this occurs all other
bodily functions will gradually and eventually end. There are five brain stem reflexes that
are tested to determine brain death: oculocephalic, oculovestibular, corneal, cough/gag,
pupillary light. There will be “no eye movement within the orbit, no eye movement after
irrigation of each ear canal, the eye will not blink, there will be no cough or gaging and
the pupils will be dilated from 4-9 mm diameter, nonreactive to bright light, and
midposition within the orbit” (Arbour, 2013).
The body can continue to heal, organs will continue to function and there can be
hormonal and body temperature regulation (Magnus, 2014). One of the physical signs
that healthcare workers use is heart rate and is considered one of the five vital signs.
There are times when a person will be defined as brain dead but the heart is still beating
(Arbour, 2013). This can cause confusion and distress for members of the general public.
Once mechanical assistance is removed from a brain dead person, the rest of the body
will stop functioning.
The heart and lungs can stop functioning. If cardiopulmonary resuscitation (CPR) is
initiated quickly and successfully a person’s heart and lung function can be restored.
There can be brain injury during the time when the brain is not receiving oxygen. It is
possible to recover from this. When the brain has died there is no possibility of the person
regaining normal function and will die.
The Problem with Definitions
There is what science says, and then there is what a person believes to be true. If these
two things are not congruent, there will be conflict. While there should be considerations
for cultural and religious practices when a person dies; issues arise when there is a
conflict in the definition of life and death or the understanding thereof.
Jahi McMath has been pronounced brain dead by three different teams of medical
professionals. Even with all of this her family does not believe she is dead because she
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still has a heartbeat. This is only possible because of the mechanical assistance that she is
receiving. If Jahi were to be removed from mechanical assistance, her heart would
eventually stop beating.
Jahi McMath’s family was not expecting her to die from the elective surgery she was
undergoing. The family had not gone with less invasive nonsurgical option such as strict
dieting. In this instance the family could be experiencing guilt because they allowed this
condition (morbid obesity) to take place along with the need for surgical intervention.
There was no time for this family to prepare for this loss and has made it difficult for her
family to come to terms with her death. Nailah Winkfield, Jahi McMath’s mother, states
that she will only accept that her daughter is dead once her heart stops (Landau, 2013).
“There are many reasons why parents may insist on futile treatment. In feeling powerless,
parents can engage in faulty reasoning, doubting the validity of the diagnosis or prognosis,
hoping for a medical miracle or placing trust in their religion” (O’Brien, et. al., 2010).
The hospital, Children’s Hospital Oakland, was able to medically show that Jahi McMath
is brain dead. The court appointed medical team also agreed that Jahi was brain dead and
that mechanical assistance be removed. Since three different medical teams have
confirmed brain death, the hospital acted in its right to not perform medical procedures
on a person who is not alive. On average, keeping a person in the intensive care unit
(ICU) on mechanical assistance can cost at least $5,000 a day (Arbour, 2013).
Decisions should never be made in an emotional environment. “Incidental emotions can
influence judgment and decision making” (Andrade, et. al. 2009). Emotions can influence
decisions long after the emotion has dissipated. Even knowing that, people tend to act and
make decisions as they have in the past based on that original emotional decision.
Hospitals have ethics committees so that cases like these can be addressed and adhere to
established ethical principles that include autonomy, beneficence, nonmalfeasance,
veracity, confidentiality, and justice.
This emotion free decisionmaking is easier said than done. Because Jahi’s heart was still
beating, her parents refused to accept the diagnosis of brain death and demanded that
another neurologist evaluate her.
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There was a comparable diagnosis. The hospital
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therefore accepted the physicians’ diagnosis, publicly declared her dead in early
December, permitted the cessation of fluid and nutritional support, and agreed with the
decision to remove life support.
The family refused the removal of life support and retained counsel, who represented the
family in a pro bono capacity. On behalf of the family, he brought an action in court to
compel a clinical evaluation by a non-aligned, court appointed neurologist to evaluate
Jahi before any equipment was shut off or removed. The court granted this request,
appointed and sent in an independent neurologist. That neurologist, too, declared Jahi to
be brain dead. The hospital pressed its point. The family, through counsel, while blamed
the hospital for what happened, continued to fight this decision to remove life support
and insisted on her immediate transfer to another, “sympathetic facility.” A mediator
finally assisted the parties to come to resolution.
Ultimately, Jahi, having been declared dead and the hospital having issued a death
certificate in early December, handed her body over to the custody of the county coroner
in early January. The coroner, in turn, released her body to her family who then
transferred her to an undisclosed medical facility that had agreed to accept her and to
keep her on life support. Since that time there has been a media blackout other than to say
that Jahi had received a tracheostomy for long-term ventilator and pulmonary
management and that she had also received a gastrostomy tube for nutrition purposes. No
one is discussing payment sources for medical expenses.
Management Issues
Any time there is an unanticipated death, a family is left in shock. So is the medical team.
This is particularly true when someone undergoes what is considered a routine elective
surgical procedure and dies during or after the procedure. When it is a minor procedure
on a minor the problem is compounded.
What makes decision making, especially clinical decisionmaking, in health care
management different from the kinds of decisions that managers would make in other
environments is the ultimate impact of that decision. Specifically, some ONE will get or
will not get a treatment modality that may result either in that person’s survival or in
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death. The clinical decision, in other to be considered valid and ethically proper, must
survive objective scrutiny that weighs in quite heavily on the reproducibility of such a
decision across similar populations. This is not the same decision matrix that enters a
managerial framework when there is a decision to buy or to sell stock, to purchase or
lease a vehicle or a piece of durable equipment, to implement a particular IT network, to
construct or to close a manufacturing plant, or to hire or downsize personnel. The end
result of a health care manager’s decision in support of a clinician’s decision can result in
survival or in death.
In the era prior to the 1970s, clinical care decisions were made entirely by physicians
with little regard for the wishes of patients, families or managers. Whatever the physician
determined to be the best decision in a particular circumstance was the decision that was
made by the physician and, more importantly, was accepted by all from patient to
administrator, to the courts and to third party insurers. The media portrayed the classic
benevolent medical doctor in any number of television and film venues. As we look at
this scenario from our current, cynical 21st century vantage point where physicians have
all but lost the prestige they once held, all we can say is “you can kiss that stuff and those
days good bye.” Simply, clinical decisions are no longer made only by physicians.
These decisions, based on a body of legal and ethical knowledge and clinical outcomes
data accumulated since the mid 1970s in first world societies around the world, are made
collaboratively. Thanks to the internet, these decisions are easily and quickly held up to
scrutiny across similarly situated practitioners and facilities. The decision collaborators
now routinely include the patient, a patient’s family, nurses, social workers, pastoral care
staff, medical staff directors and third party payer representatives. Sometimes, the courts
are dragged into the mix. In most cases of such a legal nature, however, the courts
regularly demurrer and leave the clinical decisions to those trained and equipped to make
such decisions. This hands off approach by the courts and even by administrators usually
works.
Contemporary physicians are educated in and trained by multidisciplinary teams that
include non-physician providers and administrators. They are even accustomed to
insurance account representatives weighing in on case management particularly in the
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case of difficult clinical management. Accordingly, decisions are made that usually
placate, please or at least mollify the participants. Cash or the possible withdrawal thereof
eliminates uncertainty or second guessing.
Health care institutions have anticipated situations in which, despite the best efforts of all
involved, a treatment decision may not be easily resolved. Such solutions include ethics
committees and in house legal departments. Ancillary members of such standing
committees and departments generally include a community ombudsman who is not a
health care professional.
In this case, a minor required surgery. Why she got to this situation is not a matter for
discussion or for speculation: her condition existed. In order for a decision to be made
that involved surgical reconstruction of the airway, other non-surgical interventions were
required to be attempted. Only upon failure of such interventions would surgery be an
option. Such would have been the case here. Parental consent is legally required and
would have been acquired. No one would operate on anyone let alone a minor in a non
life-threatening situation without a legally valid consent. The consent procedure would
have been expected to lay out the general and common risks and benefits of the proposed
procedure – what a typical business manager would refer to as an ROI – a return on
investment. Questions would have been encouraged and answered. The consent would
have then been signed.
There is no available information regarding who acquired the surgical consent or of the
operative surgeon. In a teaching hospital such as this, the custom would have been for a
surgical intern to acquire the consent and for a resident, probably a chief resident of the
ear, nose and throat service, to perform the procedure with a fully qualified surgeon
present in the room and supervising the procedure. Such is not only a tradition of practice
in teaching hospitals but it is one that safeguards patient safety and promotes a good
clinical outcome. From all reports, the outcome resulted in an awake and neurologically
intact patient. Whether the operating surgeon was a resident in training or an experienced
attending is also a moot issue. She got out of the operating room alive, awake, alert and
neurologically intact.
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When the situation deteriorated and she became horribly compromised, it is important to
realize and acknowledge that in critical care clinical decisionmaking, the use of
algorithms is standard and accepted practice. Why is this so?
Precisely to remove
subjectivity from the equation, to ensure thoroughness, and to eliminate useless or
inappropriate testing: situation A results in action A and so on. So even without seeing a
medical record, people accustomed to clinical decisionmaking would expect to see
certain behaviors on the part of doctors and nurses. What is also important to this
scenario is that even in the face of everything being carried out precisely and on time, a
patient can deteriorate and die. Such was the case here. Jahi’s clinical signs, symptoms
and responses would have compelled a consultation by a neurologist. A neurologist is
not a member of the surgical team. A neurologist enters the frame, evaluates available
data, conducts a physical examination and renders a diagnosis. That diagnosis then results
in a clinical decision. In this case, the diagnosis was death: the clinical decision was to
discontinue life support. To a health care professional, this is all rather routine.
Not so for the family. A family whose teenaged daughter was alive a few days earlier
and who underwent elective surgery done on a routine basis for this sort of problem and
who is now in a coma but whose heart is still beating is going to have a difficult time
listening to someone telling them that their child is dead and that her life support
machines need to be shut off. A clinician and a clinical administrator are going to be hard
pressed to insist that this happen immediately. What drives the initial kindness of the act
of forbearance then becomes a nightmare for all as the heart refuses to cooperate and to
cease beating. Parents are programmed to hope. Jahi’s parents are no different.
When a body of documentation and the opinion of multiple experts fails to result in the
expected answer (in this case, to shut off the machines) a dilemma ensues that is not the
kind of dilemma commonly discussed in business school management case studies. Here,
there is a person diagnosed as dead by commonly accepted medical diagnostics and
procedures. Here, available technology is also keeping a heart beating. If the technology
did not exist, we would not be discussing this case in the first place.
There is a procedure in place for how hospitals deal with such issues. These situations
occur more often than we would wish them to. Machines are turned off and removed. The
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body is released to the coroner or to the funeral director. Oh yes, the insurance company
stops paying for treatment of any kind once “death” and the patient’s name are joined by
the article “and.” Fiscally, someone in a situation such as Jahi’s is a fiscal disaster
because there is no financial source to compensate the hospital for either the bed or for
the use of the equipment. It’s pure loss.
Collateral Damage and Branding Concerns
Administrators, medical personnel, staff, as well as various external stakeholders of a
high-profile hospital caught up in a situation like the one described above, cannot
possibly avoid thinking about the institution’s reputation and the long-term impact of
what transpired on its ability to raise funds and continue to fulfill its mission.
Although, from the hospital’s own point-of-view, it may appear that the institution did
nothing more than follow—to the letter—State (California) Law, many others, including
the patient’s family, patient rights advocates, and part of the media, accuse the facility of
cold, corporate-like medical decision-making; according to them, the hospital leadership
seemed to be mostly concerned about the efficient allocation of the institution’s valued
resources, while callously disregarding the human element in this situation.
Irrespective of the merits of the case, the prolonged public controversy has likely
damaged the institution’s reputation; Oakland Children’s Hospital officials may have
inadvertently exacerbated the effects of this public relations crisis by using an ineffectual
response i.e., failing to employ timely and effective communication strategies to protect
the facility’s reputation and draw attention to everything positive that the hospital has
done in this case.
Bioethics, which deals with ethical questions arising at the intersection of life sciences,
biotechnology, medicine, politics, law, and philosophy is at the heart of a medical
institution’s organizational identity; effective crisis communication—based on an
existing plan—is therefore necessary to defend itself against accusations of violating
important ethical principles and avoid creating a gap between a hospital’s internal
(desired) and external (actual) brand image.
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Like any other brand, hospital brands synthesize the sum total of perceptions, images, and
expectations the particular healthcare organization generates in people’s minds, thus,
establishing a desired, distinct position in the marketplace and ensuring long-term,
sustainable growth (Kotler and Gertner, 2002).
Moreover, medical brands influence beliefs, trigger emotions, and cause behaviors; they
offer a reassurance of quality and “peace of mind”; serve as a compass to make patient
decision making easier and less anxiety-ridden. At the same time, hospital brands set
expectations; less than satisfactory performance at any point in the patient experience
results in a broken promise that damages the brand.
Most of today’s healthcare brands are built around a small number of dimensions, most
prominently organizational efficacy, quality of human interaction, and technological
capability. The latter plays a critical role in establishing a medical institution’s
positioning vis-à-vis the competition; it—directly or indirectly—affects the design and
performance of hospital systems and operations; the diagnosis, delivery, and outcomes of
medical treatment, as well as the acquisition, analysis and dissemination of health-related
information. At the same time, technology represents a key driver of healthcare costs and
therefore hospital fees. Moreover, “knowledge asymmetry” (Cardon and Hendel, 2001)
i.e., the difference in knowledge among the various parties (provider, patient, insurer, and
even the general public) involved in technology-enabled healthcare processes may hurt a
medical institution’s image and obscure its brand meaning. This could happen, for
instance, when a medical institution is accused of excessive use of medical technology to
increase productivity.
On the other hand, healthcare institutions may adopt a more holistic approach to branding
by striving to develop strong emotional ties with patients and possibly the public at large.
In many of these cases, a hospital would seek to establish a close, lasting relationship
with its patients inspiring trust and hope without specific references to attributes like
medical treatment, patient care or technology resources. Hope, in particular, could help
by making a medical problem appear solvable; it also motivates patients to take action i.e.,
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seek treatment. At the same time, the medical institution establishes itself as a solution—
not just a service—provider.
Explicitly treating a medical institution as a “brand” may be deemed inappropriate by
some of the hospital’s major stakeholders. It is this brand though that helps identify the
specific experience offered to patients by the hospital as the solution to their healthcare
problem. By creating such meaningful connections with existing and potential patients, a
hospital brand attracts patients and generates referrals producing revenue that builds
financial and operational stability over time.
Virtually all studies of crisis communication management view the brand of the party at
the center of a crisis as a potential casualty based on the—correct—assumption that a
public relations catastrophe is bound to impact on the way the public perceives the
organization/individual(s) involved and its (their) credibility.
However, a brand—one of the most valuable assets for healthcare institutions like the one
involved in this case—could also become a powerful tool in the long-term effort to
restore the reputation of an embattled healthcare provider.
Implementing a public relations strategy that could be labeled “Back to Basics,” the
affected hospital’s essential positive brand qualities i.e., “reputational advantages” should
be emphasized in a clear, consistent, and effective tone and manner through all
appropriate communication platforms and activities.
This is clearly a costly strategy requiring an extensive persuasion campaign to achieve its
goals. Nevertheless, if executed properly i.e., in an inspired but not misleading manner, it
has the potential to contribute to the successful evolution of the reputation of the hospital
at the center of this controversy and reinforce its all-important brand promise as reflected
in its mission and values statements.
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Conclusion
In this situation, management handled the case with dignity, respect, data and clinical
protocols. They also showed sensitivity to the family, their grief and to their loss.
Nonetheless, the hospital stood its ground and supported the diagnosis made by the
clinicians. There is no playbook for such a situation.
The hospital ultimately got what it needed: a decedent removed from its premises, an
open intensive care bed, the ability to treat a living person and the ability to generate
revenue.
Works Cited:
Onish, N. “A Brain is dead, a heart beats on.” The New York Times. Jan 4. 2014 A 10
Andrade, E., Ariely, D. (2009), “The Enduring Impact of Transient Emotions on
Decision Making.” Organizational Behavior and Human Decision Processes.
Vol. 109: 1-8.
Arbour, R. B. (2013). Brain Death: Assessment, Controversy, and Confounding
Factors. Critical Care Nurse, 33(6), 27-48. doi:10.4037/ccn2013215
Landau, E. (2013). When ‘life support’ is really ‘death support’. CNN.
http://edition.cnn.com/2013/12/28/health/life-support-ethics/index.html
Magnus, D.C., Wilfond, B.S. & Caplan, A.L. (2014). Accepting Brain Death. The
New England Journal of Medicine. doi: 10.1056/NEJMp1400930
O’Brien, I., Duffy, A., & O Shea, E. (2010). Medical futility in children's nursing:
making end-of-life decisions. British Journal Of Nursing, 19(6), 352-356.
Payne, E. (2014). Doctors keep brain-dead pregnant woman on life support
until baby’s birth. CNN.
http://edition.cnn.com/2014/02/04/world/americas/canada-brain-deadwoman/index.html
Cardon, J.H. and Hendel, Igal (2001). Asymmetric Information in Health Insurance:
Evidence from the National Medical Expenditure Survey. The RAND Journal of
Economics, 32 (3) 408-427.
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Kotler, P., & Gertner, D. (2002). Country As Brand, Product, and Beyond: A Place
Marketing and Brand Management Perspective. Journal of Brand Management, 9.
About the authors:
Dr. Vincent Maher is a Professor of Management and Health Care Management and Law
at Iona College, NY.
Dr. George Priovolos is a Professor of Marketing and International Business at Iona
College, NY.
Ms. Elisabeth Maher is a graduate degree candidate of Psychiatric/Mental Health Nursing
at the Frances Payne Bolton School of Nursing of Case Western Reserve University,
Ohio.
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