Tag: Resuscitation

Legal Protection of Cryonics Patients, Part 2

This article continues my survey of some of the various forms of legal protection for cryonics patients.  The previous article examined laws that directly affect what happens to a person’s body after legal death, both in the period immediately after declaration of legal death, and indefinitely thereafter.  We saw that the amount of prospective autonomy a person is permitted in this regard can vary significantly from jurisdiction to jurisdiction, with more or less consideration afforded to the wishes of the person’s next of kin, religious beliefs, societal norms and other public interests.  Two other legal structures which can and are used by cryonicists to promote the success and timeliness of cryopreservation, maintenance, and resuscitation are wills and trusts.

As before, this is a broad survey, with references to specific laws for explanatory purposes.  Given the context, it does not go too far to say that for your own safety, you must not rely on the following analysis as legal advice, and should instead consult an advisor licensed to practice in your jurisdiction.

Wills

While a person’s instructions regarding disposition of their human remains may not need to appear in their will in order to be enforceable (in those jurisdictions where such instructions are enforceable), the will’s primary function of distributing the deceased’s property can also be used to promote a cryonics patient’s interest in a timely cryopreservation and revival.

One option that should not be ignored on account of its simplicity, is that a cryonics patient can make gifts through their will to their long-term care provider, cryonics advocacy organizations, and/or relevant research organizations.  However, these gifts can only help the individual patient if they are successfully cryopreserved in the first place, and a cryonicist can use their will to promote that crucial objective as well.  In her article, “How to Protect Your Cryonics Arrangements from Interference by Third Parties”, Rebecca Lively discusses the use of “no contest” clauses in wills as financial dis-incentives to interference by next-of-kin.

“No contest” clauses are also known as in terrorem[1] clauses, or forfeiture clauses – but in terms of will construction, these clauses are actually conditional gifts, that is to say, gifts that are conditional on certain behaviour.  In the usual scenario, the trigger is contesting the will in some way: for example, applying to a court for a declaration that the will is invalid because the will-maker didn’t observe the proper formalities, or wasn’t competent to make a will at the time of its execution, etc.  A very simple forfeiture clause might read as follows: “I leave $50,000 to Mary unless she contests the validity of this Will or any part of it, in which case said $50,000 shall instead go to the Society for the Prevention of Cruelty to Animals.”  If that clause was in a cryonicist’s will, which also contained his/her consent to body donation and/or instructions regarding disposition of human remains[2] (or incorporated those directions by reference to documents outside the will[3]), then contesting the will or the validity of the consent or instruction would trigger the condition and the gift to Mary would lapse and go to the SPCA instead.  However, there are plenty of ways that next-of-kin can interfere with prompt stabilization and cryopreservation without making legal contest so, as Lively suggests, it may be wise to draft the triggering condition to include other forms of interference.  Of course, the difficulty with going beyond the categories courts are familiar with is the risk that, if challenged, a creative condition might be deemed void for uncertainty.  For instance, what quantum of delay in contacting a patient’s cryonics organization constitutes “interference”?  The answer to this question will vary by circumstance.  No doubt for this very reason, Lively suggests drafting such a clause to provide for “inheritance on a sliding scale based on the amount of time which passes between your legal death and your cryopreservation”[4], where, presumably, the entire estate goes to charity/cryonics organizations if the will-maker is not cryopreserved at all.  However, given the many factors that can contribute to delay or non-preservation over which the beneficiaries have little to no control, that kind of inflexible forfeiture clause might come across as unfair and have the undesirable effect of promoting legal interference with the patient’s will in circumstances that are already sub-optimal for other reasons.  A better alternative might be to draft a forfeiture clause that is triggered by intentional interference, the presence of which (whether by act or omission/delay) is to be decided by an expert delegate with no direct interest in the matter, with at least partial reference to specific criteria described in the will.[5]

The degree and requirements of enforceability of forfeiture clauses vary considerably from place to place.  One jurisdiction might require a “gift over” to a specific beneficiary (like the example above)[6], while another might hold valid a forfeiture clause where the gift simply lapses into the residue of the estate.[7]  As Rebecca Lively points out, forfeiture clauses are not allowed at all in Florida and Indiana[8], and in many jurisdictions where they are permitted, they will nevertheless not be enforced against beneficiaries who contest the will with “probable cause” (though this should exclude contests founded solely on hostility towards a deceased’s cryonics arrangements). Furthermore, if the will is contested successfully, and declared invalid, then the forfeiture clause goes along with the rest of it, and the next-of-kin will collect as per the jurisdiction’s intestate succession regime.  Finally, forfeiture clauses will be held void or unenforceable to the extent that they offend public policy.  For instance, some jurisdictions permit applications by a surviving spouse and/or children to “vary” a will that does not make adequate provision for them in the circumstances.[9] Strictly speaking, these support applications are not “contesting” the will, but in any case, a forfeiture clause that was drafted with the intent of foreclosing such applications may be held to be against public policy, and thus void.[10]

Support applications are not the only means whereby next-of-kin can avoid, or partly avoid the sting of a forfeiture clause.  Oregon (and thirty-nine other US states) allows a surviving spouse to opt for an “elective share” in lieu of what the deceased’s will gives them (or, presumably, doesn’t give them).[11]  The right to make this election can be waived by written agreement[12], so it stands to reason that a forfeiture clause written to exclude from the estate any person who interfered with the will-maker’s cryonics arrangements, would be declared void to the extent that it attempts to cut off an interfering spouse’s statutory elective share.  Thus, even if a spouse’s actions trigger a forfeiture provision pertaining to a specific gift to them in the will, they will still be able to elect to receive this mandated share in the deceased’s estate.

Ten of the other states operate instead on a “community property” system[13] which, generally described, means that any earnings of either spouse or partner after marriage or registration of domestic partnership becomes “community property”, as does any property acquired with such earnings or with other money expressly or impliedly designated as “community funds”.[14] In Washington, a surviving spouse automatically gets half of all community property[15]. This cannot be avoided by will[16], nor does the statute provide for waiving this right.

So what’s the moral here?  Well, depending on where a cryonicist lives, and whether he/she is married or partnered and/or has children, the use of forfeiture clauses in a will to disincentivize interference with cryonics arrangements requires not just that those special next-of-kin are given “something substantial” to ensure their abidance (as Lively suggests), but that they are given something substantial above and beyond what they are entitled to under any statutory claims they can make which either (a) avoid the effects of the forfeiture clause, or (b) don’t trigger it in the first place.  A further difficulty, for those cryonicists living in jurisdictions with support order provisions, is that the size of such an order is based on consideration of the circumstances of the surviving spouse and/or children, the size of the estate, and non-specific statutory language like “necessary and reasonable”[17], or “adequate, just, and equitable”[18], so it is impossible to know on the face of the statute just how much is enough.  In many cases, the utility of forfeiture clauses as legal protection from interference will be greater for cryonicists who do not have living spouses or children, which is unfortunate given that those particular family members often pose the biggest threat.[19]

As a final note, wills may be used to transfer assets into a patient care trust or personal revival trust, which will be examined in the next section.  However, such funds would be better insulated from the estate if they were transferred during the cryonicist’s (first) lifetime.

Trusts

The basic premise of trusts is that legal ownership of property and the right to “enjoy” (i.e. benefit from) property can be separated, the former belonging to one person or group of persons (trustees), and the latter belonging to another person or group of persons (beneficiaries).  The duties of a trustee towards the beneficiary’s interests are more onerous than the duties of contracting parties, so trusts are often used to protect and provide for vulnerable persons, like minor children and spendthrift relatives.  For this reason, one would expect trusts to play a role in the legal protection of cryonicists, and indeed they do.  The two most prominent examples are patient care trusts and personal revival trusts.

(i) Patient Care Trusts

Patient care trusts promote the maintenance and revival of cryonics patients in two important ways.  First, transferring legal ownership of the assets provided to fund those objectives to trustees protects the assets from third-party litigants.  Second, patient care trusts protect those same funds from misuse by the cryonics organization itself and misappropriation by its directors or employees, and even the organization’s dissolution.

The most intuitive way of accomplishing these objectives would be to execute a trust under which present and future patients were beneficiaries.  However, because cryonics patients are dead, legally speaking, they have no legal personality and cannot be the beneficiaries of a trust.  Hence, while the terms of the Alcor Patient Care Trust (“APCT”) do state that Alcor is “acting on behalf of the Patients in biostasis”, Alcor is designated the sole legal beneficiary.[20]  Protection against third-party litigants is effected through the magic words, “[t]he interests of the beneficiary in principal or income shall not be subject to the claims of any creditor or to legal process, and may not be voluntarily or involuntarily alienated or encumbered”[21], together with the sections of the Arizona Trust Code upholding the validity of such provisions.[22]

The APCT’s ability to protect patient care funds from misuse, misappropriation, or potential dissolution of the organization ultimately boils down to whether (or how easily) Alcor, as the sole legal beneficiary, can simply terminate the trust and reclaim legal ownership of the funds.  The only termination scenario contemplated by the APCT (wherein Alcor still exists[23]), is if all the patients are revived and reintroduced to society.  All of the Arizona Trust Code provisions addressing modification or termination of charitable purpose trusts (like the APCT[24]) require that the court hearing the application consider whether modification or termination is consistent with the purposes of the trust and, if the trust is terminated, that the trust property be distributed by the trustees in a manner consistent with the purposes of the trust.[25] Practically speaking, it would be very difficult for Alcor to appropriate the patient care trust funds for any purpose other than patient care.

The APCT was established in 1997 and became irrevocable in 1999. The Cryonics Institute (“CI”) established an Endowment Care Trust Fund in 2004, as part of its agreement with Michigan’s Department of Energy, Labour, and Economic Growth to become licensed and regulated as a cemetery.  According to the conditions of licensure, “[t]hese funds will be set aside for maintenance, which shall include liquid nitrogen storage of existing CI patients.”[26]  Obviously the scope of this trust is not as ambitious as the APCT (nor was it intended to be), but it does protect at least some of the assets earmarked for patient care from misuse or misappropriation.[27]

(ii) Personal Revival Trusts

In his article, “Personal Revival Trusts: If You Can’t Take It with You, Can You Come Back To Get It?”, Igor Levenberg points out that for all the benefits of patient care trusts, “those who are revived will eventually have to provide for their own care.”[28]  Patient care trusts provide legal protection for cryonics patients’ interests at an organizational level, but those who are interested in additional protection – during their time as cryonics patients as well as post-revival – can establish personal revival trusts for this purpose.

To some extent, personal revival trusts (aka reanimation trusts) suffer from the same legal hindrance as general patient care trusts, namely that the individual cryonics patient cannot simply name themselves beneficiary of the trust because upon cryopreservation they will lose their legal personality, and the trust would revert back to their estate.  However, Levenberg describes two ways a cryonicist can draft themselves into a trust that don’t require proof at the outset that human cryopreservation is reversible.  One option is that the revived patient is a contingent beneficiary of the trust[29]; the other is that the patient’s revival is a condition subsequent which terminates the trust, with disbursement of the trust property to the revived patient[30].  The distinction is subtle, but bears important implications.  If the revived patient is named as the contingent beneficiary, the trust must have another beneficiary in the interim, who could potentially call for modification or termination of the trust.[31]  However, on such an application, the court will have to consider the patient’s contingent future interest, and may appoint a guardian to represent that interest.[32]  On the other hand, if the revival of the patient is a condition subsequent terminating the trust, the cryonicist could choose between a trust with an interim beneficiary, or a purpose trust with no interim beneficiary (like a charitable purpose trust, or a trust for the maintenance of one’s “grave”).[33] Purpose trusts have the additional advantage of being available for this use in jurisdictions which do not otherwise allow perpetual trusts.[34]

Levenberg suggests that any concern over the possibility of the interim beneficiary hijacking the personal trust for their own benefit can be cured by designating one’s cryonics organization in that role.[35]  With the right drafting, in a jurisdiction that places emphasis on the original terms and purpose of the trust, this may well work (as with the APCT, discussed above).  An added level of assurance can be effected through the use of trust protectors, relatively recently emerged characters in trust law who can be empowered by the trust to, among other things, grant beneficial interests to new individuals – like newly revived cryonics patients… or newly legally recognized cryonics patients.[36]  Trust protectors feature in many of the personal revival trusts under development, including the Alcor Model Trust.[37]

Trusts clearly play an important role in the legal protection of cryonics patients.  However, on a critical note, it must be remembered that not all problems have financial solutions.  Cryonics patients benefit greatly from secure financial vehicles to support their continued maintenance, fund resuscitation research, and even revert to them if and when they are reanimated, but if the care of a particular patient or group of patients falls below reasonable standards due to negligent mismanagement, or is being threatened by hostile governmental policy, what can trustees really do?  Neither patient care trusts nor personal revival trusts have any means of exerting direct control over the patients themselves, regardless of circumstance.


Endnotes:

[1] Latin: “in fear”.

[2] Remember that these are actually separate legal mechanisms for transfer of custody of human remains. See Keegan Macintosh, “Legal Protection of Cryonics Patients, Part 1” Depressed Metabolism (23 February 2012), online: Institute for Evidence Based Cryonics <https://www.biostasis.com>.

[3] See e.g. Last Will and Testament for Human Remains and Authorization of Anatomical Donation, online: Alcor Life Extension Foundation <http://www.alcor.org/Library>.

[4] Rebecca Lively, “How to Protect Your Cryonics Arrangements from Interference by Third Parties”, online: Alcor Life Extension Foundation <http://www.alcor.org/Library>.

[5] This should be available in at least some jurisdictions.  See Re Tuck’s Settlement Trusts, [1977] EWCA Civ 11.

[6] Bellinger v Nuytten Estate, 2003 BCSC 563 [Bellinger].

[7] Peter G Lawson, “The rule against in terrorem conditions: What is it – Where did it come from – Do we really need it?” (2005) 25 ETPJ 71 at 80-81.

[8] Supra note 4.

[9] See Wills Variation Act, RSBC 1996 c 490, s 2; see also ORS § 114.015.

[10] See Kent v Mackay, [1982] 139 DLR (3d) 318 at para 20 (BC SC) (available on WL Can): “It is a matter of public policy that support and maintenance be provided for those defined individuals and it would be contrary to such policy to allow a testator to circumvent the provisions of the Wills Variation Act by the creation of such as [the no contest clause here].  It is important to the public as a whole that widows, widowers and children be at liberty to apply for adequate maintenance and support in the event that sufficient provision for them is not made in the will of their spouse or parent.”  This decision was followed by the court in Bellinger, supra note 6.

[11] ORS § 114.600.

[12] ORS 114.620.

[13] Leaving Georgia, which only provides a surviving spouse (along with any minor children) one year’s allowance from the deceased’s estate: OCGA § 53-3-1.

[14] See, for example RCW § 26.16.030.

[15] RCW § 11.02.070.

[16] RCW § 26.16.030(1).

[17] ORS § 114.015.

[18] Wills Variation Act, supra note 9.

[19] Mike Darwin, “Marcelon Johnson dies and is not cryopreserved” Depressed Metabolism (24 January 2009), online: Institute for Evidence Based Cryonics <https://www.biostasis.com>. See also supra note 4.

[20] Alcor Patient Care Trust, online: Alcor Life Extension Foundation <http://www.alcor.org/Library>.

[21] Ibid, art 3.

[22] ARS § 14-10502. These clauses are called “spendthrift provisions” due to their use in trusts drafted to support persons with bad borrowing habits.

[23] If Alcor ceases to exist, and the APCT cannot be converted into an independent legal entity, then the funds will be disbursed to another organization, or by some other means further the purposes of the Trust to support the care, revival, and rehabilitation of Alcor patients. See supra note 20, art 17.

[24] While Alcor drafted the APCT to be consistent with its 501(c)(3) status, whether the APCT is in fact a charitable purpose trust concerns the application of ARS § 14-10405(A). Framing the purpose of the trust in terms of scientific research and education is not necessarily conclusive of the matter.

[25] ARS § 14-10410, 14-10411, 14-10413, and 14-10414.  Not all jurisdictions mandate as strong deference to the original terms of the trust; see, for example, Trust and Settlement Variation Act, RSBC 1996 c 463.

[26] Ben Best, “Conditions to Licensure as a Cemetery” The Immortalist (March 2004), online: Cryonics Institute <http://www.cryonics.org/immortalist>.

[27] The assets designated for patient care on CI’s 2011 year-end financial report amount to more than double the contents of the Endowment Fund: Statement of Assets, Liabilities, and Fund Balance, online: Cryonics Institute <link:http://cryonics.org/financials.html>.

[28] Igor Levenberg, “Personal Revival Trusts: If You Can’t Take It with You, Can You Come Back To Get It?” (2009) 83:4 St John’s Law Review 1469 at 1494, n 129.

[29] Ibid at 1489.

[30] Ibid at 1495.

[31] Ibid.

[32] Ibid at 1489-90.

[33] Ibid at 1498.

[34] Ibid.

[35] Ibid 1495-96.

[36] See e.g. ARS § 14-10818(C)(1).

[37] Ben Best, “Asset Preservation Group Meeting” Long Life (July 2011) 23 at 24, online: Cryonics Institute <http://www.cryonics.org/immortalist>; see also Ben Best, “Fourth Asset Preservation Group Meeting” Depressed Metabolism (2 June 2010), online: Institute for Evidence Based Cryonics <https://www.biostasis.com>.

Experiment made on the mummy

As documented in David M. Friedman’s The Immortalists: Charles Lindbergh, Dr. Alexis Carrel, and Their Daring Quest to Live Forever, Lindbergh and Carrel considered the human body a living machine made of replaceable parts. A major reason why Carrel was interested in developing and refining equipment to perfuse isolated organs is because he believed that this would allow damaged tissue to be repaired outside of the body and ultimately substitute new organs for diseased organs. His ultimate objective was to conquer death itself.

In The Immortalists, Friedman writes about one experiment that should leave no doubts about Carrel’s personal commitment to the scientific conquest of death. When Lindbergh supervised the packing of Carrel’s property after his death they found:

..a 3,000-year-old Egyptian mummy the surgeon had tried to revivify  in 1925. (“A small hole was made in the abdomen of the mummy about 3 cm. from the right iliac spine. The skin was hardened and very tough,” Carrel wrote of his failed experiment.)

Without seeing the complete notes of these experiments, it is not possible to say what Carrel’s  specific intentions were. Although our knowledge about the ultrastructural effects of different preservation techniques has greatly improved since Carrel lived, it is hard to imagine that a  brilliant scientist like Carrel seriously believed in resuscitation of the 3,000-year-old Egyptian mummy. Perhaps his objective was more modest and involved recovery of material for cell and tissue experiments, an objective that would not have been unrealistic considering the recent reported findings of clonable DNA in an Egyptian mummy.

Carrel’s notes of this experiment, called “Experiment Made on the Mummy,” are included with his papers which remain at Georgetown University’s library in Washington DC.

Cryonics sets example for emergency medicine

One of the most neglected aspects of cryonics is that its procedures, and the research to support them, can have important practical applications in mainstream fields such as organ preservation and emergency medicine. Contrary to popular opinion, cryonics does not just involve an optimistic extrapolation of existing science but can set the standard for these disciplines. As a matter of fact, that is exactly what cryonics, and cryonics associated research, has been doing over the last 25 years.

The most striking example is the progress in vitrification as an alternative for conventional cryopreservation. Although the idea of eliminating ice formation at low subzero temperatures has been discussed since the beginning of cryobiology, vitrification as a serious research agenda was largely driven by the demand for ice-free preservation of the human brain. Over the last decades this research has culminated in the development of the least toxic vitrification agent to date, 21st Century Medicine’s M22.

The contributions of cryonics to mainstream science and medical practice are not confined to cryobiology. Researchers Jerry Leaf and Mike Darwin made impressive progress in the formulation of bloodless whole body organ preservation solutions to resuscitate dogs from ultraprofound hypothermic temperatures, an intervention that is increasingly being recognized as essential to stabilize trauma victims. In the mid 1990s, Mike Darwin and Steve Harris conceived and developed the idea of using liquid breathing with perfluorocarbons as a method to induce rapid hypothermia. They further validated a multi-modal medications protocol to resuscitate dogs from up to 17 minutes of normothermic cardiac arrest without neurological damage.

Although progress has slowed considerably in the non-cryobiology research areas over the last 10 years, it is encouraging to observe that some of the procedures that are routine in cryonics  stabilization protocol  are starting to catch on in mainstream emergency medicine practice as well. For example, contemporary cryonics stabilization protocol has been strongly shaped by the idea that the best strategy to limit brain injury after cardiac arrest is to combine a number of different interventions: cardiopulmonary support, induction of hypothermia, and administration of circulation-supporting and neuroprotective medications.

It is therefore very encouraging to learn that the Wake County EMS group in North Carolina has achieved impressive results in treating out-of-hospital cardiac arrest victims using a protocol that closely follows elements of current cryonics stabilization protocol. Systematic implementation of immediate induction of hypothermia, continuous compression CPR, and the use of an impedance threshold device (ResQPOD) produced an almost 400% improvement in survival and vast improvements in neurological outcome. A PowerPoint presentation about their experience and protocols are available at their website.

Such real world outcomes do not only inspire confidence in the procedures cryonics organizations can use to protect patients from brain damage after cardiac arrest, it should also serve as a wake-up call to relaunch an aggressive research agenda to push the limits of hypothermic and normothermic resuscitation. In absence of this, it will only be a matter of time before cryonics activists can no longer claim that “we did it first.”

HT Mike Darwin

Early total body washout experiments in cryonics

The question of whether cryonics “works” or not is too general and hides the  point that progressive breakthroughs can make the concept more plausible. Human cryopreservation consists of a number of procedures culminating in long term care at cryogenic temperatures. An evidence based approach to cryonics dictates that the limits of procedures that can be reversed by contemporary technologies should be investigated and pushed further. Under ideal conditions viability of the brain of the patient can be maintained until the early stages of cryoprotective perfusion. In other words, cryonics procedures can be reversed with no or minimal brain injury up until the stage where exposure of the brain to higher concentrations of the vitrification agent compromises viability. Although we do not have a good understanding of the extent of ice formation in the brain of  typical patients in which vitrification is attempted, in ideal cases the current limiting factor to reversibility of cryonics procedures is cryoprotectant toxicity.

During its existence as a research program, cryonics researchers have shown great interest in recovering animals from ultra-profound hypothermic temperatures (lower than 5 degrees Celsius). The ability to routinely lower the temperature of mammals to temperatures close to zero degrees Celsius and  recover them without adverse effects to the brain does make the initial stages of cryonics reversible. Although this procedure does not necessarily require that the blood of an animal is removed at the lowest temperatures, theoretical considerations and experimental evidence dictate that  the use of an universal organ preservation solution will improve outcome. In the 1980s, the Alcor Life Extension Foundation engaged in a series of experiments that recovered dogs perfused with a mannitol-based organ preservation solution called MHP after 5-hours of bloodless perfusion at  5 degrees Celsius without adverse neurological outcome after rewarming.

Less known than those record setting experiments are earlier explorations in cryonics into whole body asanguineous hypothermia. The following document by cryonics researcher and Alcor patient Jerry Leaf documents a Trans Time experiment during the early days of total body washout experiments in cryonics. This account was published in the November/December 1977 issue of Long Life Magazine and the scan contains an introduction by Art Quaife and an afterword by Saul Kent.

Jerry Leaf – A Pilot Study in Hypothermia (1977) PDF

Blood flow during CPR and reperfusion injury

An important objective during stabilization of cryonics patients is restoring circulation of blood to the brain. In ideal cases, this can be achieved by aggressive mechanical cardiopulmonary support, hemodilution ,and administration of vasoactive medications. In not-so-ideal cases, one or more of these interventions are omitted or delayed. This raises the question if low flow perfusion scenarios can be detrimental to the brain because of increased reperfusion injury.  In a previous post, a paper was reviewed that found that (very) low cerebral blood flow was better than no flow at all, allowing a wider therapeutic window for successful resuscitation. Why do the low flows generated during manual cardiopulmonary resuscitation (or cardiopulmonary support in cryonics) improve the likelihood of successful neurological recovery?

In a recent paper (2008) in Resuscitation, Rea, Cook and Hallstrom propose that the low flow state generated by manual CPR simultaneously protects against ischemic injury and limits reperfusion injury. They speculate that low flow during CPR “arrests” ischemia and induces post-ischemic conditioning, which reduces exposure to peak values of oxidative stress and increases resistance to reperfusion injury when normal flow is restored:

If full flow was restored early on after collapse, the accumulation of stress mediators would be relatively modest and so the cell could tolerate reperfusion injury without moderating the peak level of oxidative substrate or priming the cell’s protective pathways. However as the duration of no flow increases, stress mediators accumulate to a level where full or near-full flow would produce oxidative injury that would overwhelm the cell unless peak oxidative stress levels are mitigated and protective pathways are preemptively up-regulated, as might occur with graded flow.

The authors even speculate that in some scenarios manual CPR might be superior to newer devices and techniques (such as  automated vest CPR or active compression-decompression CPR) that can restore blood to physiological levels because manual closed chest CPR protects the heart and brain from peak levels of stress mediators.

As the authors note, if this hypothesis is correct, treatment of cardiac arrest would require a highly individualized approach “whereby certain physiologic states would be best served by different levels of circulation and hence distinct doses of CPR.” Such treatment modalities will require complicated monitoring and resuscitation efforts, such as automated control over perfusion pressure and ventilation during CPR.

Although this model makes sense from a theoretical level, it seems to be at odds with the discovery that low flow perfusion cannot reverse the “no-reflow” phenomenon. If blood flow cannot be restored to some parts of the brain, it is not likely that ischemic injury can be “arrested” in those areas. It also seems to be at odds with the work of other resuscitation researchers who found that increased perfusion pressures and hemodilution can increase the time that resuscitation from normothermic ischemia is possible. And because low flow perfusion limits the rate of external and internal cooling, such graded resuscitation strategies decrease cooling rates if resuscitation is complemented with induction of hypothermia. Perhaps the authors could also improve on their own model by allowing aggressive reperfusion but without oxygen (or just room air) during the early stages of reperfusion.

Because rapid induction of hypothermia is the most fundamental intervention in human cryonics preservation, the relevance of this model may be limited. However, in cryonics stabilization circulation is usually restored before any significant temperature decreases are possible.  Cryonics patients often have distinctly different pathophysiological characteristics, which makes straightforward application of such models, if practical at all, extremely challenging. As has been reiterated before, without the creation of realistic cryonics research models and serious efforts at monitoring cryonics patients during transport, it will be hard to evaluate the relevance of recent insights in resuscitation medicine and extrapolate its findings.

Cerebral blood flow during and after cardiac arrest

As discussed in a previous post, perfusion of the brain following long-term (>5 min) ischemia has been shown to be significantly compromised, particularly in subcortical regions. An interesting recent article by Ristagno, et. al in Resuscitation (May 2008) has added new data to the equation, using some of the most advanced technologies available for measuring cerebral microvascular blood flow.

To briefly summarize the experiment, pigs were subjected to 3 minutes of untreated ventricular fibrillation followed by 4 minutes of cardiopulmonary resuscitation and subsequent defibrillation. Blood flow in large (>20 micrometers) and small (<20 micrometers) cerebral vessels was measured during and after CPR by direct visualization using orthogonal polarization spectral imaging (OPS) together with cortical-tissue partial pressure of carbon dioxide.

Though prior studies implied a dissociation between microcirculatory flow and macrocirculation during CPR, Ristagno, et. al found “a close relationship between microvascular flows and the macrocirculation during cardiac arrest, during CPR and following return of spontaneous circulation (ROSC).” Interestingly, they also noted that cerebral blood flow was reduced, but did not stop, for more than 2 minutes after cardiac arrest, most likely due to residual compliance in the arterial circuit. After ROSC, flow progressively increased back to normal (pre-arrest) values within 3 minutes.

Importantly, the researchers also noted that cerebral cortical-tissue partial pressure of carbon dioxide (a measure of the severity of cerebral ischemia) increased progressively througout CPR, providing evidence for the fact that the pressure and flow generated during chest compressions “may minimise but do not reverse the magnitude of the brain ischaemia which preceded the start of CPR.”

Though many investigations, such as the previously reported study by Fischer & Ames reported no-reflow or hypoperfusion following ischemia, these authors observed no such phenomena, possibly because of the short duration of cardiac arrest. Indeed, they ultimately conclude that “a 3-min interval of ischaemia was therefore probably not long enough to induce alterations in blood flow during reperfusion.” Also of importance is the fact that OPS technology limits visualization of microvessels to within 1mm of the cortical surface. However, this paper still gives us better insight into the immediate effects of cardiac arrest, cardiopulmonary resuscitation, and reperfusion on microcirculatory flow in the brain.

Life not death

The idea that cryonics does not involve the freezing of “dead” people but is form of low temperature care to prevent death is almost as old as the idea of cryonics itself. In May 1968, Cryonics Reports, the publication of the Cryonics Society of New York (CSNY), writes that recognition of cryonics as a form of treatment to be administered prior to death should help overcome a major psychological impediment to its acceptance and major step forward in redirecting the aim of medicine.

LIFE NOT DEATH

Only scientific research will provide the understanding that will lead to changes in human growth and development. But to bring about these changes it must be applied to human beings. The aim of medicine is to sustain and improve life. It is therefore mandatory for the physician to utilize every known treatment in order to save a patient. Cryonic suspension is a known means of treatment, because freezing a body definitely prevents physical deterioration. The goal of cryonic suspension is preservation and it works!

The fact that resuscitation after freezing is presently impossible is irrelevant if there is the slightest chance that it will be possible in the future. By freezing the body we are stopping the spread of a condition that is certain to destroy it completely. This is a desirable and valid goal.

Perhaps the major psychological impediment to acceptance of the treatment is the concept of freezing after “death.” When we refer to “death” we mean legal death only. Because we believe it may be possible ultimately to revive a patient placed in cryonic suspension, we do not regard that patient as “dead” biologically.

A patient is declared “dead” when the attending physician decides that resuscitation is impossible by any known or available means. Death is not synonymous with absolutely irreversible damage, but only damage that can not be reversed at the time of treatment. Resuscitation technology is improving constantly; conditions that are irreversible today will easily be reversible tomorrow.

It would seem, therefore, that the term “death” should be reserved only for those special circumstances in which it is impossible to place the patient in cryonic suspension. After freezing or supercooling, the patient should be declared “in suspension.” This should be considered a temporary condition of indefinite duration.

The general acceptance of the idea that cryonic suspension is a treatment to be administered prior to “death” not after, would be a major step in crystallizing and redirecting the aim of medicine, saving the lives of many people, and clearing a pathway for an all-out drive to conquer aging.

Cryonics Reports, Vol. 3, No. 5, May 1968

H.P. Lovecraft and the science of resuscitation

H.P. Lovecraft’s Herbert West is a man of science, not superstition. Following Ernst Haeckel, he believes that “all life is a chemical and psychical process,” that the soul is “a myth,” and that “unless actual decomposition has set in, a corpse fully equipped with organs may with suitable measures be set going again in the peculiar fashion known as life.” Not satisfied with conventional medicine, West devotes his life to creating a solution that will restore artificial life after death. Like many biomedical researchers would find out after him, the same solution can have different effects on different species. But what West is really after is reanimation of humans. And reanimation of humans requires experimentation on humans.

West does not only anticipate the future science of resuscitation, but also the phenomenon of selective vulnerability of certain brain cells because we know that West fully realized “that the psychic or intellectual life might be impaired by the slight deterioration of sensitive brain-cells which even a short period of death would be apt to cause.” As a consequence, his corpses cannot be “fresh” enough. Artificial resuscitation turns out to be a step towards bigger things when we learn that West has ventured into the area of “warm” whole body preservation (suspended animation) by creating a “highly unusual embalming compound” that keeps the body fresh for future resuscitation efforts. Still not satisfied, the “materialist” West moves on to prove that there is nothing special about the brain when he attempts to create mental life by pharmacologic modulation of nervous tissue in a decapitated body. One can only guess what direction West’s research would have taken after these bizarre experiments. Science is hard, but for this medical student of Miskatonic University, resuscitation, suspended animation, and stem cell research are all in a days work.

The greatest mystery in Lovecraft’s “Herbert West – Reanimator” is that West succeeds in reanimating anything at all. Injection of West’s solution is not followed by artificial circulation, which makes one wonder how such a solution can confer such profound benefits.

Sustained abdominal compression

Conventional CPR typically generates around one-third to one-fourth of normal cardiac output, which is not sufficient to meet cerebral energy demands. In cryonics patients, cardiac output may be further compromised because many patients are atherosclerotic and/or have gone through a prolonged period of shock / multiple organ failure prior to pronouncement of legal death. However, conventional chest compression techniques can be improved and augmented to produce higher cardiac output and cerebral blood flow.

In cryonics, chest compression techniques range from manual chest compressions to mechanical high impulse active compression-decompression cardiopulmonary support (CPS). A recent technology that has been introduced to cryonics is the use of a mechanical load-distributing band CPS device, the Autopulse. Cerebral blood flow can be further augmented by using a respiratory impedance valve (such as the ResQPOD) and administration of vasoactive medications, such as epinephrine and vasopressin.

Although these interventions can improve cerebral blood flow during CPS, it is a well documented fact that many cryonics patients do not benefit from such improvements. Administration of vasoactive medications requires intravenous access which is often difficult to obtain in the typical cryonics patient. Similarly, the use of an impedance valve requires a patent airway which requires rapid and successful intubation of the patient. Clearly, it would be beneficial to have a technology that can be rapidly applied, is non-invasive, and does not require special technical knowledge or manual skills.

Abdominal compression appears to be such a technology. An air-inflatable cuff is positioned on top of the abdomen and secured in place. In some versions of the technology, a contoured cuff follows the lower border of the rib cage to minimize the chance of interference of the cuff with lung inflation during positive pressure ventilation. Constant abdominal compression is achieved by inflating the cuff during chest compressions. Abdominal compression increases coronary and cerebral blood flow by a) increasing intrathoracic pressure, b) increasing functional arterial resistance, and c) redistributing blood volume above the diaphragm out of the abdominal compartment (in: Biomedical Engineering Fundamentals, 2006).

In a recent study by Lottes et al. (2007), sustained abdominal compression was able to raise coronary perfusion pressure as much as vasopressor drugs. Progressively better results were obtained when abdominal pressure was increased from 100 mmHg to 500 mmHg. Optimal results were obtained when abdominal compression was used in combination with vasopressor drugs. This technology has also been evaluated in humans; Chandra et al. (1981) reported increased mean arterial, systolic, and diastolic blood pressure during CPR following cardiac arrest in humans.

Advantages of sustained abdominal compression in cryonics include: low fabrication costs, light in weight, indefinite shelf life, no refrigeration requirements, no electrical power requirements, easy to apply, immediate onset of action, constant effect over time (unlike medications), and immediately reversibility of the procedure.

The disadvantages of sustained abdominal compression are not evident but warrant careful consideration: (a) Abdominal compression may exacerbate ischemia-induced abdominal hemorrhage – this disadvantage is highly speculative since rupture of the inner lining of the gastric mucosa is a biochemical, not mechanical, event. It is clear, however, that abdominal compression is contra-indicated in patients with abdominal swelling and related gastrointestinal complications. The band and cuff may also interfere with placing a gastric tube to administer an antacid (I owe this point to Stephen Van Sickle). (b) Reversal of abdominal compression may rewarm the upper part of the body as a result of warmer blood having increased access to the upper torso and brain – this, again, is speculative and depends on the question of whether abdominal compression induces selective cooling of the torso. If such a scenario is possible, this effect might be limited by not reversing compression until internal cooling is started. The question remains, however, if better perfusion of the brain will offset slower cooling of the brain as a result of decreased surface cooling. (c) The inflatable cuff may interfere with the Autopulse technology – it is not likely that the two technologies will interfere because the lower part of the Autopulse band does not come into contact with the upper part of the abdominal compression cuff.

Another concern that has been raised about using this technology in cryonics concerns the possibility that abdominal binding has the effect of shunting blood to the upper torso and brain. The resulting lack of perfusion, and subsequent collapse of the vascular bed in the lower extremities, may make raising and cannulating the femoral vessels very difficult, if not impossible. An opposite view is that abdominal compression may actually facilitate femoral cannulation because it creates a bloodless field and enhances visibility of the vein by inflating and distending it (I owe this point to Brian Wowk). It should also be noted that not all cryonics stabilization cases are followed by blood washout through the femoral vessels. Examples include remote cases without blood washout, local cases, and cases in which the patient is cryoprotected in the field (in which surgical access may be obtained through median sternotomy or the cerebral vessels).

It remains to be seen if sustained abdominal compression becomes more popular in resuscitation medicine. Provided this technology is as effective as documented in the Lottes paper, contemporary cryonics stabilization procedures may benefit from such a simple technology to increase blood flow to the brain during CPS.

Selected Bibliography

Lottes AE, Rundell AE, Geddes LA, Kemeny AE, Otlewski MP, Babbs CF.
Sustained abdominal compression during CPR raises coronary perfusion pressures as much as vasopressor drugs.
Resuscitation. 2007 Dec;75(3):515-24.

Wik L, Naess PA, Ilebekk A, Steen PA.
Simultaneous active compression-decompression and abdominal binding increase carotid blood flow additively during cardiopulmonary resuscitation (CPR) in pigs.
Resuscitation. 1994 Jul;28(1):55-64.

Babbs CF, Blevins WE.
Abdominal binding and counterpulsation in cardiopulmonary resuscitation.
Critical Care Clinics. 1986 Apr;2(2):319-32.

Koehler RC, Chandra N, Guerci AD, Tsitlik J, Traystman RJ, Rogers MC, Weisfeldt ML.
Augmentation of cerebral perfusion by simultaneous chest compression and lung inflation with abdominal binding after cardiac arrest in dogs.
Circulation. 1983 Feb;67(2):266-75.

Chandra N, Snyder LD, Weisfeldt ML.
Abdominal binding during cardiopulmonary resuscitation in man.
JAMA. 1981 Jul 24-31;246(4):351-3.

End tidal carbon dioxide monitoring in cryonics

The best non-invasive indicator of cardiac output and oxygenation during cardiopulmonary support (CPS) is end tidal carbon dioxide (ETCO2). ETCO2 is the partial pressure of carbon dioxide (CO2) at the end of an exhaled breath. Until recently, cryonics standby kits were equipped with disposable colorimetric ETCO2 detectors. Some limitations of the disposable ETCO2 detectors are that they are not quantitative, not continuous, hard to read in the dark, and can give false readings. In 2006 this situation changed when Alcor used the CO2SMO, a sophisticated monitoring device that can give a complete respiratory profile of the patient, during a case.

Although devices like the CO2SMO represent the state of the art in respiratory monitoring, their cost, size and complexity may limit routine use of this equipment in remote cases. In August 2007 the cryonics company Suspended Animation added the Capnocheck to its standby equipment. The Capnocheck is similar in size to the older colorimetric ETCO2 detectors but gives quantitative and digital readings for ETCO2 and respiratory rates using infrared technology. ETCO2 readings are given in mmHg and the respiratory rate is given in breaths per minute. Some models come with an alarm that can be set for high and low ETCO2 readings.

ETCO2 can be used to evaluate the effectiveness of chest compressions and as a predictor of outcome during cardiopulmonary resuscitation. Studies have found that patients with restoration of spontaneous circulation (ROSC) have higher ETCO2 levels than patients that could not be resuscitated (levels <10 mmHg). Normal ETCO2 levels are between 35 and 45 mmHg. Because numeric readings of ETCO2 have rarely been obtained and analyzed in cryonics, knowledge about what ETCO2 levels to expect and not to expect are unknown. At this point in time, meticulous note taking of ETCO2 levels during CPS is essential to generate a series of data for cryonics patients.

Another important use of ETCO2 monitoring is that it can be used to validate correct placement of the endotracheal tube (or Combitube). If the endotracheal tube has been placed in the esophagus, or has become dislodged, one would expect to see negligible ETCO2 readings. Another issue that needs to be taken into account is the effect of stabilization medications on ETCO2. For example, administration of the vasopressor epinephrine will decrease ETCO2 readings although cerebral blood flow may be improved. Some cryonics technologies such as liquid ventilation appear to be incompatible with ETCO2 monitoring altogether.

ETCO2 monitoring does not give direct information on how well the brain of a cryonics patient is being perfused. New non-invasive technologies that can do this will be reviewed in the future.