Alcor 1997 Stabilization and Transport Manual
Table of Contents

Chapter 4: Team Coordination

Many patient transports have been improved by the cooperation and kindness of strangers. Even people who have had no previous involvement with cryonics may be willing and able to provide assistance to transport team members. These people could be morticians, hospital workers, hospice volunteers, or neighbors from next door. For transport team members who have been dispatched to an unfamiliar city to transport an unknown cryonicist, gaining the cooperation of friendly, local residents could mean the difference between a great transport and a disaster.

Transport team members should be prepared to explain cryonics to individuals who've never heard of cryonics (although this is becoming increasingly rare). Most people appear to be familiar with the concept and many have just a few questions which simply must be answered. Feel free to respond to such inquires, as long as conversation does not disrupt or interrupt the transport preparations.

When the transport team members reach the patient before pronouncement occurs, the full transport protocol should be implemented (see Chapters 5 to 10). Each step of the transport protocol has a purpose, and each plays a unique role in maximizing structural integrity. Cooling the patient; reestablishing circulation and oxygen support; administering membrane-stabilizing medications; replacing the blood with an organ preservation solution; and transporting the patient to Scottsdale, Arizona for cryoprotective perfusion are all important. How well each step is ultimately carried out will be heavily dependent upon the quality of advance preparation. The unique circumstances of each transport will determine how much time is available to prepare for and carry out these procedures. Some teams have had weeks to set up, and some have had an hour. Time factors are difficult to determine in advance, so everything should be pre-pared as quickly as possible just in case.

Arrangements should be made with a local mortician or funeral director to obtain an immediate release of the patient after pronouncement and to provide a location where the stabilization procedures may be carried out. Transport personnel will also be responsible for securing the cooperation or noninterference of hospital, hospice, or nursing home personnel.

All cases begin best if the patient is still clinically alive when the transport team is present and prepared. But before an actual transport may begin, the patient must be declared dead by a physician (or otherwise authorized individual), after the patient has died from the natural progression of illness or injury. It is also important to be aware that there are two methods physicians may employ for the pronouncement of legal death.

Varying Definitions of 'Death'

  • Clinical death: cessation or absence of heartbeat and breathing following bedside observation of the course and symptoms of a disease.

  • Legal death: irreversible cessation of heartbeat and breathing, or brain death (as defined below), where a qualified individual (generally, the patient's physician) is willing to or has already signed the death certificate.

  • Brain death: complete and irreversible cessation of cerebral cortex function [2].

In a hospital setting, the pronouncement of legal death is generally based upon the observation of clinical death. A physician will usually be on-call to provide this pronouncement once a patient's breathing and heartbeat have ceased. Under normal (non-cryonics) circumstances, pronouncement will occur at the convenience of the hospital staff. This laissez faire attitude is unacceptable for cryonic suspension patients, however. Transport team members must always make arrangements for immediate pronouncement and release of the patient.

For the cryonic suspension patient, brain death requirements for pronouncement are undesirable. An EEG monitor is used to record the cessation of brain electrical activity and may require an absence of activity for up to 24 hours. This method for pronouncement will result in hours of normothermic ischemia (normal body temperature cellular deterioration with no heartbeat or respiration) for the patient. The physiologic ramifications of this damage and the resultant effects upon the cryonic suspension of a patient are not yet fully understood and are beyond the scope of this manual. However, medical journals contain a vast number of papers published on the causes and effects of cellular damage [3,6,11,22], and it's clear that this kind of damage is severe.

Pronouncements based upon the more rigorous brain death criterion may be required by a hospital where administrators are concerned about legal liability. It may also be demanded in cases where the patient is expected to be autopsied or when artifical life support systems are being used prior to pronouncement. As yet, no Alcor patient has ever been pronounced on the basis of cerebral cortex function. No transport team member should ever suggest that this method for pronouncement be used. If hospital and team member relations appear to be deteriorating, and the hospital administrators are dropping hints about attorneys and are considering requiring the brain death criterion for pronouncement, notify Headquarters immediately. Instructions for pursuing or discontinuing discussions will be provided by Alcor's President after consultation with the Board of Directors.

Assessing Hospital Cooperation

Gaining the cooperation or noninterference of the hospital is an important aspect of transport preparations. Negotiations must occur while the patient is still alive and should involve at least one sympathetic member of the patient's family, if possible. These negotiations will generally be initiated by the transport team leader and involvement should be limited to the fewest possible transport personnel.

When dealing with a hospital, one of the first requirements is to forward a copy of the patient's cryonic suspension paperwork to the primary care physician and hospital administrators. This paperwork is essential to proving the patient's choice to be cryonically suspended, which is one of the first ethical issues that will arise. Copies of the cryonic suspension paperwork may be faxed to transport personnel with little notice, and original documents should be delivered as soon as possible. Key documents to have are the Authorization for Anatomical Donation, the Consent for Cryonic Suspension and the Cryonic Suspension Agreement. The first demonstrates the patient's desire to make an whole-body anatomical donation to Alcor, and the second is the service contract between Alcor and the patient that obligates Alcor to accept the anatomical donation under very specific conditions.

A great deal of information must be obtained by the transport team about the status of hospital cooperation or interference with transport preparations. Cooperation and noninterference are not the same thing, and transport team members should be clear on which policy the hospital has adopted. Noninterference is the course most often chosen by hospital administrators. It usually entails a prompt pronouncement and release of the patient, with all hospital personnel prohibited from assisting Alcor personnel. Cooperation is the term used for a hospital which, in addition to prompt pronouncement and release of a patient, will place an IV line (or if one is already in place, leave it) and allow cardiopulmonary support and the administration of medications on the hospital premises. See the illustration for some important questions.

Information should be collected for every institution which is caring for an Alcor suspension client in advance of pronouncement, as the patient may be transferred from one facility to another with little or no notice to the transport team members. "Hospital" is used to generically imply any health care facility (hospice, nursing home, etc.).

Determining the level of cooperation is essential to arranging the logistics of a transport. If transport team members are unable to start the transport procedures on the hospital premises, the patient can be expected to undergo ischemic times of at least transport time to the mortuary (although, for example, medications may be administered while in the Alcor ambulance or mortuary vehicle) plus the time required for the physician to officially pronounce the patient plus the time required to release the patient to Alcor personnel plus any unanticipated delays (e.g. if the mortician is not on-hand to accept the patient and sign the release documents). Minimizing these delays is critical to providing the patient with a good cryonic suspension.

Assessing hospital cooperation

Is the hospital agreeing to non-interference?

Is the hospital willing to cooperate?

Has the hospital recognized Alcor's authority to accept this donation?

Will the patient be released promptly to Alcor personnel?

Will the patient be pronounced promptly?

Will a physician be available 24-hrs to pronounce?

Will all lines (IV, catheters, airways, etc.) be left in place?

May Alcor personnel wait nearby (in the floor lounge)?

Can Alcor equipment be stored nearby (in an empty room)?

Are large quantities of ice available in the hospital?

Will hospital personnel assist with the transport stabilization?

Will they intubate the patient?

Will they begin an IV?

Are they willing to provide cardiopulmonary support?

Additional notes (include list of involved personnel):

Mortuary Cooperation

Transport team members may reduce the ischemic time experienced by the patient through coordinating with both hospital and mortuary personnel in advance of pronouncement. Coordination with hospital personnel has already been discussed, and coordination with mortuary personnel is similar.

Historically, mortuary personnel have been very helpful to transport teams. They have stored equipment and have allowed the blood washout circuit to be set up in advance of pronouncement, where space was available. They are often willing to standby with the team, if called when the patient appears clearly agonal (and seems less than an hour from pronouncement). Morticians have been unusually good-natured in cases where such standby calls were premature, but the threshold for such good-nature should not be tested. Morticians are essential contacts for Alcor. It is difficult to transport a patient across state boundaries without the cooperation of a local mortician or funeral director.

Assessing mortuary cooperation

Will the mortician be available 24-hours?

Will little or no notice produce a fast response?

Is the mortician willing to stand-by with the team?

Will Alcor receive priority over other clients?

Will an embalming table be available 24-hours?

Is the mortician willing to assist with the surgery?

Can the equipment be set up in advance?

Can additional equipment be stored on-site?

Will the portable ice bath fit inside the transport vehicle?

Additional notes:

Negotiating Service Contracts

Transport team members may be required to draw up a contract for use of mortuary facilities and funeral director services. Contracts may be reasonably requested by funeral directors to protect their business from nonpayment for services and other financial liabilities. Contracts should be clear and concise, stating the required services and facility usage, the financial compensation the funeral director will receive, and when payment will be made.

Note that this contract has been drawn up to satisfy requirements of the Arizona State Board of Funeral Directors and Embalmers and some provisions may not apply to a remote transport situation. Not all of the questions listed in the "Assessing Mortuary Cooperation" illustration have been addressed in this contract, as they are not relevant to Scottsdale capability (e.g. in Phoenix, the equipment is set up and stored at Alcor Headquarters). Similarly, transport team members are unlikely to need clauses discussing annual retainers, unless a local group chooses to make arrangements for an on-call funeral director to be available for local standby in advance of a transport arising. While not required, it is highly recommended that a friendly mortician or funeral director be found before a local Alcor client needs suspending.

Agreement of Participation as Funeral Director
of the Alcor Life Extension Foundation

I, ________________, currently licensed to practice embalming and funeral directing in the State of Arizona, hereby agree to serve as the Funeral Director of the Alcor Life Extension Foundation (hereinafter known as "Alcor").

I understand that my responsibilities as Funeral Director shall include ensuring that Alcor's cryonic suspension procedures are carried out in compliance with accepted funeral and embalming standards with respect to the protection and preservation of public health interests. Such responsibilities shall also include the execution of disposition permits and other required documents as Alcor's Funeral Director and Embalmer. I also agree to regularly review Alcor's procedures for the control of infectious disease, disposal of infectious waste, handling of infectious materials, and storage of human tissues and bodily fluids at cryogenic temperatures.

I understand that because cryonic suspension procedures contain few similarities to standard embalming or mortuary practices, my responsibilities shall be confined to the public health and embalming aspects of Alcor operations, and will not extend to other aspects of the cryonic suspension procedure (such as the selection of appropriate cooling rates or mediums, the selection of perfusion pressures or tubing materials, etc.) except where such procedures contain public health considerations.

My acceptance and adherence to this agreement is contingent upon receiving annual retainer of $250.00 for the provision of 24-hour availability of my services as a licensed embalmer and funeral director in the State of Arizona. Should I fail to be available for a particular cryonic suspension, I agree to provide Alcor with an alternate licensed embalmer.

The term of this agreement is not to exceed one year from the date of execution, and may be subject to renewal at that time.

Assessing Family Cooperation

If the patient has family members nearby, and these relatives are interested in the impending cryonic suspension procedure, talk to them. Tell them what cryonics is about. Reassure them in as many ways as you can. Be professional.

Of all the people a transport team member is likely to encounter during transport operations, family members are most likely and able to thwart the cryonic suspension, especially if they disapprove of cryonics and the patient is unable to communicate clearly with the family. If the patient has not chosen a medical or legal surrogate before falling ill, the duty of directing health care decisions will fall to the family: spouses first, then children or parents, then siblings, followed by more distant relations (the exact order may vary between states). In many states, a relative's signature is also needed to cremate the remains of a neurosuspension patient.

In an attempt to ward off the death of someone they love, these family members may decide to have the hospital pursue all possible treatments for the patient. While this is admirable in many circumstances, cryonic suspensions generally occur after a patient has contracted an incurable disease (e.g. some cancers, AIDS, or simply old age). Resuscitation efforts can be prolonged until the patient is being supported solely through artificial means. If successful resuscitation would lead to a poorer quality of life, the family should be tactfully informed of the effects such extraordinary measures might have on a cryonic suspension. Many hospitals will only perform extraordinary measures if the patient made the decision for aggressive treatment, but some will bow to the wishes of the family, when the patient's wishes weren't established in advance. It is the patient's choices which are most important to transport team members. And those choices include cryonic suspension.

Transports generally go well, logistically and psychologically, when the family of a patient is supportive, understanding, and accepting of the patient's desire for cryonic suspension. However, in the face of extreme stress (watching someone you love die is not easy), this support, understanding, and acceptance could easily change to aggression, fear, and distrust. It is important for transport team members to gain the trust of the family and the patient. Gaining this trust is difficult, since the transport team members will probably be strangers to the family, and quite possibly to the patient as well. All reserves of empathy should be drawn upon when dealing with the patient and family. (Keep in mind that the patient and family members will all be very aware that an Alcor standby means that death is considered imminent, or at least a strong possibility.)

Most people perceive actions more clearly than words, so set an example that will foster trust and cooperation. If the transport is scheduled to begin in the patient's home, once preparations are complete, help around the house. Get coffee; wash a few dishes; offer to help keep the patient comfortable (e.g. by turning the patient to prevent bedsores). Be discreet, and try to avoid being an additional source of stress for the household. If the patient is in a hospital or hospice, similar things may be done to lighten the load.

As the family gets more comfortable with the transport team's presence, it becomes more likely they will want the suspension to go well. As a minimum, it's within their power to withdraw any extraordinary medical treatments which will prolong, but not improve, the patient's life. While it's unfortunate that death must be declared before the anatomical donation and cryonic suspension can occur, it is the only way that a suspension will occur. Euthanasia is illegal. Alcor's goals are to provide the best cryonic suspensions in the world, and only by being nearby at the moment of pronouncement can the best cryonic suspension occur.

Be open and honest with everyone, especially the patient and any relatives. Their support could curtail many of the hassles which can arise during a transport. With the next-of-kin's voice raised with Alcor's, an autopsy may be reduced in scope, if not prevented; mortuary personnel will be more cooperative; the transport will proceed better; and the patient's chances of an eventual revival will improve.

Networking Local Cryonicists

The growing network of cryonicists is another resource upon which transport team members may draw. Another cryonicist may live nearby and be willing to assist with the transport preparations. Alcor will be able to provide the names and phone numbers of local cryonicists to the transport team or, in the interest of client confidentiality, may contact local members directly to solicit assistance.

Cryonicists are slowly covering the globe. There are few remaining states in this country which contain no cryonicists, and the number is dwindling annually. Isolated cryonicists may welcome an opportunity to participate in a transport and associate with like-minded individuals. With all of the things which must be done, remembered, and recorded during a transport, any and all competent assistance should be embraced.

Conclusion

Family members, medical and mortuary professionals, and local cryonicists may all help smooth the way for an impending transport, as may other local cryonicists. Determining what level of assistance will be available for each different aspect of the protocol is essential to the well-prepared transport. With help, unexpected turns of events will be less threatening, and planning for contingencies will be shared. Cryonicists will almost always be interested in helping and eager to gain a practical understanding of cryonics. Additional assistance may be provided by "strangers," and many of these interactions should help spread acceptance of cryonics. Anything that transport team members can do to encourage acceptance (without interfering with the timely transport and suspension of a patient) will help improve the perception of cryonics and, likely, its practice as well.

 

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