A different courtroom, a different hospital, different doctors. In the end, the verdict was the same.
Two weeks ago, the final chapter in Israel Stinson’s young life was closed when a Los Angeles Superior Court judge ruled that the child was brain-dead and could be permanently removed from a ventilator. Hours later, the 2-year-old ceased breathing at Children’s Hospital Los Angeles after being taken off mechanical support.
As his parents, Nate Stinson and Jonee Fonseca, prepare for his funeral Monday in Fairfield, court documents provide some answers to the final treatment decisions about the toddler, whose medical and legal odyssey took him to hospitals in Sacramento, Guatemala City and, finally, Southern California.
While the Vacaville couple, who also have a 1-year-old daughter, are “a little more ready to get back to our regular routine,” Fonseca said she still has “a lot of unanswered questions.”
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One of the biggest questions was why Children’s Hospital agreed to accept a child who was declared brain-dead and had a death certificate issued by Kaiser Permanente Hospital in Roseville.
Last April, Israel suffered cardiac arrest at UC Davis Medical Center after being admitted for a severe asthma-related respiratory attack. Based on a set of nationally established tests, he was declared brain-dead, a diagnosis later confirmed at Kaiser Permanente. But in a months-long legal fight, his parents filed lawsuits in state and federal courts to block removal of his ventilator, then flew with Israel by air ambulance to Guatemala City, where doctors inserted breathing and feeding tubes. After more than two months, the toddler, who never opened his eyes or regained consciousness, was flown back to the U.S. and admitted to Children’s Hospital on Aug. 7.
In court documents, Dr. Barry Markovitz, medical director of the Children’s Hospital pediatric intensive care unit, said he was unaware of Israel’s complete medical history until after his admission as a patient.
“When considering whether to accept this transfer, we understood the history of events ... that this was a 2-year-old, who suffered cardiac arrest” following an asthma episode, Markovitz stated. He said Israel was admitted as a “lateral transfer” from a Guatemala City hospital, Nuestra Señora del Pilar, to be evaluated for possible care at home with a ventilator.
It was not until after Israel was admitted, he states, that Children’s Hospital became aware of his brain-death diagnosis, which was confirmed in medical records sent by Kaiser Permanente.
During Israel’s initial two weeks at Children’s, Markovitz said he showed “no signs” of brain function, except spinal reflexes. He said a formal assessment of brain death was not conducted at Children’s “largely because the determination has already occurred” at UC Davis and Kaiser Permanente. He said Israel’s mother, in an Aug. 9 handwritten note included in the court documents, declined allowing a brain-death apnea test to be performed on her son.
Seeking an ethical consultation, Markovitz brought in Dr. Cheryl Lew, chairwoman of the hospital’s ethics committee and a clinical pediatrics professor at the University of Southern California’s Keck School of Medicine.
“It is clear ... there is no possibility that this child’s brain will recover to the extent ... that he could resume his personhood,” Lew stated in her report. Although Israel is deceased, she stated, “his corpse must be treated with respect” and not subjected to “inappropriate medical interference.”
She recommended that the hospital give the family adequate time to find alternative care elsewhere, then proceed with removing the “un-natural medical interventions ... which are of no benefit to a dead child and serve only as unnecessary intrusions on his corpse.” She called it “morally permissible and even obligatory” for Children’s Hospital to discontinue all mechanical support “and free this child’s body from inappropriate manipulation.”
On Aug. 13, Markovitz said he informed Israel’s parents of the decision to withdraw medical services “because of the futility of it.” He offered the family time to arrange for Israel’s transfer to a different facility but said the hospital planned to halt its medical services Aug. 18.
That day, Fonseca filed a request for a temporary restraining order, blocking removal of her son’s ventilator, in Los Angeles Superior Court. In court documents, Fonseca said a Loma Linda facility, Totally Kids, which cares for children with traumatic brain injuries, had indicated it would have a bed open within a month.
“If Israel cannot be transferred to home care, I would like him to go to a facility that specializes in children with special needs,” she said.
Her request was granted until Sept. 8 and the hospital was told to allow an outside neurologist, Dr. Alan Shewmon, to perform an independent examination of Israel. That abruptly changed Aug. 25, when the hospital filed its appeal, asking for the restraining order to be dissolved, partly because Sacramento courts had already upheld Israel’s brain-death declaration by UC Davis and Kaiser Permanente physicians. In one argument, the appeal noted that Shewmon opposes brain death diagnoses and Children’s Hospital had no obligation to admit him onto its premises. The appeal said Israel’s family was free to find another location where Shewmon, a UCLA professor emeritus, could conduct his examination.
Daniel Woodard, the Southern California attorney who handled the family’s lawsuit pro bono through the Life Legal Defense Foundation, said he’s haunted by the court’s Aug. 25 ruling. “I had my credit card at the appellate court, ready to file an appeal, when I got the call that they had removed the ventilator,” he said. “Professionally, it was the worst day of my life. I was the last person standing between Israel’s life and death.”
But doctors said that life had essentially ended back in April, when he underwent cardiac arrest at UC Davis following a severe asthma attack and was declared brain-dead under commonly accepted U.S. medical standards.
More than five months after Israel’s medical saga began, Fonseca said she and Israel’s father are trying to get their lives back together. The couple both took disability or medical leaves from work. Fonseca said she plans to start classes to become a nurse or perhaps return to her job as a pharmacy technician.
On Monday, Fonseca said, she hopes her son’s service will be “a going home” celebration.
“At this point, I don’t feel closure,” she said. “I don’t know what the rush was. I don’t know why Children’s took us, (if) they were just going to do what they did. So many questions go through my mind.”