The Cryonics Institute’s 93rd Patient
dressed for his own funeral
The Cryonics Institute's 93rd patient is a 43-year-old man who had legally changed his name in 2002 to William Constitution O'Rights (Bill O'Rights, name at birth: Billie Joe Bonsall). He described himself as an "extreme libertarian". He lived in the State of Maine and both of his parents had been born in Maine.
Bill joined the Cryonics Institute (CI) in June 2000, but delayed making cryopreservation arrangements because he wanted to thoroughly analyze the contracts. He eventually completed his CI paperwork in July 2008.
Bill was a lifetime member of the Immortality Institute (ImmInst), which he joined in August 2002. He made nearly ten thousand postings to ImmInst forums. Before he lost computer access in 2005 he was an ImmInst record-holder for greatest number of postings. He posted under the name "thefirstimmortal" (after the book THE FIRST IMMORTAL) and he was pleased that he might live up to this name by being the first CI patient from the State of Maine.
According to an article in the Portsmouth Herald Maine News, on January 6, 2005 police entered Bill's home with a search warrant and seized 40 pounds of marijuana, $82,000 in cash, a loaded handgun, an assault rifle and evidence of drug trafficking. According to Bill, he lost not only his freedom when he was sent to prison, but he lost his house and a half-million dollars.
Bill was scheduled to be released from prison (the Windham Correctional Center) near the end of May 2008. At the beginning of December 2007 Bill weighed about 180 pounds, but he lost over 30 pounds during the month. (When he arrived in Michigan in May 2009 he did not weigh much over 80 pounds.) He had been experiencing a lump in his chest since July 2007, but the prison medical staff didn't take his complaints seriously until he was exhibiting severe vomiting and breathing difficulties. Early in 2008 he was diagnosed as having an 11.4 X 6 cm tumor associated with extensive small cell lung carcinoma.
Tobacco smoking is the major risk factor for small cell lung cancer. Bill had been a cigarette smoker until entering prison where smoking was banned. No longer able to smoke, Bill's weight ballooned. In prison he was no longer able to take nutritional supplements (he had been taking about 150 pills per day, many of which were Life Extension Foundation products). The sudden loss of supplements was undoubtedly a shock to his system.
The cancer spread to his stomach, lymph nodes, kidney, liver, left femur, right arm, etc. The mass put pressure on his left atrium and narrowed the lumen of his esophagus. Bill was given a life expectancy of 6 to 8 months, with no hope of cure. (emedicine gives an even more dismal prognosis, noting that this form of cancer spreads very rapidly). Bill was given palliative chemotherapy of cisplatin with etoposide, and later irinotecan as a monoagent. He had radiation treatment to his leg. Bill devoted his considerable intelligence and resolve to fighting for his life — a war against cancer by every means at his disposal. A very lengthy thread on the ImmInst Forum is devoted to extensive dialog between Bill and members of the Immortality Institute on the subject of therapies that can be used against cancer. A whole collection of ImmInst threads shows how many people and how much discussion was devoted to the subject of Bill's survival among Immortality Institute Forum participants.
Bill lived far beyond his initial prognosis. By aggressive chemotherapy Bill's 11.4 X 6 cm tumor was shrunk to 1.8 X 4 cm by the time he was released from prison in May 2008. It was back up to 8 cm in July and back down to 4.5 cm in September. Vomiting and esophageal blockage often made him unable to take supplements. He sometimes went weeks at a time without eating at all.
Initially Bill received medical treatment as an inmate, but when released he was declared an indigent and was given MaineCare ("Maine MediCare"). In July 2008 the Society for Venturism began a fundraising campaign to raise $30,000 to pay for the cryopreservation of Bill at the Cryonics Institute. By December the campaign had stalled at $13,000 and there seemed to be little prospect that more money would be forthcoming. Bill refused to consider the possibility of KrioRus or other low-cost alternatives. "CI or die," he said.
But on January 17, 2009 the Immortality Institute announced a program to match donations (up to $8,000) made by others for Bill's cryopreservation. That in itself might not have been adequate, but on January 21st long-time cryonicist Marce Johnson was cremated, which freed up money that had already been donated for her cryopreservation. By February the full $30,000 had been raised.
Early in 2009 I began calling Bill at least weekly. To respect his confidence, I did not speak or write about most of what Bill told me. He said that after he was in Michigan that I could write about any of the things he had told me. From the time he had been released from prison, Bill had been living with a woman named Carol, the mother of one of Bill's friends. Carol could not stand the thought of allowing Bill to die alone. Carol had considerable experience caring for other members of her family who had died. Her house was in the backwoods of rural Maine.
I did not have much sympathy for Bill before I began talking to him. I had not read many of his ImmInst postings, and he struck me as a reckless, combative person who brought many of his troubles upon himself. But I developed a great deal of empathy and respect for him.
I respected his intelligence and his determined fight against death. Bill is a man who relentlessly questions and distrusts authority, thinking for himself. He clung to life with every fiber of his being. He would never think of hastening death to avoid discomfort. He preferred to endure his pain rather than blunt his consciousness with painkillers. He read my description of my own hospitalization and agreed with me fully about painkillers. He said that no amount of pain or discomfort would cause him to seek death, although sometimes he would find the pain to be so intolerable that he relented and took painkillers.
Bill had a single-minded focus on survival that was not hampered by the emotions one might expect from someone so close to death. He dealt with every aspect of his pre-mortem and post-mortem treatment with great composure. He said that without cryonics he might not have such great composure.
Bill was unfortunately at the mercy of an oncologist who did not share Bill's values. The oncologist reportedly expected his patients to defer to his authority. Bill wanted MRI scans to target his cancer for radiation treatment, but his oncologist would only approve cat scans. Bill wanted different chemotherapy than what his oncologist would give him. Bill wanted his oncologist to give him a prognosis so that he could find a hospice, but the oncologist insisted that a prognosis would only be given to a hospice. In the Spring of 2009 the oncologist told Bill that there would be no more chemotherapy. It sounded like a death sentence the way Bill described it. Bill made efforts to get another oncologist — and to take legal action against this oncologist. Ultimately Bill reached the point where more chemotherapy would have quickly killed him. If his oncologist had this in mind, he never bothered to explain it to Bill. I get the impression that Bill's oncologist thought that a few weeks or months of life more or less for a cancer victim doesn't matter very much (or is not worth the expense). But for Bill, every moment of life mattered enormously, even if it is filled with torment. But it is also possible that the oncologist was making personal judgments about his patient's personality that affected his professional conduct.
In discussing Bill's medical issues with him I was concerned that he might suspect that I would be more interested in hastening his deanimation than in delaying it. But the issue never came up, and I was truly sympathetic to his struggle to survive. I don't want to be — or be seen as — a vulture or "grim reaper".
As soon as Bill had become funded for cryopreservation I encouraged him to move to Michigan. But he said that he needed to report to his parole officer and that his parole stipulated that he could not leave the State of Maine. He probably also would have had problems with MaineCare paying his medical expenses.
I sent Bill the bed-alarm, autodialer system that I had been testing with Robert Ettinger. The system will detect lack of heartbeat in someone sleeping, and will phone up to four numbers with a recorded message. In the same box I included a CI necklace & bracelet, along with CI's Funeral Director Guidelines and Hospital Instructions. Bill was not able to lie down properly, so he mostly slept in his chair. He spent some time trying to find a way to put the heartbeat detector in his chair, but finally told me that it was unworkable.
I then discovered that Bill had not told Carol, the woman he was living with, that he had become funded for cryonics. Carol often spoke to Bill's family on the phone, and Bill was afraid she would accidentally inform his family — who Bill said were all anti-cryonics — about his cryonics arrangements. He did not want to risk having his family interfering. But if Carol did not know about the arrangements, she could not be of help to him if he deanimated. Bill wanted to wait until he was closer to death before informing her.
Bill took the initiative to find his own funeral director, and he found an excellent one named John Black. CI Facility Manager Andy Zawacki sent Mr. Black an insulated Ziegler shipping box that could be packed with ice. The first Ziegler was damaged in shipping, so Andy sent a second one inside a protective particleboard box.
I had a conference-call conversation with John Black and Bill that relieved many worries. Maine must be one of the best states (aside from Michigan or Arizona) for a cryonicist to deanimate. Very few autopsies are done in Maine. In exceptional cases autopsies are done in a special autopsy facility in the state capital. For a terminal patient such as Bill, Carol had the authority to pronounce death and pack ice around his head immediately. In Michigan it would be necessary to call 911 to get a physician to authorize a paramedic or EMT to pronounce death before applying ice. Mr. Black had already cleared with the medical examiner the fact that Bill was a terminal patient. Maine law allowed Mr. Black to write his own shipping permit, which meant that he could ship Bill to Michigan immediately if Bill deanimated on a weekend (as actually happened) without having to first file the death certificate with the health department during (weekday) business hours.
Carol was eventually informed of the cryonics arrangements, and Mr. Black was helpful in getting the documents for Bill to sign that would give Carol (rather than Bill's family) legal authority over the disposition of his remains. Mr. Black's funeral home was at least a half-hour drive from the rural house where Bill was staying, so I was concerned about Bill's head being immediately packed in ice. Bill did not want (or did not want to suggest) for any of the food in the small refrigerator freezer to be displaced by ice. He said that it would be impractical for them to get a dedicated freezer for ice. It was finally arranged for Carol to get ice from neighbors when needed.
Carol proved to be very supportive of Bill's wishes to be cryopreserved. When Bill was hospitalized, one of the nurses told Carol that Bill had changed his mind about cryonics, and had decided to be an organ donor. Carol drove to the hospital to confront the nurse and to ensure that the false rumor was completely dispelled among all of the staff. When Carol informed Bill's father, Bill's father said that he would back Carol 100%. He wanted his son to know that his father loved him, and would support him fully in seeing that his wishes for cryonics were respected. Carol said that this news brought a smile to Bill's face. (A nurse may have misinterpreted "whole body donor" on Bill's necklace.)
Bill was hospitalized twice shortly before his deanimation. The first time, when he was feeling very weak and dizzy, 911 was called, and an ambulance drove him to Goodall Hospital in Sanford. The hospital said they could do nothing for him and discharged him within a few days — adding that he would not be admitted again for any reason. Not too long thereafter Bill had a friend drive him to York Hospital where he asked to have a tube placed in his esophagus so that he could eat. Apparently the hospital could not even do that. Somehow Bill was able to get himself transferred to Maine Medical Center — another hospital which had previously sent him home saying there was nothing they could do for him. Bill managed to stay at Maine Medical Center long enough to die there, which is what he wanted — he felt safer there. The hospital put Bill into an ice-filled body bag immediately after he was pronounced dead, with ice concentrated around his head. The funeral director promptly came and arranged for shipment to Michigan. Bill deanimated early Saturday afternoon and he arrived at the Detroit airport early Sunday afternoon (Sunday, May 10, 2009).
The patient was packed in ample ice when he arrived at the funeral home of Jim Walsh. Jim's daughter, Sara Walsh (who is also a funeral director), thought that the patient was an elderly man on the basis of his appearance.
The chest was opened with a sternal saw and chest spreader. A large white-spotted cancerous lump was prominent. Despite the slenderness of the patient, there was a great deal of fat around the heart. Mr. Walsh noted that the aorta appeared to be fragile, as he had noted for the previous patient (also a cancer victim). Bill had an installed Port-a-Cath which allowed for administration of cancer chemotherapy agents directly into the heart for fast & effective distribution throughout the body. Possibly the anti-cancer drugs attacked arterial tissue in the aorta.
A tear was evident at the juncture of the aorta and the branchiocephalic trunk. Mr. Walsh unsuccessfully tried to cannulate into the tear. As a fall-back (as had been done with the 92nd patient) two steel embalming cannulae were used, one in the branchiocephalic trunk and one in the left common carotid artery coming off the aorta. Mr. Walsh was able to clamp the subclavian artery and the descending aorta, so there was no unnecessary diversion of the perfusate, as had happened with the previous patient. The superior vena cava was cannulated to allow for effluent sampling.
Perfusion was begun at 3:10pm. The patient was given four liters of 10% ethylene glycol and four liters of 30% ethylene glycol. The 10% ethylene glycol was hyperosmotic with an additional 100 milliosmols of sodium chloride. Both the 10% and the 30% ethylene glycol solution were iso-oncotic with 20,000 molecular mass polyethylene glycol (PEG). There was a good dehydration of the head and face, and no sign of edema from the ethylene glycol solutions. Rat experiments comparing equimolar hypertonic sodium chloride and mannitol have shown that hypertonic saline is superior for reducing brain water content. Sodium chloride solution has been replacing mannitol in medicine for cerebral edema, partly because 10% of mannitol will seep across the Blood-Brain Barrier, but sodium chloride does not cross the BBB at all.
One bad sign, however, was large clots, the largest clots seen on vitrifying a brain since CI started doing vitrification perfusion. No heparin had been given to the patient. The original plan for the patient to deanimate at home meant that the funeral director could not reach the patient in less than half-an-hour after he was pronounced dead — and chances were not good that his deanimation would be observed (which would have allowed for speedy pronouncement after the event). Under these circumstances it seemed to me that if heparin was administered it would be far too late to do any good. So I did not send the funeral director any heparin.
Some clotting had been observed in doing body perfusions, but aside from that the only notable clotting I knew of for a head vitrification was a clot seen in the previous patient, also a cancer victim. Some of our patients had received heparin, but many had not. I had become complacent about heparin, and skeptical about its efficacy. Part of my complacency was associated with my understanding that it is common practice for low molecular weight heparins to be given in hospitals as prophylaxis against deep vein thrombosis. Researching the issue after this perfusion, I found that this is done in less than one-third of cases — and was surely not done in this case. Part of my skepticism was associated with recent animal experiments which showed no effectiveness of heparin, and a book review in Depressed Metabolism which concludes that clotting is agonal (associated with the dying process, not with death). If clotting is agonal, it is not surprising that the research animals would have shown no benefit from heparin insofar as they were killed quickly under experimental conditions. Cancer victims, on the other hand, die very slowly. And few cancer victims probably die as slowly as Bill did — he was "hanging on" (to life) "for dear life". In my post-perfusion research I also discovered that low molecular weight heparins are a standard of care for cancer patients.
I knew a couple of days before Bill deanimated that he would be deanimating in the hospital rather than at home. I could have sent the CI hospital instructions to the hospital. I might have been able to persuade the hospital to administer heparin after cardiac arrest, and to administer low molecular weight heparins during the last few days before cardiac arrest. I now know to do this for future patients, but that will not help Bill. If others blame and contempt me for not having gotten heparin into Bill, it will be hard to match my own self-castigation. Nonetheless, I still think that many of the clots were formed during the dying process and that heparin would at best have only reduced some of the clotting. I have altered the CI hospital instructions to recommend low molecular weight heparin for terminal cryonics patients as prophylaxis against clotting.
Note-taking was poor due to attention required for sampling and observation. At 3:30pm, after 2.5 liters of 70% CI−VM−1 had been perfused into the patient, burr holes were inserted. Perfusion continued until the patient had received 12.5 liters of 70% CI−VM−1. The refractive index (RI) of 65% CI−VM−1 is 1.4220 and the RI of 70% CI−VM−1 is 1.4275. RI of effluent from the superior vena cava rose fairly rapidly such that saturation was above 65% after 8 liters, and gave an RI above that of 70% CI−VM−1 (1.4283) at 11 liters.
Nasopharyngeal temperature was 3.7ºC when perfusion began, and continued to rise to a maximum of 7.1ºC until perfusion with cold 70% VM−1 solution (which had been in the freezer) was begun. Nasopharyngeal temperature was down to 1.5ºC when perfusion was completed. Perfusion data is given in the table below.
Refractive Index values taken during CI−VM−1 perfusion
|3:31||7.0||Inserted Burr Holes|
At the end of perfusion flow from the superior vena cava had ceased, possibly due to damage to the jugular and possibly due to increased flow in collaterals. There was no evidence of blockage of inflow of perfusate. The lack of flow from the superior vena cava was probably not evidence of impeded flow due to clotting. Clots had only been seen at the very beginning of perfusion — none were seen thereafter. Clotting in hospital patients happens in veins (particularly large veins), and cryoprotectants are good at dislodging clots. This is not to be rationalizing away potential blockage of flow due to clots.
|VM−1 Perfusion RIs|
Fluid dripped from the right burr hole, and by 10 liters of VM−1 perfusion (3:57pm) this fluid had an RI exactly matching 70% VM−1. Peculiarly, the cerebral cortex under the right burr hole — initially about 2 millimeters below the skull — shrank another 5 millimeters, swelled back to the initial state, and then shrank about 5 millimeters again.
The cerebral cortex below the left burr hole was initially about 2 millimeters below the skull, and did not change. It was difficult to get any fluid from the left burr hole. Near the end of perfusion fluid from the left burr hole reached a high of 1.4233.
The ears began swelling at 3:57pm. At the end of perfusion there was edema in the ears, lips and chin.
After perfusion the temperature probes were stitched to the patient and the patient was moved from the perfusion table to a moveable cart. The patient's head was placed in the plastic head enclosure with his neck resting on the edge of the box. Isopropyl alcohol was added to create a cold, head-cooling slurry. Then the patient was driven to the Cryonics Institute.
At the CI Facility the dry ice pellets were scooped out of the plastic head enclosure until the patient's head could be lifted free. The patient was then rolled to the computer-controlled cooling box and lifted into the box. When cooling-box cooling began at 5:42pm, naso-pharyngeal (core brain) temperature was −7.1ºC.
|First 22 hours||"Annealing" step|
Brain surface (skull) temperature was cooled to −115ºC in just over two hours, cooled more slowly for another half-hour to −120ºC, cooled slowly for an additional half-hour to −122ºC, and then held at −122ºC for about eighteen hours while the brain core temperature dropped more slowly to approach −118ºC. The purpose of this was to avoid thermal stress while solidification temperatures are approached. Even though vitrified tissue should still be liquid above −122ºC, the viscosity is so great that the danger of freezing ( de-vitrification) is very small.
|Full 124 hours|
After holding skull surface temperature at about −122ºC for about 15 hours brain temperature became more uniform. The "annealing" step consisted of raising skull surface temperature to −117ºC over a period of about an hour, which allowed skull surface temperature to rise above nasopharygeal temperature for more than an hour. Subsequent cooling allowed the brain surface temperature to drop back below the nasopharyngeal temperature and then rise toward the nasopharyngeal temperature. This step was intended to increase uniformity of brain temperature so as to minimize thermal stress during the long, slow cooling to liquid nitrogen temperature. This is not actually "annealing", because annealing involves warming a solid to just below melting temperature as a means to relieve thermal stress in a solid.
While the patient was cooling in the cooling box I received a phone call from John Black, the Maine funeral director who had been responsible for shipping the patient to Michigan. By an outrageous coincidence (and he assured me it was a coincidence), John was visiting a funeral director friend of his in Toledo, Ohio. John, his wife, his friend and his friend's wife all wanted to come to see the Cryonics Institute Facility. When I told John that we would be moving Bill into liquid nitrogen on Friday, he was delighted to have the opportunity to see the move in person.
John, his wife Lori, and their two friends arrived at the CI Facility at about 7pm on Friday, May 15, 2009, shortly after Andy's brother-in-law David Fulcher arrived to help with the move. I gave the funeral directors and their wives a brief tour of the Facility. Lori works with John in their funeral home, and I had spoken to her on the phone. Lori had known Bill before the time he had changed his name — which she said was about ten or fifteen years ago. John met Bill for the first time when he entered John's funeral home wanting service in the Spring of 2009.
All of the visitors seemed very intrigued by all aspects of our operation. Lori said that she was fascinated, even though she is not a "science person". The visitors watched the whole process of Bill being removed from the cooling box, being tied to his backboard while Dave kept Bill cooled-off with buckets of liquid nitrogen, and finally watching Bill descend into the cryostat where he will reside with his new neighbors.
|Andy greets the visitors||John Black scopes the Facility|
|Inspecting Bill's new home||
Photographing Bill being
tied to his backboard
After Bill was placed in liquid nitrogen, Bill's father Rod Bonsall began posting about his son on the ImmInst Forum. Rod said that he loved his Bill very much, and would greatly miss the long, interesting conversations that they used to have. But Rod had no illusions about his son's character flaws, saying (among other things) that Bill was a chronic liar. Rod said that Bill knew very well that no one in his family would oppose Bill's cryonics arrangements. Bill had apparently misled people on the ImmInst Forum, not letting them know that he immediately resumed smoking upon his release from prison, despite the cancer. One ImmInst Forum member expressed regret at having devoted so much energy trying to help Bill, given that Bill was still smoking. Bill had contended that the cancer had been caused by excessive X−ray use following a 1996 motorcycle accident.
When I was questioning Bill for information to put on his death certificate, Bill told me that his highest level of education was PhD. Rod told me that Bill had graduated from Sanford High School, but never attended college. Bill also claimed to be an ordained minister based on what his father called a "phoney internet degree". Bill told me that his occupation was "Investor". Because Bill had no legal occupation, "Investor" was left on the death certificate.
Seeing many negatives about Bill can make it difficult to see his positives. I find it difficult to describe them, but he definitely had fine and unique qualities from my perspective. He was a larger-than-life presence in the Immortality Institute Forums, touching very many people very deeply. Anyway, I don't think that patient care should be compromised for any patient based on personal feelings. Unfortunately, each patient is a learning experience, but fortunately each subsequent patient benefits from what is learned from the previous one. When we are trying to do our best for a patient, we learn what needs to be improved about our best efforts.