Justice Antonin Scalia—The Wrong Message

Journal of Clinical Sleep Medicine, Vol. 12, No. 5, 2016 I read with interest the reports that Justice Antonin Scalia was found dead in bed with his CPAP neither attached to him nor even plugged in. Many of the news reports noted that: “...the chance of death from skipping a single day is tiny, and patients can and do take breaks because they have a cold, forget to take the machine on a short trip or because the masks are irritating. Typically the only immediate ill effects are snoring and possibly getting up at night gasping.” 1 But oh how I wished the message was different! Given Justice Scalia’s reported comorbid illnesses and his probable severe sleep apnea (I am guessing his neck circumference at least 18+ inches), the likelihood that he died of either a cardiac arrhythmia, massive stroke or pulmonary embolism is quite high. We will never know if he wore his CPAP that night, would he be alive today, however it is likely that if he had been using his CPAP that night, assuming the final event was a cardiovascular event, there would have been a reduced likelihood of a mortal event. Reportedly, Justice Scalia’s death certificate listed the cause of death as “myocardial infarction” although the county judge who completed the death certificate noted that he “died of natural causes.” No autopsy was performed and the death certificate was not released to the public (in Texas that takes 25 years). Rear Admiral Brian Monahan, Scalia’s physician, did state in a letter that he suffered from “sleep apnea, degenerative joint disease, chronic obstructive pulmonary disease and high blood pressure.” What we don’t know if any of these disorders were listed on his death certificate—but it is important that sleep disorders do start getting listed on death certificates. Having a sleep disorder listed is extremely valuable as these contain important data used by policy makers to prioritize public health agendas and funding health care and research2; it would also raise the level of consciousness about the seriousness of these disorders. Sleep disorders in general and sleep apnea in particular are challenging disorders to manage as often the patient has little awareness of the problem. The patient will come to medical attention via their bedpartner or because of a comorbid condition that puts them at high risk of having OSA (e.g. resistant hypertension or stroke). We, as sleep specialists, labor to convince the patient that the disorder is serious and that the treatment is necessary. I usually show the patient the sleep study results and go over it in some detail, pointing out the dips in oxygen levels, the length of apneic and hypopneic events and the sleep disruption accompanying the sleep disordered breathing EDITORIALS