brain-damaged Florida woman Terri Schiavo

[nabraxas]

the story

i guess most ov you are familiar w/this story.

i also guess most here would agree that if she wants to die she should be allowed to.

the tragic aspect is that the only way she can die legally is by being deprived ov food & water.

that seems to me a very cruel, undignified & inhuman way to end your life. But it seems that in "life is so sacred--unless you're Iraqi" America, this is all the choice she has.

God forbid someone should give her a heroin & cocaine speedball overdose.

[Torsten]

its not a matter of her wanting to die, but rather a matter of her husband wanting her to be allowed to die. She herself has no brain function and cannot even express the simplest emotion, let alone indicate a wish.

I am all for the right to die, but this case irks me. Firstly, I would feel much more comfortable if the husband wasn't going to gain financially in such a big way from her death. Secondly (and more importantly), I would have serious problems letting my loved one starve to death. Seeing how the law is so fucked that he has no other option, this must be a very tough decision for him too. I don't think the real problem here lies with the family or with the husband, but rather with society as a whole. We seriously need to look at the right to die with dignity.

On a related note, the australian government is passing some law currently that has serious implications for euthanasia here. I think it plans to restrict the dissemination of information and advice on the topic, as well as stopping the supply of any contraption or material that can be used to end one's life. A major step backward in so many aspects.

[X. Torris]

quote:

---

I would feel much more comfortable if the husband wasn't going to gain financially in such a big way from her death.

---

How does he stand to gain financially from her death?

[Torsten]

OK, I had to do a bit more research on this, which ended up changing my mind entirely.

There does not appear to be a financial motive. There does not appear to be any significant insurance. The malpractice settlement amount is pretty much used up for her care, and so is most of her estate (which was mostly the settlement anyway).

In essence, the husband could resign his guardianship at any point and leave the financial responsibilities to the family. The family has offered that he could keep any remainder of the estate if he was to do so. he has also been offered a million dollars by some religious nut collective. In fact, it looks like he could gain a fair bit if he was to simply resign his guardianship. But he isn't. And that's what makes this interesting.

Terri's parents are religious nuts and have the backing of every irhgt to life and anti euthanasia group in the country. But this isn't about euthanasia. This is about a patient's right to refuse medical treatment. In a vegetative state this means her guardian makes that decision if he can show that it would have been her wish. He has.

I've also done a bit of reading on the bit that bothers me the most - the starving to death part. It conjures up all sorts of horrendous images, but in fact it happens all the time and usually to fully conscious individuals. The medical carers know how to take care of this to allow painfree death.

This case is important because each individual needs to be sure that his wishes will be respected even whe he is incapacitated.

I don't have a problem with the removal of the feeding tube and inevitable death anymore.

The most concise information page I could find was this:

http://majikthise.typepad.com/majikthise_/...vo_reprise.html

[Torsten]

I should point out that I didn't just read a bunch of libertarian blogs to come to my position. In the last 3 hours I read more nauseating far right christian pro-life religious rants than in the whole rest of my life!!

[Torsten]

A rational assessment of the facts by the New England Journal Of Medicine.

n engl j med

352;16

www.nejm.org april

21, 2005

quill-1

PERSPECTIVE

Terri Schiavo — A Tragedy Compounded

Timothy E. Quill, M.D.

The story of Terri Schiavo should be disturbing to

all of us. How can it be that medicine, ethics, law,

and family can work so poorly together in meeting

the needs of this woman who was left in a persistent

vegetative state after having a cardiac arrest?

Ms. Schiavo has been sustained by artificial

hydration and nutrition through a feeding tube

for 15 years, and her husband, Michael Schiavo, has

been locked in a very public legal struggle with

her parents and siblings about whether such treatment

should be continued or stopped. Distortion by

interest groups, media hyperbole, and manipulative

use of videotape have characterized this case and

demonstrate what can happen when a patient becomes

more a precedent-setting symbol than a

unique human being.

Let us begin with some medical facts. On February

25, 1990, Terri Schiavo had a cardiac arrest,

triggered by extreme hypokalemia brought on by an

eating disorder. As a result, severe hypoxic–ischemic

encephalopathy developed, and during the subsequent

months, she exhibited no evidence of higher

cortical function. Computed tomographic scans

of her brain eventually showed severe atrophy of

her cerebral hemispheres, and her electroencephalograms

have been flat, indicating no functional activity

of the cerebral cortex. Her neurologic examinations

have been indicative of a persistent vegetative

state, which includes periods of wakefulness alternating

with sleep, some reflexive responses to light

and noise, and some basic gag and swallowing responses,

but no signs of emotion, willful activity, or

cognition.

1

There is no evidence that Ms. Schiavo is

suffering, since the usual definition of this term requires

conscious awareness that is impossible in

the absence of cortical activity. There have been only

a few reported cases in which minimal cognitive and

motor functions were restored three months or

more after the diagnosis of a persistent vegetative

state due to hypoxic–ischemic encephalopathy; in

none of these cases was there the sort of objective

evidence of severe cortical damage that is present in

this case, nor was the period of disability so long.

2

Having viewed some of the highly edited videotaped

material of Terri Schiavo and having seen

other patients in a persistent vegetative state, I am

not surprised that family members and others unfamiliar

with this condition would interpret some

of her apparent alertness and movement as meaningful.

In 2002, the Florida trial court judge conducted

six days of evidentiary hearings on Ms.

Schiavo’s condition, including evaluations by four

neurologists, one radiologist, and her attending

physician. The two neurologists selected by Michael

Schiavo, a court-appointed “neutral” neurologist,

and Ms. Schiavo’s attending physician all agreed

that her condition met the criteria for a persistent

vegetative state. The neurologist and the radiologist

chosen by the patient’s parents and siblings,

the Schindler family, disagreed and suggested that

Ms. Schiavo’s condition might improve with unproven

therapies such as hyperbaric oxygen or vasodilators

— but had no objective data to support

their assertions. The trial court judge ruled that the

diagnosis of a persistent vegetative state met the legal

standard of “clear and convincing” evidence,

and this decision was reviewed and upheld by the

Florida Second District Court of Appeal. Subsequent

appeals to the Florida Supreme Court and the U.S.

Supreme Court were denied a hearing.

So what is known about Terri Schiavo’s wishes

and values? Since she unfortunately left no written

advance directive, the next step would be to meet

with her closest family members and try to understand

what she would want under these medical

circumstances if she could speak for herself, drawing

on the principle of “substituted judgment.”

Some families unite around this question, especially

when there is a shared vision of the patient’s views

and values. Other families unravel, their crisis aggravated

by genuine differences of opinion about

the proper course of action or preexisting fault lines

arising from long-standing family dynamics.

Here Ms. Schiavo’s story gets more complex.

Michael Schiavo was made her legal guardian under

Florida law, which designates the spouse as the decision

maker above other family members if a patient

becomes irreversibly incapacitated and has not

designated a health care proxy. After three years of

trying traditional and experimental therapies, Mr.

Schiavo accepted the neurologists’ diagnosis of an

irreversible persistent vegetative state. He believed

that his wife would not want to be kept alive indefinitely

in her condition, recalling prior statements

that she had made, such as “I don’t want to be kept

alive on a machine.” The Schindler family, however,

did not accept the diagnosis of a persistent vegetative

state, believing instead that Ms. Schiavo’s condition

could improve with additional rehabilitative

treatment.

The relationship between Mr. Schiavo and the

Schindler family began breaking down in 1993,

around the time that a malpractice lawsuit revolving

around the events that led to Ms. Schiavo’s cardiac

arrest was settled. In 1994, Mr. Schiavo attempted

to refuse treatment for an infection his wife had,

and her parents took legal action to require treatment.

Thus began wide-ranging, acrimonious legal

and public-opinion battles that now involve multiple

special-interest groups who see this case as a

cause célèbre

for their particular issue. Michael Schiavo

has been criticized for being motivated by financial

greed, and his loyalty to his wife has been questioned

because he now lives with another woman,

with whom he has two children. The Schindlers

have been criticized for not accepting the painful

reality of their daughter’s condition and for expressing

their own wishes and values rather than hers.

The right of competent patients to refuse unwanted

medical treatment, including artificial hydration

and nutrition, is a settled ethical and legal

issue in this country — based on the right to bodily

integrity. In the Nancy Cruzan case, the Supreme

Court affirmed that surrogate decision makers have

this right when a patient is incapacitated, but it said

that states could set their own standards of evidence

about patients’ own wishes.

3

Although both

the Schiavo and Cruzan cases involve the potential

withdrawal of a feeding tube from a patient in a persistent

vegetative state, the family was united in believing

that Nancy Cruzan would not want to be kept

alive in such a state indefinitely. Their challenge, under

Missouri law, was to prove to the court in a clear

and convincing manner that this would have been

Nancy Cruzan’s own wish. The Schiavo case raises

much more challenging questions about how to define

family and how to proceed if members of the

immediate family are not in agreement.

The relevant Florida statute requires “clear and

convincing evidence that the decision would have

been the one the patient would have chosen had the

patient been competent or, if there is no indication

of what the patient would have chosen, that the decision

is in the patient’s best interest.” Since there

is no societal consensus about whether a feeding

tube is in the “best interest” of a patient in a persistent

vegetative state, the main legal question to be

addressed is that of Terri Schiavo’s wishes. In

2001, the trial court judge ruled that clear and convincing

evidence showed that Ms. Schiavo would

choose not to receive life-prolonging treatment

under her current circumstances. This ruling was

also affirmed by the Florida appeals court and denied

a hearing by the Florida Supreme Court. When

Terri Schiavo’s feeding tube was removed for the

second time in 2003, the Florida legislature created

“Terri’s Law” to override the court decision, and

the tube was again reinserted. This law was subsequently

ruled an unconstitutional violation of the

separation of powers.

On March 18, 2005, Ms. Schiavo’s feeding tube

was removed for a third time. The U.S. Congress

then passed an “emergency measure” that was

signed by the President in an effort both to force

federal courts to review Ms. Schiavo’s case and to

create a legal mandate to have her feeding tube reinserted

yet again. Although the U.S. District Court

in Florida denied the emergency request to reinsert

the feeding tube, the final outcome of Congress’s

extraordinary maneuver is not yet clear.

This sad saga reinforces my personal belief that

the courts — though their involvement is sometimes

necessary — are the last place one wants to

be when working through these complex dilemmas.

Although I have not examined her, from the data

I have reviewed, I have no doubt that Terri Schiavo

is in a persistent vegetative state and that her cognitive

and neurologic functions are unfortunately

not going to improve. Her life can be further prolonged

with artificial hydration and nutrition, and

there is some solace in knowing that she is not consciously

suffering. I also believe that both her husband

and her family, while seeing the situation in

radically different ways, are trying to do what is

right for her. If and when her feeding tube is permanently

removed, her family may be reassured that

dying in this way can be a natural, humane process

(humans died in this way for thousands of years before

the advent of feeding tubes).

4

In considering this profound decision, the central

issue is not what family members would want

for themselves or what they want for their incapacitated

loved one, but rather what the patient would

want for himself or herself. The New Jersey Supreme

Court that decided the case of Karen Ann Quinlan

got the question of substituted judgment right: If

the patient could wake up for 15 minutes and understand

his or her condition fully, and then had to

return to it, what would he or she tell you to do? If

the data about the patient’s wishes are not clear,

then in the absence of public policy or family consensus,

we should err on the side of continued treatment

even in cases of a persistent vegetative state in

which there is no hope of recovery. But if the evidence

is clear, as the courts have found in the case

of Terri Schiavo, then enforcing life-prolonging

treatment against what is agreed to be the patient’s

will is both unethical and illegal.

Let us hope that future courts and legislative

bodies put aside all the special interests and distractions

and listen carefully to the patient’s voice

as expressed through family members and close

friends. This voice is what counts the most, and in

the Terri Schiavo case, it has been largely drowned

out by a very loud, self-interested public debate.

1.

Jennett B. The vegetative state: medical facts, ethical and legal

dilemmas. New York: Cambridge University Press, 2002.

2.

The Multi-Society Task Force on PVS. Medical aspects of the

persistent vegetative state. N Engl J Med 1994;330:1499-508,

1572-9. [Erratum, N Engl J Med 1995;333:130.]

3.

Gostin LO. Life and death choices after Cruzan. Law Med

Health Care 1991;19:9-12.

4.

Ganzini L, Goy ER, Miller LL, Harvath TA, Jackson A, Delorit MA.

Nurses’ experiences with hospice patients who refuse food and fluids

to hasten death. N Engl J Med 2003;349:359-65.

Copyright © 2005 Massachusetts Medical Society. All rights reserved.

Downloaded from www.nejm.org on March 23, 2005 .

[nabraxas]

ok, while i admit the "starving to death" seems to be "managed" well enough; i still think you were right in your initial assessment that the whole notion ov the "right to die with dignity" needs debate--starving to death, no matter how it's managed, is never a dignified choice.

an od ov aneasthesia or the speedball od (which i believe has been used on cancer patients--in their last moments--not to kill but to blissfully relieve there last pain), would be choices.

oh, & thanks for taking the time to look for that

[ 24. March 2005, 03:29: Message edited by: nabraxas ]

[reptyle]

do you want to die under the influence of drugs?

even someone in that condition with no apparent perception of reality may still have their mind stream effected in their last seconds of life by an OD. starving to death may seem undignified and maybe painful but i think a "natural" and clear headed death would be a favourable way to enter the transition from reality to reality (if you believe in that). suffocation seems an even more favourable way to go if it were one of the choices, who would commit the murder though?

[apothecary]

While everyone is debating over the right to die or live, which is a moot issue if you ask me, I'm seeing some interesting points arise.

1. Euthenasia will not, I repeat, will not be allowed in a country with its roots so entrenched in the christian bible as this one or the united states.

God states in no uncertain terms that a person can't kill themselves, or be killed because it removes them from his greater plan. It removes their chance to redeem themselves (don't dwell on this paragraph, I don't want a religious argument).

2. What the fuck happened to separation of church and state? Since when did the US president get to decide whether a person lives or dies according to his religious belief?

3. I think the only view worth looking at is "what the patient would want for him/herself". It's simple. If the lady said she didn't want to live on a machine, then she shouldn't have to!

[mr toodly]

 

quote:

---

Originally posted by apothecary:

 

1. Euthenasia will not, I repeat, will

not

be allowed in a country with its roots so entrenched in the christian bible as this one or the united states

---

Oregon.

quote:

2. What the fuck happened to separation of church and state? Since when did the US president get to decide whether a person lives or dies according to his religious belief?

What is liberalism but a sprig from Judeo-Christian principles?

quote:

3. I think the only view worth looking at is "what the patient would want for him/herself". It's simple. If the lady said she didn't want to live on a machine, then she shouldn't have to!

I don't think it is simple. Say, "It's simple". Wait two minutes, and give me a strong argument that you said it. One can't make a strong argument.

It's not simple. This will establish precedent. This is not about a single vegetable. It is not simple.

[bloodbob]

All I can say is I hope that they atleast are keeping this woman doped up incase the diagnosis is wrong about her mental capacity.

[Northern Gnome]

Lots of us over here on this side of the world are not very happy about this situation. Now we have doctors stating that she might not be in a completely vegetative state after all.

After hearing an audio tape and seeing other video material I am convinced she isn't without an amount of mental faculty. I also heard a nurse who had cared for her speak about when her husband was alone in her room with the door closed for 15 minutes she came in after he left and found her shaking and sweating with four needle marks hidden in the folds of her skin and her blood sugar level tests showed extremely low and then found an empty bottle of insulin hidden in some papers in the trash.

Sounds like he tried to kill her himself, as far as the insurance money, wouldn't you think he desperately needs it more than ever now after all of the bills trying to get her to be unplugged?

[Rev]

Just sign her up for the national guard

I hear they take anyone and she'll be off to baghdad or Kabul in no time anyway

(maybe they can put here in charge of finding WMD or Osama - she fits the profile perfectly)

problem solved

[Northern Gnome]

I know what you mean about the profile.

[Floyd]

people "starve" to death all the time. Among the elderly limited food intake is characteristic of being ready to die. Your body releases alot of painkillers when you starving so you dull pain in other parts of you body. From what i've read the general consensus seems to be that anorexics have poor body images and then become addicted to painkilling chemicals released after a period of continued starvation.

Right wing attacks on this woman's husband are disgusting. He has publicly been offered 1 million dollars to hand over custody of his wife to her parents, and his lawyer says that privatly he was offered 10 million. So if its true he stands to gain nothing from her death. Unless you believe that he attempted to murder her or whatever and he's afraid that she'll wake up and tattle. But it that seems rediculous to me

The whole thing is blown out of proportion by the pro-life movemnt because they think this case is linked to abortion rights.

oh and those videos you see on the news are about 10 years old. The whole reason this is an issue now is because she ISN'T like that anymore. She's been steadily declining for 15 years. But of course no one is taking video footage of her now.

[mr toodly]

 

quote:

---

Originally posted by Floyd:

 

[QB] The whole thing is blown out of proportion by the pro-life movemnt because they think this case is linked to abortion rights.

 

/QB]

---

I think the right is worried about the State permitting euthanasia, actually. Read: Oregon, Death with dignity.

[nabraxas]

do you want to die under the influence of drugs ...yes. if i'm in pain.

i don't care if they're natural endorphins or synthetic.

i see your point about a clear mind, but my understanding ov the speedball OD for advanced cancer patients, is that the cocaine, actually makes those last few moments more lucid, by breaking through the fog ov pain killing medications.

apparently the patient starved to death has everything pretty well managed chemically anyway; it's just avoiding actually killing w/chimicals.

[2b]

RIP,and while I'm at it RIP Paul Hester , no mention here but a sad reflection on mental illness and mens health here in Oz.

[smogs]

dying witha clear mind... i dont think thats ever possible unless it happens suddenly!

how could you have a clear mind knowing your going to die? also alot of conditions affect the mind in alot of weird ways... for example if you can have brain damage that amkes you a completely different person and be more wacked out than any drug could do