10/11/2009

"They changed the way people looked at life and death"...

A short history of Karen A. Quinlan, Nancy Cruzan and Terry Schiavo and how they "changed the way people looked at life and death". Their life served a purpose...
Quinlan, Karen Ann. On April 15, 1975, Karen Quinlan lapsed into a coma, apparently as a result of consuming alcohol and drugs. Karen was brought unconscious to a hospital emergency room. After her condition stabilized, feeding required a nasogastric tube (artificial nutrition and hydration) and breathing required a respirator. She was eventually diagnosed as being in a permanent coma, i.e., a permanent vegetative state in current terminology. Karen Quinlan’s father sought court appointment as guardian of her person for the express purpose of authorizing removal of her respirator, whether or not she died as a consequence. He was opposed not only by Karen’s physicians but by the local prosecutor and the state attorney general. The New Jersey trial court denied Mr. Quinlan’s request to be appointed guardian and also his request to terminate the use of the respirator, holding in effect that the decision was solely that of the attending physicians acting in accordance with prevailing medical standards. It rejected the argument that there is a viable legal distinction between ordinary and extraordinary means to sustain life. The New Jersey Supreme Court reversed the decision and granted Mr. Quinlan’s request. Karen’s physicians gradually weaned her from the respirator during May of 1976. She continued to breathe on her own. Her father did not want artificial nutrition and hydration stopped, though the Supreme Court gave permission for all life-support to be withdrawn. Karen lived another ten years. In its considerations regarding this case, the New Jersey Supreme Court advocated giving decision-making authority to a hospital ethics committee (which were still largely non-existent at the time). As a result of this case, ethics committees grew in number and debate arose regarding their appropriate role and authority. Most experts now agree that any authority an ethics committee has is limited and must appropriately respect the decision-making authority that properly belongs to patients, surrogates, and care-providers. [Source: In Re Quinlan, 355 A.2d. (N.J. 1976).]

Cruzan, Nancy. On December 11, 1983, 25 year-old Missourian Nancy Cruzan was in a serious car accident, pronounced dead at the scene by police, then resuscitated by paramedics. Years later, Cruzan’s parents wanted to withdraw the artificial hydration and nutrition that kept their daughter alive in a persistent vegetative state. The facility caring for Cruzan insisted on a court order before doing so, and the case entered the legal system. The trial court ruled that tube feedings could be withheld, but the nursing facility appealed. The Missouri Supreme Court reversed the decision of the trial court and severely restricted family decision-making on behalf of incompetent patients. It required "clear and convincing evidence" of the patient’s wishes to refuse treatment, such as a living will. On June 25, 1990, the U.S. Supreme Court affirmed the right of the State of Missouri to demand clear and convincing evidence of a person’s expressed wishes made while competent. The majority opinion also held that competent patients have a "constitutionally protected liberty interest in refusing unwanted medical treatment" under the due process clause. The court stated, however, that incompetent patients need certain protection because they cannot exercise this right directly. Thus, states may establish procedural safeguards for incompetent patients. The individual’s durable right to refuse treatment, which they affirmed, must be balanced against relevant state interest in the preservation of life. After the Supreme Court ruling, the Cruzans petitioned the trial court in Missouri to rehear their request to discontinue tube feedings. New witnesses came forward. One of the women who had worked with Cruzan said that during one conversation, Cruzan had agreed that if she were a "vegetable" she would not want to be fed by force or kept alive by machines. Cruzan’s physician also changed his mind in favor of stopping the feedings. As a result, authorization was given to remove feedings and Cruzan died shortly thereafter. This case encouraged the development of advance directives that appoint a patient advocate or proxy. [Source: 497 U.S. 261 (1990); see also Supreme Court Collection.]

Schiavo, Terri. In February of 1990, Michael Schiavo found his wife, Terri, lying unconscious on the floor of their bathroom. Due to a Potassium deficiency, Terri had suffered a heart attack and was in an anoxic state that would ultimately leave her with the diagnosis of being in a Persistent Vegetative State (PVS). In September of 1993, Michael Schiavo authorized the nursing home she resides in to write a DNR order for Terri. In February of the same year, the case entered the Florida court system when Terri's parents filed a petition to have Michael removed as Terri's legal guardian, because he refused to authorize antibiotic therapy on Terri's behalf for a urinary tract infection, which could potentially lead to Sepsis and death. In a deposition to the court, Michael Schiavo testified that he knew that Terri's condition might be fatal without treatment, but that he was making a decision that was consistent with what he understood to be Terri's previously expressed wishes regarding continued treatment in her current condition. Despite the infection, Terri survived, and the guardianship suit was dismissed in February of 1994. In 1997, Michael's lawyer sent Terri's parents a letter notifying them that Michael was petitioning the court to authorize the withdrawal of Terri's feeding tube, i.e., artificially delivered nutrition and hydration (ADNH). Terri's parents then petitioned the court for an injunction to stop the withdrawal of treatment on the basis that, contrary to what Michael testified, they believed Terri would have wanted treatment continued. In 1998, the court appointed a guardian ad litem for Terri. In June of 1999, the guardian ad litem was dismissed by the court on the basis of failing to act impartially. In 2000, the court approved the removal of the feeding tube, based on clear and convincing evidence that Terri had previously expressed a desire not to receive life-sustaining treatment in such circumstances. Subsequently, Terri's parents filed an appeal with the Florida Appellate Court to overturn the lower court's ruling, claiming that Terri is not in fact in a PVS and had never expressed to them a desire to forego life-sustaining treatment. In January of 2001, the Appellate Court found that Terri is in a PVS and would not have wanted life-sustaining treatment. On this basis, the Appellate Court refused to overturn the decision of the lower court, but did issue a 30 day stay on the action. Over the next two years, the case worked its way up to the Florida Supreme Court, which ultimately ruled that Terri is in a PVS and that there is clear and convincing evidence that she would not have wanted ADNH. On Tuesday, October 21, 2003, just after the Florida Supreme Court ordered the withdrawal of the ADNH, the Florida Legislature enacted a law giving Florida Governor Jeb Bush the authority to override a court's ruling in cases in which a patient is in a PVS, has not executed a living will and in which there is disagreement between family members regarding the appropriateness of life-sustaining medical treatment - in essence, tailoring the legislation to this specific case. The action of the Florida Legislature in this case is unprecedented insofar as it gives the Governor the authority to intervene in individual cases and overturn a court's rulings. Ordinarily, it is the role of the judicial branch of government to rule on individual cases, not the role of the legislative or executive branches. Michael Schiavo has filed suit in Florida State Court to have the new law overturned as unconstitutional. [See also: Ascension Health's Talking Points on the Case of Terri Schiavo.]

Short commentary: Multiple forces contribute to medical situations mired in controversy over the appropriateness of providing or continuing aggressive life-sustaining medical treatment. These forces reflect values that have permeated the culture both inside and outside of health care. At least three major factors contribute to the wider cultural context emphasis on individual autonomy; fascination with the marvels of highly technological medicine; and preoccupation with health as "complete and achievable wellness." All that has impact on how we see end-of-life care today. Finally, as I don't want to go further here, let me propose that Christian theology and accompanying pastoral care can make valuable contributions to those cases in which religious reasons are invoked in the process of making end-of-life decisions.[1] Although this contribution will not result in easy solutions to such cases, the resources of Christian theology and pastoral practice may be able to achieve two valuable goals: ( 1 ) offer alternative narratives and symbols that may help reframe understandings about communal connectedness, God, miracles, and life and death; and (2) provide a wider context for interpreting Christian faith convictions concerning what constitutes appropriate medical treatment.

Sources:
* Russell B. Connors, Jr., Martin L. Smith, "Religious insistence on medical treatment: Christian theology and re-imagination", in Hastings Center Report (July-August, 1996).
*Other similar cases: http://www.ascensionhealth.org/ethics/public/cases/all_cases.asp

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