Ethical Issues in the Terri Schiavo case

1
Ethical Issues in theTerri Schiavo case

• Richard L. Voet, M.D., M.A.
• Lisa H. Clark, M.D.

2
Nancy Curzan1990

• 33 yo in a PVS after an automobile accident
• After 3 years, the parents requested that the
  feeding tube be discontinued
• Hospital insisted on a court order
• A year before the accident, she indicated to her
  housemate that she would not want to live as a
  vegetable

3
Supreme Court

• Cruzan is not brain dead or terminally ill
• Cruzan's right to refuse treatment did not
  outweigh Missouri's strong policy favoring the
  preservation of life
• her conversation with her housemate was
  unreliable for the purpose of determining her
  intent
• States may require clear and convincing
  evidence
• beyond a reasonable doubt (criminal - 99)
• clear convincing evidence
• preponderance of the evidence (civil - 51)

4
U.S. SUPREME COURTCRUZAN v. DIRECTOR,
MDHJustice Scalia

• While I agree with the Court's analysis
  today, and therefore join in its opinion, I would
  have preferred that we announce, clearly and
  promptly, that the federal courts have no
  business in this field.

5
Nancy Curzan1990

• further witnesses satisfied Missouri courts that
  such clear and convincing evidence of her wishes
  did exist
• medically assisted nutrition and hydration were
  removed in December of 1990
• Pro-life demonstrators kept a vigil outside
  Cruzans nursing home.
• Cruzan died two weeks later

6
(No Transcript)
7
Impact of the Cruzan case

• State by state variation
• States may insist on clear and convincing
  evidence that the patient would refuse
  life-sustaining treatment
• Excludes quality of life as a consideration
• Err on the side continuing treatment
• Federal Patient Self Determination Act

8
Physician Assisted Suicide1997

• Two cases brought before the US Supreme Court
• Unanimous ruling (9-0) that there is no
  constitutional right to PAS
• States have an interest in preserving human life,
  preventing suicide, protecting vulnerable groups,
  protecting the integrity of the medical
  profession and avoiding the slippery slope to
  euthanasia
• Withdrawal of treatment is distinct from PAS
• Encouraged palliative care and adequate pain
  control

9
Terri Schiavo

• February 1990 Age 27 suffered a cardiac arrest
  from hypokalemia secondary to an eating disorder
• June 1990 - Court appoints Michael Schiavo as
  guardian Terri Schiavos parents do not object
• November 1990 - Michael Schiavo takes Terri to
  California for experimental thalamic stimulator
  implant
• July 1991 - Terri is transferred to skilled care
  facility where she receives continuing
  neurological testing, and regular and aggressive
  speech/occupational therapy through 1994
• May 1992 - Terri parents, Robert and Mary
  Schindler, and Michael Schiavo stop living
  together.

10
Terri Schiavo

• August 1992 - Terri Schiavo is awarded 250,000
  in an out-of-court medical malpractice settlement
• November 1992 another malpractice trial awards
  Michael Schiavo about 300,000 and about 750,000
  was put in a trust fund specifically for Terri
  Schiavos medical care
• February 1993 - Michael Schiavo and the
  Schindlers have a falling-out over the course of
  therapy for Terri Schiavo Michael Schiavo claims
  that the Schindlers demand that he share the
  malpractice money with them
• July 1993 - Schindlers attempt to remove Michael
  as Terris guardian first guardian ad litem,
  John H. Pecarek, states that Michael Schiavo has
  acted appropriately and attentively toward Terri
  Schiavo the court later dismisses the suit.

11
Terri Schiavo

• February 1994 Terri developed a UTI, and in
  consultation with Terris physician, Michael
  requested not to treat the UTI and a DNR order
  the nursing staff challenged the orders and
  Michael cancelled the request
• May 1998 - Michael Schiavo petitions the court to
  authorize the removal of Terri Schiavos PEG
  tube the Schindlers oppose, saying that Terri
  would want to remain alive.  The court appoints
  Richard Pearse, to serve as the second guardian
  ad litem
• December 1998 Pearse issues his report
  concluding that Terri Schiavo is in a PVS with no
  chance of improvement Michael Schiavos
  decision-making may be influenced by the
  potential to inherit the remainder of Terri
  Schiavos estate and Terris prior comments to
  Michael were not clear and convincing evidence
  that she would want the feeding tube withdrawn

12
Terri Schiavo

• February 11, 2000 Trial court ruling by Judge
  Greer
• Medical evidence supports a diagnosis of PVS
• Terris comments were clear and convincing
  evidence that she would not wish to have life
  sustaining treatment if she were in a PVS
• Terris comments did not limit or restrict the
  type of life sustaining treatment
• The decision was appealed and upheld

13
Terri Schiavo

• Multiple motions and appeals
• The Advocacy Center for Persons with
  Disabilities, Inc. files a federal court lawsuit
  that claims that the removal of Terri Schiavos
  PEG tube is abuse and neglect.
• Political frenzy with a variety of opinions from
  diverse points of view
• The feeding tube was withdrawn and Terri died on
  March 31, 2005

14
Ethical Decisions in Clinical Medicine
Medical Condition Patient Preferences
Quality of Life Contextual Features
Diagnosis Prognosis Treatment options
Informed consent Living will Healthcare proxy
Religious or cultural issues Conflicts of
interest Family dynamics Financial pressure
Prospects for recovery Residual
impairments Burdens of treatment
15
Ethical Decisions in the Schiavo
CaseUncertainty, conflicts and priorities
Medical Condition Patient Preferences
Quality of Life Contextual Features
No living will Terris prior comments Who should
be the surrogate Husbands intent
PVS vs. MCS
Sanctity of life
Roman Catholic Financial conflicts of
interest Family dynamics Disability
discrimination Right to die advocates
16
Papal Allocution on Feeding Tubes

• the administration of water and food, even when
  given by artificial means, always represents a
  natural means of conserving life, and is not a
  medical act
• Pope John Paul II
• March, 2004

17
Feeding Tubes

• Benefit or Burden?

18
In 1991 81,105 Medicare beneficiaries had claims
submitted for gastrostomy insertion

• In-hospital mortality 15
• 30 day mortality 24
  
• 1 year mortality 63
• 3 year mortality 81
• JAMA 19982791973-1976.

19
In patients with advanced dementia feeding tubes
have shown

• No survival advantage.
• No decreased risk of infection or pressure sores.
• No improvement in functional status.
• (conclusions from a complete review of
  literature) JAMA 19992821365-1370.

20
Burdens of feeding tubes in advanced dementia
patients

• Restraints are frequently required (in some
  studies 50).
• Self extubations are common (up to 61).
• Aspiration pneumonia occurs in about 50.
• Two-thirds require tube replacement at some point.

21
Conclusion of Johns Hopkins review

• Feeding tubes for severely demented patients
  should be discouraged on clinical grounds because
  of lack of evidence of benefit.
• JAMA 19992821365-1370.

22
Death by Dehydration

• Decreased oral intake is part of the natural
  history of severe illnesses including severe
  dementia and metastatic cancer.
• Endstage dementia patients steadily lose weight
  even when carefully fed and encouraged to eat and
  drink.
• Many believe that dehydration aids comfort in the
  dying patient by decreasing secretions, coughs,
  nausea, and edema. The rising BUN and creatinine
  result in an altered level of consciousness that
  appears to be peaceful.

23
My Approach

• Goal Support the wishes of the patient as best
  as they can be determined.
• Questions to be asked
• Is there a Directive to Physicians?
• Is there a Medical Power of Attorney?
• Who is the surrogate decision maker?

24
I explain

• Feeding tubes are technically feasible and an
  option.
• They do not appear to prolong life, prevent
  infection or pressure sores, restore function,
  and they do not appear to provide comfort.
• If a tube is not used, dehydration will almost
  certainly be a part of death.
• Dehydration does not appear to be a painful
  pathway to death.

25
I explain

• Food, drink, ice chips, or moisture swabs may be
  offered and used as desired.
• Medicines for pain and discomfort will be
  available.
• Hospice services are an option.

26
Additionally

• I stress to the family that there is no absolute
  right or wrong.
• I will support any decision they make.
• I acknowledge that I have an anti-tube bias based
  on my background and medical knowledge and
  experience.