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End of Life Issues in the News

A feeding tube has been removed from a brain-damaged Florida woman at the centre of a right-to-die battle fought for years in the courts, her husband's lawyer said. A last-ditch bid by US Congress to keep the woman alive was "nothing short of thuggery", lawyer George Felos said. The court-ordered removal of the tube follows a protracted legal dispute between Terri Schiavo's husband and legal guardian Michael Schiavo, and her parents Robert and Mary Schindler. The tube has kept Mrs Schiavo alive since a heart attack starved her brain of oxygen in 1990, leaving her in what the courts declared was a permanent vegetative state. Mrs Schiavo was 26 when she became ill, without a will or written directive about what end-of-life care she might want. Her husband said she would not want to be kept alive. Her parents argued that she responded to them and could be helped with therapy. Court-appointed doctors said Mrs Schiavo, now 41, was in a persistent vegetative state and would not recover.  [Read more]

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To many people, death by removing a feeding tube brings to mind the agony of starvation. But medical experts say that the process of dying that begins when food and fluids cease is relatively straightforward, and can cause little discomfort ... In fact, declining food and water is a common way that terminally ill patients end their lives, because it is less painful than violent suicide and requires no help from doctors. Terri Schiavo, who is in a persistent vegetative state, is "probably not experiencing anything at all subjectively," said Dr. Emanuel, and so the question of discomfort, from a scientific point of view, is not in dispute. Patients who are terminally ill and conscious and refuse food and drink at the end of life say that they do not generally experience pangs of hunger, since their bodies do not need much food. But they can suffer from dry mouth and other symptoms of dehydration that can be treated effectively. Once food and water stop, death usually comes in about two weeks, and is caused by effects of dehydration, not the loss of nutrition, said Dr. Sean Morrison, a professor of geriatrics and palliative care at Mount Sinai School of Medicine in New York. "They generally slip into a peaceful coma," he said. "It's very quiet, it's very dignified - it's very gentle." [Read more]

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Hospitals and nursing homes don't track how many Americans die each year after being "unplugged" from some form of life support, but the number is likely to be at least in the tens of thousands, doctors said Friday ... Every day at hospitals and nursing homes, relatives of patients who have been rendered unresponsive by a stroke or Alzheimer's disease instruct doctors to detach their loved one from a ventilator or remove a feeding tube ... "It's so common, many hospitals don't require these kinds of decisions to be brought before an ethics panel anymore," said Laurie Zoloth, a professor of medical ethics Northwestern University. American Medical Association guidelines bar doctors from performing euthanasia or participating in assisted suicide, but also require physicians to respect a patient's wishes to forgo care, even if it is life sustaining. [Read more]

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Legal challenges to both the will of state voters in the Oregon case and the will of Michael Schiavo to fulfill his wife's end-of-life preferences in Florida illustrate remarkable abuses of authority. And the courts have said as much. Prolonging both cases with increasingly tedious litigation is really more about advancing political and philosophical agendas than about honoring the clear wishes of the electorate or those of a husband on behalf of his severely brain-damaged spouse. [Read more]

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It was a somber family gathering in the days after Michael Schiavo's grandmother died in 1988. Doctors had tried to revive the woman despite her written directive that she not be resuscitated. As family talked at a luncheon after her death, someone recalled Terri Schiavo speaking her mind. "Terri made mention at that conversation that, "If I ever go like that, just let me go. Don't leave me there. I don't want to be kept alive on a machine,"' Scott Schiavo, Michael Schiavo's brother, told lawyers years afterward. As lawyers and the public debate Mrs. Schiavo's life, a look back at hundreds of pages of court transcripts reveals testimony largely forgotten in the national debate about her right to die. That testimony helped a judge decide in 2000 that Mrs. Schiavo, left severely brain damaged after collapsing in 1990, would not want to be kept alive by artificial means. [Read more]

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The sanctity of marriage: Remember the recent debate about gay marriage and the sanctity of the bond between husband and wife? Nearly all of those now trying to push their views forward about what should be done with Terri Schiavo told us that marriage is a sacred trust between a man and a woman. Well, if that is what marriage means then it is very clear who should be making the medical decisions for Terri — her husband. But, isn't it true that tough questions have been raised about whether he has her best interests at heart? They have. But, these charges against Michael Schiavo have been heard in court again and again and again. And no court has found them persuasive. Has there really been careful review of this case? Is Terri really unable to think or feel or sense? Will she never recover? The flurry of activity in Washington and Tallahassee might make you think there has not. But that is not so. There have been at least 11 applications to the Florida Court of Appeal in this case resulting in four published decisions; four applications to the Florida Supreme Court with one published decision (Bush v. Schiavo); three lawsuits in federal district court; three applications to the U.S. Supreme Court and nearly untold motions in the trial court. This has got to be the most extensively litigated "right-to-die" case in U.S. history. No one looking at what has gone on in the courts in this case could possibly deny that all parties have had ample opportunity for objective and independent review by earnest and prudent judges of the facts and trial court orders. [Read more]

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Legal experts say no more than 20 percent of Californians put their wishes about life-sustaining medical treatment in writing. However, the Health Care Decisions Law, which went into effect about five years ago, established directions for how people can record their intentions. The law provides that a person, while still competent, can direct life support to be withdrawn under "conditions specified by the person and not limited to terminal illness, permanent coma or persistent vegetative state.'' Among other things, a person can designate a legal surrogate to make medical decisions if he or she is rendered incompetent. So-called ``advance directives'' can be obtained easily from lawyers, doctors, the California Medical Association and retail outlets that carry legal documents. [Read more]

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A persistent vegetative state is something different, "sort of like being in an awake coma," said Dr. David A. Goldstein of the Keck School of Medicine at the University of Southern California. The patients' eyes are open, they have sleep-wake cycles, and it often appears that they are interacting with visitors, which makes it very hard on families. The brain of such patients is functioning only at a very rudimentary level, said Dr. Kenneth V. Iserson of the University of Arizona Health Sciences Center in Tucson. They cannot feel pain, express themselves or receive communication. They may even have grimaces or smiles or other facial movements that look like they are reflecting emotions, but "there really isn't a significant relationship with the outside world," Goldstein said. And the longer the state persists, "the less likely they are to come out of it," Keane added. Schiavo has been in this condition for 15 years, "and it is very, very unlikely she would wake up," he added. Now that Schiavo's feeding tube has been removed, changes in her condition will be slow to occur and barely perceptible at first. In the first couple of days, she may -- or may not -- feel some pangs of hunger or thirst. "Most patients don't seem to give any outward evidence that they are in pain," Goldstein said. After a couple of days, her kidneys will begin to fail, releasing toxins into her blood stream that will anesthetize her body. Soon after, she will lapse into a coma. Eventually, she will stop breathing. The whole process could take from one to two weeks total. "This is not a cruel procedure," Goldstein said. "It is unlikely that [she] will feel pain in any way that we as sapient people will identify. Many family members think it is a very comforting procedure, ... because this is not the way we think we want to live."  [Read more]

In May 1998, eight years after his wife lost consciousness, Michael petitioned Florida's guardianship court. Why? To terminate life-prolonging procedures. He asked the court to let her die. Terri's brain had deteriorated. Any hopes for recovery, short of a true miracle, were gone. Michael believed Terri would choose to die if she could decide for herself. She wouldn't want to be kept alive artificially. The trial court determined Terri was in a persistent vegetative state and that Michael was right. Terri's parents disagreed and challenged the decision, kicking off court proceedings that continue to this day. On October 15, 2001, after the Florida Supreme Court denied the last in a string of appeals, Terri's nutrition and hydration tube were to be removed. [Read more]

Senate Republicans, embroiled in the life-or-death legal battle over the severely brain-damaged Terri Schiavo, invited the Florida woman to testify to Congress in a procedural move intended to keep her on life support. The Senate Health Committee has requested that Terri and her husband Michael appear at an official committee hearing on March 28. A statement from the office of House Majority Leader Bill Frist, R-Tenn., on Friday said the purpose of the hearing was to review health care policies and practices relevant to the care of non-ambulatory people. Frist's statement noted that it is a federal crime to harm or obstruct a person called to testify before Congress, thus stopping any action that could threaten the health of the woman. [Read more]

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The law would mean that if patients do not have a living will (about 85 percent of us), family members would find it almost impossible to follow their loved ones' wishes that they avoid invasive tube feeding ... It is worth noting that most people, when asked whether they would want to be kept alive by a feeding tube if they became permanently unconscious like Terri Schiavo, answer "no" ... It would simply extend the suffering experienced by her family to countless others by tying the hands of those trying to respect their loved ones' wishes.  [Read more]

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Surely Terri Schiavo's God-given and inalienable right to life should trump Michael Schiavo's judicially created "right" to kill her, by withholding food and water until she expires, based solely on highly interested testimony that Terri had expressed an aversion to being kept alive artificially and notwithstanding the credible testimony of a friend of Terri with no financial interest in the case that Terri disapproved of cruel Karen Ann Quinlan jokes and euthanasia. But, Judge Greer won't admit it. So it's up to the Bush administrations in Washington, D.C. and Tallahassee, Florida and the Florida Legislature to act.  [Read more]

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This is the "Bible" of the right-to-die movement by a man who helped his terminally ill wife fulfill her wishes to die with dignity. Derek Humphry later began the modern right-to-die movement by starting the Hemlock Society. "Final Exit" is the most famous textbook on dying with dignity. It is the ultimate "how-to" textbook selling worldwide since 1991. It provides guidance for the terminally or hopelessly ill competent adult who wishes to avoid further unrelieved pain and distress. [Read more]

Medical ethicists Quill and Battin introduce 21 classic and new arguments for the US legalization of physician-assisted dying. They argue that pitting "Death with Dignity" laws against palliative care is a false framing of the debate. Scholars, legal experts, and advocates examine ethical issues, end-of-life options, the views of patients and people with disabilities, and the Dutch and Oregon experiences. [Read more]

Nursing a parent, spouse, other relative, or friend through the painful progress of a terminal disease is not a road best traveled alone. This book offers warmth, encouragement, and the medical, legal, financial, and emotional advice you need when caring for an ailing loved one. Drawing on the experiences of dozens of ordinary people who have cared for relatives and friends ill or dying from cancer, Alzheimer's disease, heart disease, stroke, emphysema, diabetes, AIDS, and other serious conditions -- along with the practical wisdom of distinguished medical, legal, financial, and psychological experts -- this sound, compassionate guide provides field-tested advice on every aspect of caring for the sick including: doing battle with insurance companies, managing symptoms such as nausea or pain, exploring experimental and alternative therapies, and maintaining cash flow and coping with bills. [Read more]

In 1987, as a young lawyer, Colby took as his first case what appeared to be a simple probate issue - guardianship rights of the parents of a young woman who was in a persistent vegetative state after being severely injured in a car accident. Because the Cruzans wanted to remove their daughter's feeding tube, the case generated a firestorm of publicity and protests from right-to-lifers. Drawing on the taped recollections of Cruzan's father and his own records, Colby chronicles the stark human drama of a family forced to live its most intimate moments in the courts and the media. He tracks the case from its beginning in probate court in a small town in Missouri to the U.S. Supreme Court. After three years of litigation and seven years spent in a vegetative state, Cruzan was finally permitted to die. This is a truly riveting look at the case that sharpened public debate about the medical and legal issues surrounding brain death and the right to die with dignity.  [Read more]

This book provides an overview of the Death With Dignity movement, a history of how and why Oregon legalized physician-assisted suicide, and an analysis of the future of physician-assisted suicide. Engaging the question of how to balance a patient's sense about the right way to die, a physician's role as a healer, and the state's interest in preventing killing, Dying Right captures the ethical, legal, moral and medical complexities involved in this ongoing debate. [Read more]

TV journalist Betty Rollin chronicles her mother's two-and-a-half year illness with ovarian cancer, from the diagnosis to her decision to end her unrelenting pain and nausea through suicide. The details of Rollin's role in helping to carry out her mother's last wish by providing information, support, and the means necessary to act upon the decision are widely known through prepublication media coverage. [Read more]

Identifies clinical, ethical, and public policy challenges in end-of- life care and offers recommendations on how to better address these problems. Part I focuses on building relationships among doctors, patients, and families, cultural differences in attitudes towards palliative care, and what to do when the patient cannot speak for himself. Part II presents practical approaches to common problems, illustrated with clinical cases in management of pain, depression, and delirium. Part III deals with legal, financial, and quality issues. Snyder teaches bioethics at the University of Pennsylvania Center for Bioethics; Quill teaches in the Program for Biopsychosocial Studies at the University of Rochester School of Medicine. [Read more]