I was just wondering what you all think about the man in Florida who won the right to discontinue his wife's feeding tube (she has been in a coma/vegetative state for 10 years) against the wishes of her parents. Now governor Bush signed something saying that it must be replaced. What are your thoughts on this? I have a feeling this will be a good debate!

Ok, I'll start as I must admit this is a politically, emotionally charged arguement but I know there will be some good opinions out there and maybe someone will come up with something that I haven't thought of yet (oh amyk where are you...you always make such good and articulate points!) Anyway, I for one am hopping mad that they are making this woman (and her family) a political bean bag. I'm also really upset that they are taking this decision away from her husband (who has the right to make it) and instead the governor is making the decision! I for one will be spending the weekend making out my living will, as even though I know my husband knows my wishes I don't want him (or any of the rest of my family) to have to make any decisions that would be hard for them to make...instead they can just read it off the paper and take it to court if they need proof of "my wishes"...

I absolutely think that people have the right to die. We talk so much about patient autonomy and giving patients all the options so that they can make an intelligent choice. If all the options have been laid out for them, and the patient says "I do not wish to be kept alive artificially," then who are we to say they made the wrong decision? Specifically, who do the politicians think they are to get involved in this? Have powers over life and death suddenly become the responsibility of the public domain?

Some people argue that the woman is brain damaged and perhaps not mentally capable. However, I have had discussions numerous times with people I love and they have clearly expressed their views on how they want to die. I would find it very hard to believe that her spouse would not be aware of her wishes. If there's a living will, that's supposed to be as good as a legal contract! Interfering in this case would be just as bad in my mind as the government suddenly invalidating other random contracts that people make.

Just my :twocents:

Audrey

Sorry, momsurg, I don't have a lot to say on this one. It seems v. political-business-as-usual. I thought the woman had no living will, and that's what the problem was -- no documents. Putting the tube back in satisfies the religious right, the miracles crowd, and (I'm guessing) a good chunk of the senior population. I just hope the in/out doesn't go on too much longer, it's grotesque.

Government always has final say over life/death, from morning-after pills to "don't let 'em go" rules in advanced old age. I think it's only recently that many states took failed-suicide laws off the books, too. Only way I know of to avoid gov't interference in death is to go swiftly on your own, or to see it coming and arrange to be in another country with more liberal assisted-suicide laws. My own father, whose cancer is in remission, lives in dread of being kept hanging on with tubing, and I wouldn't be surprised if one day he kissed everyone goodbye and flew off to Amsterdam to take care of things on his own terms & as swiftly/painlessly as possible. And I can't really say I blame him.

amy

Yes, I think the contentious issue in this "debate" is the fact that there is nothing in writing...only the husband's "she wanted..." versus her parent's "she wanted...". I still think that legally the husbands rights (as next of kin and legal guardian) need to outweigh her parents beliefs, unless of course she had given them health care power of attorney (as she did not). Now the husband is denying the rest of the family the right to see her, which seems to be taking a horrible situation and making it WORSE! The thing that I'm so bothered by is the government's weighing in on it, and reversing an "already made" decision. This scares me, they are undermining the legal guardian, the healthcare profession, and basically making what should be a dignified death a horror show. Again, everyone out there, don't settle for "telling" your next of kin what your wishes are, WRITE it down...

Actually I'd say the senior population would most likely side with the husband bc they are a lot closer to facing the question themselves and ( in practice) are more realistic than all those do-gooders out there...THE HUSBAND of course should have the decision-making power (unless he was a convicted pychopath or something) and it HORRIBLE that this is getting bounced back and forth. LET THE WOMAN DIE for goodness sakes!

First, she is NOT in a coma. Terry IS brain damaged. Due to a potassium imbalance she suffered a heart attack and although she survived, she lost a great deal of her mental capacity. That said, she CAN talk...although it is only a few words such as "momma". She DOES have preferences such as "she doesn't like blankets tucked around her". She DOES recognize a few people. So the question is not concerning someone who is completely comatose and unresponsive.

SEcond her husband is living with a woman who is expecting their second child. I think perhaps HE MAY have interests other than Terry's at heart. If he truly thought Terry's wish were to die this way, why did he wait THIRTEEN years after her accident to decide to starve her? And why did he wait until AFTER the one million doller settlement was spent before taking this action?

Third, dehydration is a horrible way to die.....not to mention the nausea, hallucinations etc. We would condem anyone who treated an animal this way...why do we think it's acceptable for a human being to be starved/dehydrated to death?

You know, I was just at an end of life conference in San Francisco...and interestingly, they (experts in the field of ICU, and end of life care) actual believe (now) that dehydration and starvation isn't so horrible. They explained that when the body goes into starvation mode, ketones are produced, an acid which actually blunts the nerve endings sensitivity to pain. Endorphins are produced in this "starvation" state which helps relax the body and makes the individual feel more at ease. The lack of water helps keep pulmonary secretions at a minimum and helps maintain the airway. They say that, when terminal patients were asked about their end of life fears, the number one fear was the fear of pain...and number 2 was the feeling of suffocation. If the airway remains dry, and their sensation to pain is dulled...they argue that the end of life experience is better. These experts recommend withdrawing all feedings and liquids which only serve to prolong life, miserably.

I think the thing that really complicates this situation is what Cynthia mentioned - that the husband has apparently now spent all the settlement money. And has been in a relationship with someone else but for some reason hasn't gotten a divorce. And the parent's disagree.

I agree myimd- they've known since the mid 90's that starvation is the mor epleasant way to go and I susually bring that up pt's families who are deciding what to do w/ a feeding tube ( or whether to put one in in the first place.)

We aren't talking about a TERMINAL patient! ...and TERRY isn't in pain. She's NOT suffering and has many more years to live. She ENJOYS LIFE!!! So a "better way to die"??? She ISN'T dying! ...or at least wasn't until they refused to feed her.

As for the "better way to die"...have you actually WATCHED a person die of starvation and dehydration? I have. My grandfather was 95 and very frail. Eating was a chore....one day it was just too much of a chore and he stopped. The starvation wasn't so bad but the dehydration?....THAT stinks. What about the CRAMPS and PAIN as all your body organs and functions close down? ....a better way to die? compared to WHAT? Compared to cancer...perhaps. Compared to a heart attack...perhaps. But to say it's an EASY way to go is absurd. It DOES HURT, and there IS PAIN. The most merciful thing was when my grandfather slipped into a coma.

Terry isn't dying of ANYTHING except starvation or perhaps it's better to say she's dying of dehydration. To try to compare her misery to any other way of dying is odd to me. 30 years from now perhaps this issue of HOW Terry should die would be an appropriate topic. Perhaps then she will be facing a crisis that makes dehydration seem pleasent....perhaps....but then again, perhaps NOT. Perhaps she will die in her sleep of old age and dehydration would have been the AWFULL option for her.

Cynthia, you're right, it does depend on the individual situation. Clearly, if you take an otherwise healthy person, and starve them, their death would be unpleasant. But somewhere between *healthy*, and *dead*, there's this "dying, teminal" patient that may benefit from these measures. I've seen many, many people die in our ICU...and some certainly have benefited from less NGT feedings, and IVF (as evidenced by the CXR, the level of agitation, including the vital signs). I didn't bring up starving people and say that it may have benefits for some, to say that everyone should be starved...or even this woman Terry should be. Honestly, I don't know much about Terry, or this case...I simply stated the above to demonstrate a growing idea among intensivists.

Cynthia, just curious, how do you know she enjoys life?

amy

while i don't believe that the husband is thinking in terms of the patient's best interests (another woman..large legal settlement..stinky to me), BUT if the court ruling is that she must die..(forgive me for my lack of medical knowledge) can't they give her some sort of more humane way to die? if i recall my pharmacology class correctly, there are drugs (can't for the life of me remember what) which in large doses induce peaceful sleep and then...cause death. does this exsist? starvation and dehydration just doesn't seem right. perhaps this is one of those "do not kill", just "let die" things?

What I think this all comes down to is would this woman want to be kept alive by artifical means (which is what is happening) or would she prefer to be allowed to die. This may be a very different answer for each person and dependent on the situation. Every doctor that I have seen interviewed about this woman said that she does extremely little that could be considered meaningful. But beyond all of this, I think the thing that is more scary is that the government is stepping in and reversing the rights of the husband. Now, yes maybe his motives are confused right now, but this court case has been going on for YEARS, far before the settlement money ran out and I can't even fault him for moving on-I sure wouldn't expect my husband not to move on with his life if I was in the same state as this woman. I don't know what the right answer is as far as this woman is concerned, but I am pretty convinced that it is not government intervention!

From what I've read, I think the government stepped in at the request of the rest of the family. The husband seems to be the only person in the family that thinks food and liquids should be withdrawn. It just seems fishy to me, considering the monetary benefits for the husband, that perhaps he's not thinking only of his what his wife would have wanted. It's difficult to know though. It also doesn't seem to be a clear cut case of her suffering in her present condition though either - it's not as if she seems to be in pain - just in kind of a suspended or brain damaged state. How can you know that a person in this condition would rather be dead.

As usual, there is a lot more to the story than meets the media's eye. I'm from the area, and many of my med school professors are intimately involved in the case. First of all, she IS in PVS. Any responses she has are innate, rudimentary reflexes and NOT because she enjoys life or can think. Secondly, she had a heart attack secondary to anorexia (think about it: low blood postassium in a 27 year old woman...). This speaks volumes because both the husband & the parents blame each other & won't take responsibility for ignoring the problem. This brings up another issue. The marriage was on the skids & her parents have never liked her husband. Furthermore, Teri never had a conversation with her husband about end of life issues, but he "seems to remember one time that she mentioned that she would not want to be put on life support." Maybe you can start to see why it is so complicated (the family dynamics are a mess), but it also boils down to one thing: attorneys. Teri's husband has the right to make the decision, but because Teri's parents are well-off, they continue to hire very expensive lawyers, etc, to try to win the right. Also, try to remember that the video footage they show of her are from 6 years ago or so (they haven't let cameras in her room in a long time). I hear she is now curled up in a fetal position & looks rather emaciated, etc. Keep in mind that this battle has been going on for 12 to 13 years!!! Let the poor man get on with his life and let Teri gracefully end hers!

It is frightening to think that our governor has made (the latest) end-of-life decision for this woman.

No one will EVER really know what Teri would have wanted. Her husband claims that she didn't want to be on life support......and she's not. In fact, the ONLY thing she requires is tube feeding. And her doctors do NOT all agree that she is in a PVS. So what do we call Teri? What do we call people who aren't by our determination "normal"? What do we call ANYONE who requires tube feedings but no other intervention? What do we call people who aren't on life support, aren't terminal, aren't in pain, aren't DYING? ..........we call them disabled....nothing more, nothing less.

It's interesting to me that our founding fathers wrote in the declaration of independance that "ALL men are created equal and endowed by their creator with certaiin unalienable rights... life, liberty, and the pursuit of happiness" They didn't say only those with a mental capacity above a certain level and they didn't say only those with perfect physical ability....they said ALL men have the "privelege" of life simply by being a citizen.

The declaration goes on to say that to "secure these rights, Governments are instituted among Men" ....so YES, the government DOES have the right to step in and give Teri her "privelege" to live.

Permitting government to make life/death decisions is a slippery slope. People have a right to live, but they also have a right to die in dignity. The decision maker should be the person themselves. If they are unable to, then someone else does it for them. Someone who loves them, and ideally knows what intervention is desired by the patient. I wouldn't want government telling me that I don't have a right to automomy, or the right to make a decision on my child's behalf. And if government is allowed to (and supported in) making these sorts of decisions, where is the line drawn? And, Cynthia, please understand, Terry is only one case. This government intervention may extend beyond Terry if this precedent is set. Let's broaden our views beyond just this one case.

Just to clarify, the government does make life/death decisions all the time, and has done since we've had a government. Legislatures set the bounds of permissible actions re: life/death, whether we're talking murder, rights to have children, or permission to end one's own life. Judiciaries impose death penalties. Governors issue pardons and reprieves. What we're really talking about here is arbitrary, politically-motivated executive-branch decisions on who lives and who dies. It's just a little damn close to rule by fiat.

amy

That's exactly what worries me. The disabled need to know they have protection.... what happens if a disgruntled family member decides to shove ol' sis off this planet? There HAS to be some boundaries. If it were merely this one case at stake I wouldn't be as upset...it is the rights of disabled people everywhere that are at stake.

I'm not arguing the needs of the terminal, and the end of life decisions. I AM supporting protection for the disabled no matter how disabled they are. Teri is just ONE case, but it has ramifications for all disabled people because she is NOT at the end of life, nor is she terminal....she IS severely disabled.

In an ideal world family members would always have the best interests of their "loved ones" at heart. However, in our world things are far from Ideal. Our society is plagued by child abuse, spouse abuse, elder abuse, and yes, abuse of the disabled. This is why things like childrens services, safe houses, and senior services exist.....to protect those who are weak and need our protection. This is why they MUST exist. Teri's case threatens ALL disabled people. If Teri is starved/dehydrated to death, then ALL disabled people are at risk....they in fact lose their right to...."life, liberty, and the pursuit of happiness" and we become an America only for those deemed "non-disabled"

Cynthia-
You do have a very valid point...there is no one that can judge what a person's quality of life is except for that person themself. And it does seem as though her wishes previous to the heart attack were not crystal clear.

To everyone...my intention for posting this (besides to start a good discussion) is to urge everyone (doesn't matter how old you are) to discuss this with your families. Know what their wishes are, and make sure they know what your wishes are. Ideally, put it in writing but at the very least make sure more than one person knows! This situation happens a lot more frequently than we would like to admit, and it is heartbreaking as a physician to have to A)broach these subjects for the FIRST time as a patient is in the situation (instead of beforehand) and B) watch families become torn up over this...

moved to debate forum....

In any case where there is no living will on record, the next of kin must show the courts "clear and convincing" evidence that the patient did not want life sustaining efforts and that the patient was not likely to recover.

All of the husband's doctors as well as the court-appointed doctors have agreed that this woman is in a PVS and will not recover. In fact, her CT scans show that most of her cerebral cortex has deteriorated to the point that she could not recover. The parents are hanging on the idea that, with therapy, she could regain some of her ability.

This case has been in the courts for at least 10 years. The husband and parents have been arguing over whether she made her wishes clear to anyone. Clearly, the courts believed that the husband had shown enough evidence to order removal of the feeding tube. As to his motives, he has not been living with this woman for a decade. He only began dating again within the last 2 years or so. He has said that he remained married to her so that he can remain her legal guardian because he believed that she would not want to be kept alive artificially and he knew that her parents would never allow the tube to be removed.

While the courts saw the entirety of her parents' video of Terri and heard testimony from a number of doctors, the legislature did none of this. This law was a knee-jerk reaction to letters they were receiving from people who saw an excerpt from that video on the parents' website. The video excerpt makes it appear that she can respond and has some awareness of her surroundings. Apparently, when viewed as a whole, in context, it becomes more clear that she has no conscious response.

I could only hope that my husband would have the forethought to not divorce me in the same situation. I can only imagine what decisions my own family would make! It seems to me that there's no benefit to him in Terri's death. He could divorce her at any time. He has moved on with his life. Whether or not they are married should not determine what happens to a settlement that was awarded 10+ years ago. (No matter if it is mostly spent or not...it was likely disbursed soon after the judgement). So what would it benefit him to stay married to her except to see that her wishes are carried out?

Bev~

While this is certainly impassioned, it is flawed because the Declaration of Independence holds no weight in a court of law. It was a document written as a declaration of war. It's analogous to saying that a particularly eloquent speech sending us to war with Iraq holds some weight for generations 200 years from now in their court decisions.

The Constitution is relatively silent on the issue; however the Supreme Court decided in the Cruzan case that the patient--or the next of kin--were well within their rights to decide what measures should be taken to extend life.

Bev~

The problem with this case is that contrary to what people may beleive...feeding is not considered life support. For this reason, Terri is not considered to be on life support.

While I have not personally seen the video, there are others who have seen it in it's entirty...one person I can think of is Dr. James Dobson who said of his viewing....that she DOES appear to respond, although at a low level. Terry CAN say a few words such as "Momma". people in a PVS CANNOT speak even a few words. That is by definition of PVS.

The questions remains if family have the right to starve her to death. This is obviously a very "heated" issue for many. I think we must look at what the rights are of every other member of society. Although most parents have the best interests of their children at heart and parents have the right to raise their children as they see fit, they DO NOT have the right to starve their children, nor do they have the right to abuse their children. Our rights as parents end where our childrens rights begin. The same can be said of spouses or the elderly. We DO have the right to do what we see as best for our families. However, those rights end where our family members rights begin.

Teri has not indicated that she wished to die of starvation. Her husband says he "might" remember one instance where she "might" have said that she did not wish to be on life support. As I've said before, Teri is not on life support.


The issue of "life sustaining efforts" applies to the "end of life" issues surrounding those individuals who are in the process of dying. Teri is NOT in the process of dying. She IS a disabled individual whose husband "thinks" she would have desired to be starved to death. This differs from "life sustaining efforts" given as a patient faces the end of life.

Teri's husbands rights end where Teri's rights begin. No matter how disabled she may be, she is entitled to be protected just as our children are entitled to be protected.