Ethical Issues in the Terri Schiavo case - PowerPoint PPT Presentation

About This Presentation
Title:

Ethical Issues in the Terri Schiavo case

Description:

Ethical Issues in the Terri Schiavo case Richard L. Voet, M.D., M.A. Lisa H. Clark, M.D. Nancy Curzan 1990 33 yo in a PVS after an automobile accident After 3 years ... – PowerPoint PPT presentation

Number of Views:1005
Avg rating:3.0/5.0
Slides: 27
Provided by: phdresCar
Category:

less

Transcript and Presenter's Notes

Title: 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.
Write a Comment
User Comments (0)
About PowerShow.com