A 42 yearold man whose wife requests withdrawal of support

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A 42 year-old man whose wife requests withdrawal
of support

• Douglas B. White, MD
• UCSF Department of Medicine
• April 22, 2003

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(No Transcript)
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HPI (cont)

• Physicians expected him to survive for many
  years, but did not expect further neurologic
  improvement.
• The feeding tube became dislodged several times
  over the next 6 month and was replaced.
• The wife, who was the patients conservator,
  refused to authorize reinsertion because she
  believed he would not want it.

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HPI (cont)

• Subsequently, the doctors asked the patient a
  series of yes-no questions, some of which he
  answered correctly.
• When asked Do you want to die? he gave no
  answer.

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• The patients wife, brother and daughter recalled
  statements he made before his accident
• About his father-in-law on a ventilator I
  would never want to live like thatwouldnt want
  my children to see me like that.
• 5 days before his accident, when told by his
  brother that his drinking would soon cause an
  accident that would leave him in a vegetative
  state Mike, whatever you do, dont let that
  happen. Dont let them do that to me.
• Per his daughter if he couldnt be a provider
  for his familyif he couldnt do just basic
  things, feeding himself, talking,
  communicatinghe would not want to live.

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• The patients wife, brother and daughter, as well
  as the patients physicians, the hospital ethics
  committee and county ombudsman for patients
  agreed to not replace the feeding tube.
• An anonymous call was placed to the patients
  mother, who then went to court to block the plan.
• The court ordered the tube feedings be continued
  pending a judicial decision.
• 6 years later, after a series of lower court
  rulings and appeals, the California Supreme Court
  accepted the case. The patient died of pneumonia
  while the court was still deliberating.

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Legal Aspects of Withdrawal of Support

• Douglas B. White, MD
• April 22, 2003

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Persistent Vegetative State (PVS)Awake but
unconscious

• Definition no cortical function, but preserved
  brainstem function unconscious and without
  awareness of their environment.
• Sleep-wake cycles are present.
• Roving eye movements often observed.
• Smiling, grimacing, tearing can occur, but are
  unrelated to stimuli.
• A clinical diagnosis that requires serial exams
  by a neurologist.

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Legal Rulings on Persistent Vegetative StateThe
case of Karen Ann Quinlan

• The case 22 year-old intubated woman in a PVS
  secondary to an unknown illness. Her father was
  appointed her legal guardian and he requested
  that mechanical ventilation be withdrawn.
• Physician refused, stating withdrawal of support
  would not conform to medical practices,
  standards and traditions.
• The ruling patients right to privacy extended
  to her right to decline treatment guardian able
  to withdraw support.
• State interest in protecting life weakens and
  the individuals right to privacy grows as the
  degree of bodily invasion increases and the
  prognosis dims.

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Minimally Conscious State (MCS)

• Definition A condition of severely altered
  consciousness in which minimal, but definite,
  behavioral evidence of self or environmental
  awareness is demonstrated.

• Behavioral Criteria for MCS
• Verbalizes intelligibly
• Gives yes or no responses verbally or with
  gestures
• Demonstrates purposeful behavior
• Appropriate smiling, etc in response to emotional
  stimuli
• Responding to content of questions.
• Purposeful reaching for objects
• Modification of grasp to accommodate size of
  object.
• Visual pursuit or sustained vision fixation on
  external object.

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Types of Severe Alteration of Consciousness
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The Conservatorship of Robert WendlandKey Points

• Patient in a minimally conscious state (MCS)
• Not terminally ill
• Court acknowledged that, under appropriate
  circumstances, conservators can withhold all
  forms of health care.
• To withhold or withdraw support for the purpose
  of causing the patients death, there must be
  clear and convincing evidence that this is the
  patients wish or in his best interest.

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What is Clear and Convincing Evidence? The
Conservatorship of Robert Wendland

• A degree of evidence greater than preponderance
  of evidence (gt50) and less than beyond a
  reasonable doubt.
• Acceptable written advanced directive, oral
  directive or specific statement about disease and
  intervention.
• The standard of clear and convincing is used in
  other civil cases to protect particularly
  important individual interests that are more
  substantial than mere loss of money.
• Clear and convincing evidence required for
  involuntary commitment to a mental hospital,
  termination of parental rights, or deportation.

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The Conservatorship of Robert WendlandKey Points

• The California Supreme Court gave significant
  weight to
• The fact that Wendland could interact with others
  and that simple interventions could keep him
  alive for many years
• The fact that withdrawing support would have been
  irreversible and led to the patients death
• The idea that an erroneous decision to withdraw
  support is more perilous than one to continue
  treatment, which is reversible and maintains the
  status quo.

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Concern for Inappropriate Application of the
Wendland Ruling

• In a major right-to-die case, the court ruled 6
  to 0 that the wife of a Stockton man severely
  injured in a car accident could not withdraw his
  feeding tube because he left no formal
  instructions of his wishes.

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To Whom Does Wendland Not Apply?

• Competent patients
• Incompetent patients who are terminally ill
• Incompetent patients whose family members are in
  agreement about limiting support.
• ? Patients in a persistent vegetative state?
• ? Acutely ill incompetent patients in whom death
  would not be unexpected despite therapy?
• States interest in protecting life weakens and
  the individuals right to privacy grows as the
  degree of bodily invasion increases and the
  prognosis dims.

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Key Points

• Patients in a PVS are awake but unconscious they
  have no cortical function, but preserved
  brainstem function.
• Patients in a MCS have severely altered
  consciousness in which minimal, but definite,
  behavioral evidence of self or environmental
  awareness is demonstrated.
• Clear and convincing evidence is needed to
  withdraw or withhold life support from patients
  in a MCS who are not terminally ill.
• The Wendland verdict should not be broadly
  applied to terminally ill incompetent patients.

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References

• Wendland v. Wendland 26 Cal. 4th 519 (2001)
• In the matter of Karen Quinlan, 70 NJ 10 335A
  (1976)
• Giacino JT et al. The minimally conscious state.
  Neurology. 200258349-53.
• The Multi-Society Task Force on PVS. Medical
  aspects of the persistent vegetative state. NEJM
  19943301572-79.
• Lo et al. The Wendland Case- withdrawing life
  support from incompetent patients who are not
  terminally ill. NEJM 20013461489-93.
• Eisenberg et al. Legal implications of the
  Wendland case for EOL decision making. West J Med
  2002 176124-27.