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Miscellaneous thoughts and ramblings
Friday, March 18, 2005
 
Yahoo! News - Brain-Damaged Woman's Feeding Tube Removed
Yahoo! News - Brain-Damaged Woman's Feeding Tube Removed:

"It is expected that it will take one to two weeks for Schiavo, 41, to die"

At least convicted murderers have the right to be killed humanely.

Edited to include this excerpt from the court's decision:

"No matter who her guardian is, the guardian is required to obey the court order, because the court, not the guardian, has determined that the decision that Mrs. Schiavo herself would make.”

When the courts begin making these determinations for the individual, we've crossed over a dangerous threshold.
Comments:
As I've explained before, she will not suffer. (There may be other reasons to oppose removing her feeding tube, but that she'll die painfully is not one; she will die comfortably.)

Though it's irrelevant, I doubt she'll be alive next Thursday. I have no idea where they got the 1 to 2 week figure from. I don't know how someone can go a week without fluids.
 
I guess I'm just not buying that Bean. They're starving her to death. You can attempt to take comfort from the fact that they'll give her enough morphine to dull the immediate agony of the starving and dehydration. It doesn't change the fact that she's going to be killed through a long drawn out process. If we were to put a convicted murderer through the same process (starving with morphine drip), I'm certain that SCOTUS would rule it to be cruel and unusual punishment.

Terri's wishes aren't known. This is just plain wrong.
 
"Terri's wishes aren't known. This is just plain wrong."

That's a reasonable point. It may be wrong if we don't know what she wants. And it is wrong if this isn't what she wants. The husband says he does know what she wants.

But the method is completely without suffering. I've seen it a bunch of times. I've ordered it a bunch of times. I know what patient suffering looks like. Why wouldn't I tell you that this was painful and horrible if that's what I saw? I don't have an agenda here. I realize it sounds like it would be miserable, but I'm telling you that (1) I've seen this and (2) I've seen patients being miserable, and (3) this doesn't result in patients being miserable. Also, stop calling it starvation. It's dehydration that will take her life. She won't even be "starving" long enough to lose any weight.
 
Now if they kept feeding her, but made her watch "The Ballad of Bilbo Baggins" over and over again, then I would insist that SCOTUS get involved...

(Sorry... Making light of a horrible situation.)
 
She lasted 6 days the last time they did this. I'm starving if I don't have breakfast. It's legitimate to call it starving. Although, more to your point, dehydration is probably more painful.

I don't find it comforting that a patient high on morphine doesn't demonstrate suffering. Assuming that the morphine removes the physical pain (and doesn't simply remove the patient's ability to indicate suffering), I believe it's still a cruel treatment. It would be unacceptable to do it to a healthy person. I don't believe that a person's (absent her known wishes) incapacitation makes it any more acceptable.
 
Re: The Ballad...

Before going out last night and giving myself a hangover, I saw William Shatner hosting a show on one-hit-wonders. Nimoy wasn't mentioned.
 
I totally agree that her incapacitation doesn't make it more acceptable. The whole thing simply rests on what she wants (or would want if she could understand her current situation).
 
Totally off topic, Nomad, I'd love to read your thoughts on Ralphie's post about two weeks ago on gay marriage. You're pretty much a small gov't libertarian type of guy on social issues. What do you think? (I guess you can comment there...)
 
Good stuff on the schiavo topic over at Galley Slaves
 
Received this via email from my dad, who points out the slippery slope issue.


I find this incredible!! I just can not believe that in a civilized society this judge has determined that poor Terry can be starved to death. If this were a convict, the mention of death by starvation would bring crowds of protesters to the streets. It would be considered cruel and unusual punishment. Here we have a helpless woman who is functioning independent of life support machines and, this idiot judge has decided it is fine to kill her. If this kind of barbarianism is allowed to stand, who will be next? I visit a nursing home daily to see my Dad and there are plenty of elderly who can not feed themselves nor have much of a mind left. Maybe they will be next. Once this kind of barbarianism starts, who knows where it will stop. I believe that a verse out of Romans is appropriate for the FL judicial system today: professing to be wise, they became fools. God Bless
 
Galley Slaves' discussion of the husband's finances is certainly worrisome. He seems to have a financial interest in her death. What I don't get is conservative's reflexive jump to be against letting her die. I understand that we're supposed to be the "pro life" side, and I'm adamantly against euthanasia (and that's frankly where I think the battle lines should be drawn). But the fight here seems to be strictly on who knows best what she wants. Why should I or anyone else have a side on that because we're conservative?

Nomad: As to your dad's slippery slope. I really think you and he don't realize how frequently this happens. We've already slipped to the bottom of the slope and it's not so bad here. Usually it happens with the patients stated wishes, and usually it's an infection that the patient doesn't want treated that ends his life, not his inability to reach for a glass of water and swallow, but the doctor's action is the same: medical care is withdrawn, and the patient dies.
 
"Usually it happens with the patient's stated wishes"I guess usually doesn't cut it for me. Not in the context of "usually we have the patient's permission before letting them die." Where human life is concerned, there needs to be a higher standard.

As for the fact that it currently happens frequently, frequency doesn't make it okay. If it did, we'd be able to justify all sorts of unacceptable things.
 
"Usually it happens with the patient's stated wishes."

By that I meant that the rest of the time it happens with the family in agreement that that's what the patient wanted. It never happens because I don't like the patient or because he owes me money.

By mentioning the frequency, I wasn't saying that it's right because it's frequent, I was only saying that the slippery slope that your dad was affraid of (i.e. this thing happenning all the time) has already come to pass.
 
Fox News this morning did present an anecdotal email from a viewer claiming to have witnessed a relative’s death from withdrawal of a feeding tube. The description was horrific. She stated that, towards the end, the patient’s tongue was swollen and protruding. She stated that a relative surreptitiously gave the patient a syringe of water and that the patient, who did not have use of their hands, grabbed the syringe like a baby bottle with their arms and tried to drink. Granted this might be a planted email, on the other hand, maybe not. Here’s the point. You might be able to infer how I am feeling when a woman gives birth by facial expressions, monitors, etc., but I can guarantee you that you could not EVER know what childbirth feels like. What have we come to as a society when we infer what someone’s wishes are absent any tangible evidence of those wishes?

Doctors drawing this imaginary line between out and out euthanasia and withdrawal of a “medical treatment”, strikes me as moronic. It’s ok to draw out someone’s dying by denying them basic human needs, but it is wrong to end their suffering and or their loved ones’ suffering, in a moment of medical intervention. “Peaceful coma” seems to be the operative word of the day, but I’m not buying it.
 
Just a quick point: what makes it OK to let someone die even if they want to? Should the matter of life and death be left up to someone's choice? Isn't it the job of the doctors to cure and prolong life by any means rather than to allow someone to die? Suppose someone indicates that he or she wants to be allowed to die under certain conditions, but then gets injured or falls ill, changes mind, but can no longer communicate his or her wishes, and then the condition deteriorates? Now, we have the indication of the person's *previous* beliefs, but how do we know that the person didn't change his mind?
 
Irina,

Your comment reminded me of a story my mother relayed here a few weeks ago.

A great lesson was taught to me years ago when my mother-in-law had a heart attack that was so severe that it was explained to her and to us that she could not survive without a ventilator. Her son and myself, knowing her so well, and knowing that she had spent a lifetime career as a geriatric nurse, strongly told the doctors that she would not want to be hooked up to a ventilator and miscellaneous other tubes, etc. Wrong! With great determination she made it know that she did, indeed, want to live ventilator dependent or otherwise. As the doctor stated later, “People are very cavalier while sitting in their armchairs contemplating their demise, but when standing on the cliff looking over the edge, the drive and will to live is so strong that most opt for life.” I say, that in this case, no one knows Terry’s desire. No one truly knows her mental status. Her wish is a mystery, just as is life. In my opinion, we, as a society, are entering dangerous territory if we actively terminate this woman’s life. Mama Nomad
 
What I have been dying to comment for days (no pun intended) is to Irina's comment. No, from what I have seen a doctor's job is not to prolong life by any means. A doctor's job is to review the options with the patient and make suggestions based on his best knowledge. Sometimes, this knowledge is that the patient will die and the only suggestions offered are how to make the dying painless. Only bad doctors (and Doctor Bean has told me about lots of them) avoid discussing death and try to prolong life as long as possible. Also, can people change their minds after the event they feared and when they are unable to communicate? Sure, but what are we supposed to do with that information (or lack of information)? I think it is outrageous that the Congress is getting involved in a decision that should be between the doctor and the family. Imagine the slippery slope of that.

Note to self, create "advance directive."
 
Any chance we reached the point of the slope where we can off an elderly yet not-currently-dying relative who is pretty annoying and may very well be leaving us a bunch of cash that would come in handy right about now? Just wondering.

On a serious note, I was wondering about something along the lines of Irina's comment. From what I've read, Terry is conscious and does not rely on a respirator. Even if there were a written DNR available, would that apply to removing her feeding tube? I can understand turning off a respirator, or witholding CPR, or letting an infection do its thing. But taking away food? What if she could hold down food taken orally, but couldn't actually feed herself, and relied on her parents or a nurse to get the spoon to her mouth. Could a judge order the nurse to stop doing that?
 
Or, to make it more tangible, my grandfather's pretty much shot due to Alzheimer's. Suppose my dad decided that he shouldn't be fed any more. Is the ability to chew and swallow where we draw the line? I'm thinking no.
 
Irina: Your question perfectly crystallizes the difference between secular (i.e. American legal) medical ethics (which is what I practice) and Jewish religious medical ethics (and, though I know less about it, probably the medical ethics of most Christian faiths). In secular medical ethics, the principle of autonomy is supreme. The principle of autonomy says that an informed patient can refuse any care, including life-saving care. So, yes, under American law, it is OK to let someone die if they want to. Actually, it's not just OK, legally it's battery to give any kind of medical care that an informed patient has refused. So it's mandatory to let someone die if they want to. Judaism says that the patient's life doesn't belong to her; it belongs to her Creator, so she and her doctors must always choose life.

Your suggestion that we should always prolong life sounds like the sweet idealism of someone who has not yet had and elderly relative suffer a protracted fatal illness. May you continue to be so blessed. You have to realize the extraordinary things that I can do to prolong life. You also have to realize that we do those things most of the time, but we don't do them when the patient doesn't want us to. You also should realize what consequences would occur if we did those things all the time. Almost no one dies quietly in their beds anymore. Almost everyone who has a life threatening problem can get to the ER in time. Doing everything every time would mean that everyone would spend their last month of life (or more) in an intensive care unit. Their last weeks on a respirator. Their last minutes getting CPR, for the fifth time. A 75 year old with colon cancer may reasonably choose to avoid all that, and, because we live in a free society, we allow any informed patient to avoid that regardless of how old they are or their health.

It's true, people frequently change their minds, but the same objection can be raised with wills, or any other important decisions we make. On her deathbed, unable to communicate, Jane may realize that she should distribute her assets differently among her children. What can be done? That's not an argument against wills. The best you can do is to act on the best information available. Would you rather make it so that no care could be refused, since at the last moment a patient could have changed her mind without being able to tell us?

Ralphie & Nomad: Good questions. What care is so basic that it can not be refused? What care is so basic that if it is not provided it is considered neglect, even if the patient doesn't want it? Most medical ethicists agree that any kind of medical treatment including medicines, intravenous fluids, and ventilators are artificial interventions to try to cure or treat a disease, and therefore can be refused. Feeding and fluids by mouth, on the other hand is considered "natural" basic care, and not the treatment of any medical problem, so even for a dying patient who does not want their pneumonia treated with antibiotics, most ethicists would say that the patient must be brought a food tray, and if he wishes, must be fed. Tube feedings, however, because they require a surgically placed tube and are delivered by electric pumps, are considered treatments and are put in the category of medicines and ventilators, not in the category of a tuna sandwich and glass of juice.

I think there was a case where a patient decided she didn't want to be fed any more (Quinlin??). I don't remember what happened. Can another doc help me here? Psychotoddler?

I'm droning way too long. One more thing.

Galley slaves links to an article by Peggy Noonan which argues that GOP Representatives and Senators should act to save Schiavo and will suffer politically if they don't. (The second part may be true; I have no opinion about that.) You know how much we love Noonan here, so it breaks my heart to say this, but she has no clue what she's talking about. Here's the proof. She asks "At the heart of the case at this point is a question: Is Terri Schiavo brain-dead? That is, is remedy, healing, physiologically impossible?" No, that's not the question. There is no one suggesting she's brain dead. Brain death means one can't breathe on one's own, much less open one's eyes. If she was brain dead, there'd be no court case. Legally (at least in California) brain dead is just plain dead. You have a funeral for people who are brain dead, not lawsuits. She's in a permanent vegetative state. Even that isn't contested by any of the medical witnesses in the case. The only people who say that she's able to interact with anyone are her parents, but (as far as I understand) none of the doctors that the parents have hired. So actually, the question at the heart of the case is "Did Terry Schiavo tell her husband that she would not want to live in her current state?" That's the only question. If the answer is yes, at least in California, the tube would be removed. Because the parents contested the husband's report, there was a trial. A judge decided that her husband is the best person to know her previously stated wishes and therefore should be her surrogate decision maker. Do you really want Congress stepping in? Peggy: whatever happened to our tenth amendment?
 
Docotr Bean, here you are wrong. I have a very close relative who is terminally ill and is living with me under the same household. We are doing everything we can to support her life. It's not going to be any better, we know that, but we have no right to do otherwise. It is from this viewpoint that I look at such cases. I wish I could afford to be idealistic about it, but I can see how terrible suffering is, and it's not even the worst of it yet. My opinion on this subject is informed.
 
Again, when do we judge when the suffering is "too much" or "just enough"? Some people have more pain (and other suffering) tolerance than others. Some people may want even if they are "only" partially paralyzed. Where do we stop?
 
Irina: I'm very sorry to hear of your loved one's illness and appologize for presuming that you were unexposed to such misery. God bless you for your attentive care of her.

"Again, when do we judge when the suffering is 'too much' or 'just enough'?"

We shouldn't judge. You and your family's only task is to figure out what your relative wants. If she wants her life prolonged as long as possible she should have that. Some want everything done short of a major surgery, others want everything done but not CPR or ventilators... There are as many right answers as there are patients. That is autonomy. I wish you strength and your relative some comfort.
 
Thank you!
By the way, I just thought of another angle to this story - the role of Congress and the President. Does anyone care to comment?
 
For the sake of defragmenting the conversation about the Schiavo case, please make all further comments on this thread. Thank you.

Move along. Nothing to see here.
 
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