March 8, 2005, 12:33AM



Hospitals can end life support
Decision hinges on patient's ability to pay, prognosis
By LEIGH HOPPER
Copyright 2005 Houston Chronicle

Bill Olive / Chronicle
(L-r)Mario Caballero, Spiro Nikolouzos Jr. and Jannette Nikolouzos. St. Luke's notified Jannette Nikolouzos in a March 1 letter that it would withdraw life-sustaining care of her husband of 34 years, Spiro Nikolouzos, in 10 days.
A patient's inability to pay for medical care combined with a prognosis that renders further care futile are two reasons a hospital might suggest cutting off life support, the chief medical officer at St. Luke's Episcopal Hospital said Monday.


Dr. David Pate's comments came as the family of Spiro Nikolouzos fights to keep St. Luke's from turning off the ventilator and artificial feedings keeping the 68-year-old grandfather alive.

St. Luke's notified Jannette Nikolouzos in a March 1 letter that it would withdraw life-sustaining care of her husband of 34 years in 10 days, which would be Friday. Mario Caba-llero, the attorney representing the family, said he is seeking a two-week extension, at minimum, to give the man more time to improve and to give his family more time to find an alternative facility.

Caballero said he would discuss that issue with hospital attorneys today.

Pate said he could not address Nikolouzos' case specifically because he doesn't have permission from the family but could talk about the situation in general.

"If there is agreement on the part of all the physicians that the patient does have an irreversible, terminal illness," he said, "we're not going to drag this on forever ...

"When the hospital is really correct and the care is futile ... you're not going to find many hospitals or long-term acute care facilities (that) want to take that case," he said. "Any facility that's going to be receiving a patient in that condition ... is going to want to be paid for it, of course."


Patient showed emotion
Caballero said he believes the hospital wants to discontinue care because Nikolouzos' Medicare funding is running out.

Spiro Nikolouzos, a retired electrical engineer for an oil drilling company, has been an invalid since 2001, when he experienced bleeding related to a shunt in his brain. Jannette Nikolouzos, 58, had cared for her husband at their Friendswood home, feeding him via a tube in his stomach. Her husband couldn't speak, she said, but recognized family members and showed emotion.

On Feb. 10, the area around the tube started bleeding, and Nikolouzos rushed her husband to St. Luke's for emergency care. Early the next morning, she said, the hospital called and said he had "coded" and stopped breathing and had to be placed on a ventilator.

A neurologist told her, she said, that he is not brain-dead and the part of the brain that controls breathing is still functioning. Although his eyes were open and fixed when he first was placed on the ventilator, he has started blinking, she said.


A missed opportunity
Dr. Marcia Levetown, director of palliative care at The Methodist Hospital, said moving Nikolouzos to a nursing home or other type of facility may not be an option if his body is dependent on several types of technology, such as mechanical ventilation and kidney dialysis.

Levetown said when families and hospitals take their disagreements to court, it often means the hospital has missed an important opportunity in the family's emotional healing.

Often missing from aggressive medical care is empathy for family members and acknowledgment of grief, she said.

"The acknowledgment of 'You clearly love your husband very much. You've done the good fight' " makes a difference, she said. Levetown also tells families, "Whatever might be beneficial, you've made sure he's gotten that. We all wish he could get better ... How can we best honor this man ... as we accompany him in his next journey?"


Law allows removal
State law allows doctors to remove patients from life support if the hospital's ethics committee agrees, but it requires that the hospital give families 10 days to find another facility.

A similar case is still in the courts. Texas Children's Hospital wants to discontinue life support on 5-month-old Sun Hudson, who was diagnosed shortly after birth with a fatal form of dwarfism. His mother, Wanda Hudson, wants her son's care to continue at the hospital.

On Wednesday, a judge will consider whether Harris County Probate Court judge William McCulloch may remain on the Hudson case. Caballero, who represents Wanda Hudson, filed a motion that McCulloch remove himself from the case after making what Caballero said were biased statements.

leigh.hopper@chron.com

http://www.chron.com/cs/CDA/ssistory.mpl/m...politan/3073295

Passage of Schiavo Bill Temporarily Blocked
In Special Session, House Democrats Thwart GOP Effort on Legislation Aimed at Reconnecting Fla. Woman's Feeding Tube
By Mike Allen, Manuel Roig-Franzia and Lexie Verdon
Washington Post Staff Writers
Sunday, March 20, 2005; 2:51 PM


Congressional leaders, who yesterday announced a compromise that they said would require doctors to restore sustenance to a brain damaged Florida woman, held extraordinary Palm Sunday sessions of both chambers this afternoon.

But some Democrats vowed to fight the measure, and both the House and Senate recessed quickly while leaders sought to get members home from their districts for a vote that could come early Monday morning.

The White House said that President Bush was returning to Washington this afternoon from his ranch in Crawford, Tex., to sign the bill, which would allow a federal court to review the case.

The extraordinary intervention by Washington for a single person, in a wrenching question that families typically wrestle with in private, began at 1 p.m. when House Speaker J. Dennis Hastert gaveled his chamber to order. It recessed moments later. The same procedure was followed in the Senate an hour afterward.

A handful of Democrats -- including several from Florida -- held a news conference today denouncing the bill as an inappropriate intervention into a private family matter by federal officials. They argued that the case has been fully reviewed by state courts and a variety of judges.

Rep. Jim Davis (D-Fla.) said, "This case is a tragedy, but what Congress is trying to do is another tragedy. . . . Congress should be following the law, not trampling the Constitution."

Senate Majority Leader Bill Frist (R-Tenn.) who spoke on the Senate floor today before it quickly recessed, disagreed. "Now is the time for us to act," he said. "Terri deserves it."

Frist said the agreement on the bill, which he first announced yesterday evening, was a bipartisan effort. He expressed confidence that the measure would be passed.

The legislation would prolong a medical and legal drama that has pitted the incapacitated Florida woman's husband against her parents.

In a memo distributed only to Republican senators, the Schiavo case was characterized as "a great political issue" that could pay dividends with Christian conservatives, whose support is essential in midterm elections such as those coming up in 2006.

Schiavo, 41, spent a full day off of nourishment and fluids yesterday at a hospice in the Gulf Coast suburb of Pinellas Park, Fla. Her feeding tube was removed Friday afternoon after a state judge ignored subpoenas from Congress and enforced a deadline that lawmakers had thought they could thwart by declaring her a witness who must be protected for a future hearing they would conduct at her bedside. Late Friday, the U.S. Supreme Court, without comment, denied an emergency request from the House committee that had issued the subpoenas.

Doctors said she could probably live as long as two weeks before dying of dehydration. Schiavo has been in a vegetative state for 15 years after a heart attack brought on by a chemical imbalance caused severe brain damage.

The two-page compromise bill, "for the benefit of the parents of Theresa Marie Schiavo," would give a federal court in Florida the jurisdiction to consider a claim "relating to the withholding or withdrawal of food, fluids or medical treatment necessary to sustain her life."

House Republican leaders had wanted a bill that would apply to similar cases across the nation, but they agreed to limit it to Schiavo as the main element of the compromise with the Senate. That difference in bills the two chambers passed last week had provoked unusually bitter exchanges between Republican leaders.

Outside Schiavo's hospice in Florida, tension and anxiety rose yesterday among the demonstrators who have turned the roadside into a small tent city. At least three protesters were arrested early yesterday, including a man who said he is a priest and who walked toward the hospice demanding to administer Holy Communion to Schiavo.

Police increased the number of officers guarding the hospice, even as Schiavo's parents -- who are fighting to have her feeding tube restored -- asked demonstrators to refrain from civil disobedience.

In Washington, lawmakers yesterday announced the agreement four hours after Schiavo's mother, Mary Schindler, went before television cameras on her way into the hospice and tearfully begged, "President Bush, politicians in Washington: Please, please, please save my little girl."

Schiavo's husband, Michael Schiavo, raged against Congress in a series of interviews, saying on CNN that the government is "getting in the middle of something they know nothing about."

House Majority Leader Tom DeLay (R-Tex.), who pushed Congress to consider the legislation, said yesterday that he is "confident that this compromise will restore nutrition and hydration to Ms. Schiavo as long as that appeal endures."

DeLay said he did not know if it would mean she would be spared indefinitely. "That's not the point," he said. "The point is that Terri Schiavo should have the opportunity. We should investigate every avenue before we take the life of a living human being, and that's the very least we can do for her."

The tube was also removed for two days in April 2001, after state and federal courts refused to intervene, and for six days in October 2003, after the state judge handing the case determined she had no hope of recovery. The Florida legislature hastily passed a bill allowing Gov. Jeb Bush ® to intervene.

After the eight-minute Senate session, Sen. Tom Harkin (D-Iowa) said House Republicans should have dealt with the matter last week. "I do not believe there was a need for this to be dragged out in the media yesterday, today and now into the weekend," he said.

Republicans acknowledged that the intervention was a departure from their usual support for states' rights. But they said their views about the sanctity life trumped their views about federalism.

An unsigned one-page memo, distributed to Republican senators, said the debate over Schiavo would appeal to the party's base, or core, supporters. The memo singled out Sen. Bill Nelson (D-Fla.), who is up for reelection next year and is potentially vulnerable in a state President Bush won last year.

"This is an important moral issue and the pro-life base will be excited that the Senate is debating this important issue," said the memo, which was reported by ABC News and later given to The Washington Post. "This is a great political issue, because Senator Nelson of Florida has already refused to become a cosponsor and this is a tough issue for Democrats."

House members today were scrambling to return to Washington from across the country. Leaders acknowledged yesterday that they expected some Democrats to object to the legislation, which would prevent the bill from passing in the House under rules available for today. So House leaders said they are likely to have to meet again, at 12:01 a.m. Monday, when they can put the bill on a calendar that would deny Democrats some ways to stall action.

With lawmakers scattered from Iraq to Australia, leaders hope to use parliamentary methods -- such as a voice vote rather than a roll call -- to pass the bills without calling back their entire memberships.

House Majority Whip Roy Blunt (R-Mo.) said yesterday that the outcome is clear and that it is "just how we get there." He said that if Democrats demand a roll call vote, Republicans will need to come up with 218 votes and two-thirds of the House, and he said it would be "just a matter of time" before enough of the 232 Republicans could be rounded up to do that. A vote would not begin until then.

Roig-Franzia reported from Pinellas Park, Fla.

http://www.washingtonpost.com/wp-dyn/artic...-2005Mar20.html

Experts Say Ending Feeding Can Lead to a Gentle Death

By John Schwartz

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.

"From the data that is available, it is not a horrific thing at all," said Dr. Linda Emanuel, the founder of the Education for Physicians in End-of-Life Care Project at Northwestern University.

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."

The process of dying begins in the kidneys, which filter toxins from the body's fluids. Without new fluids entering the body, the kidneys produce less and less urine, and the urine becomes darker and more concentrated until production stops entirely.

Toxins build up in the body, and the delicate balance of chemicals like potassium, sodium and calcium is disrupted, said Deborah Volker, an assistant professor of nursing at the University of Texas who has written extensively on end-of-life issues.

This electrolyte imbalance disrupts the electrical system that triggers the action of muscles, including the heart, and eventually the heart stops beating.

http://www.nytimes.com/2005/03/20/national...hSJA&oref=login

Posted on Mon, Mar. 21, 2005

POLITICS
Social conservatives pressure Bush and Congress to act
Key members of the coalition that brought Bush to office are wielding their clout. Before, they lacked the influence on the GOP- controlled government that they had wanted.
BY STEVEN THOMMA
sthomma@krwashington.com

WASHINGTON -- The extraordinary effort by the federal government to try to save the life of Terri Schiavo is a testament to the political passion and influence of social conservatives.

Once the feeding tube was removed from Schiavo on Friday, outraged conservatives rose up to demand action from a government they helped put in office.

The response was immediate. In a matter of hours, Republicans brushed aside questions about intruding in traditionally local affairs, settled a squabble between the House and Senate, and summoned members back to Washington from their Easter recess for a remarkable Palm Sunday session to begin enacting legislation unheard of a week before.

Keith Appell, a veteran political strategist, worked with social conservative groups on the Schiavo case.

`MAJOR ROLE'

''They've played a major role,'' he said. ``There's been an enormous amount of pressure brought to bear on conservative members of Congress to get involved.''

Social conservatives -- represented by such groups as Focus on the Family and the Christian Coalition -- are a major part of the coalition that has twice elected President George Bush and kept Republicans in control of Congress. Yet until now they have not had as much influence in the Republican-controlled government as they would like.

They could not get approval of a constitutional amendment banning gay marriage. And they have not been able to overturn the 1973 Supreme Court decision legalizing abortions.

Still, Bush and many Republican members of Congress are eager to please them. Primarily, they tend to agree with social conservatives on cultural and moral issues. Politically, they are also mindful that Christian and social conservatives are an organized voting bloc.

Conservative Peggy Noonan warned Republicans controlling the federal government they risked a significant backlash if they failed to take action to save Schiavo. ''The Republican Party controls the Senate, the House and the White House. The Republicans are in charge. They have the power. If they can't save this woman's life, they will face a reckoning from a sizable portion of their own base. And they will of course deserve it,'' she wrote in The Wall Street Journal on Friday.

As Schiavo's feeding tube was removed Friday, some tried to turn the blame on liberals. Conservative radio talk show host Rush Limbaugh said, ``The problem we face in the country here, folks, is that the left and the courts have created a culture of death.''

The Christian Coalition blamed Democrats when Republicans could not agree on legislation Friday. The group said ''the party of death'' blocked a quick vote in the Senate. Others worked to keep the pressure on the Republicans in charge. Groups like the Concerned Women for America and Focus on the Family urged members to flood Congress with calls and e-mail.

Radio talk show host Sean Hannity got House Judiciary Committee Chairman Rep. James Sensenbrenner, R-Wis., to explain why he couldn't reach agreement with Senate Republicans and then pressured Sensenbrenner to negotiate on the air with Sen. Rick Santorum, R-Pa.

DISPUTES ARISE

By Sunday, there were disputes over the wisdom of planned legislation.

''The most disturbing feature about the Terri Schiavo case is the intrusion of political forces into the process of family decision-making at the most vulnerable of times in the life of a family and person,'' said Richard Payne, director of the Institute on Care at the End of Life at Duke University Divinity School in North Carolina.

Appell, the strategist, noted that Congress decided to act only grudgingly. ''Being conservative, there is a natural reluctance to get involved in something that is local,'' he said. ``But they stayed out of this as long they could.''

Also the partisan effects were not at all clear. Many Democrats were involved in the negotiations, including Sen. Harry Reid of Nevada, the minority leader, Sen. Tom Harkin of Iowa, and Rep. James Oberstar of Minnesota.

But there was no doubt that social conservatives made themselves heard in Washington. ''You've had a rare moment where the traditional Christian conservatives and the social conservatives have come together with people representing the disabled community,'' Sen. Mel Martinez, R-Fla., said on the Fox News Sunday program. ``Those two forces have coalesced to do something good.''

http://www.miami.com/mld/miamiherald/news/...on/11189416.htm

Medical Aspects of the Persistent Vegetative State— First of Two Parts
The Multi-Society Task Force on PVS


ABSTRACT

This consensus statement of the Multi-Society Task Force summarizes current knowledge of the medical aspects of the persistent vegetative state in adults and children.

The vegetative state is a clinical condition of complete unawareness of the self and the environment, accompanied by sleep-wake cycles, with either complete or partial preservation of hypothalamic and brain-stem autonomic functions. In addition, patients in a vegetative state show no evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile, or noxious stimuli; show no evidence of language comprehension or expression; have bowel and bladder incontinence; and have variably preserved cranial-nerve and spinal reflexes. We define persistent vegetative state as a vegetative state present one month after acute traumatic or nontraumatic brain injury or lasting for at least one month in patients with degenerative or metabolic disorders or developmental malformations.

The clinical course and outcome of a persistent vegetative state depend on its cause. Three categories of disorder can cause such a state: acute traumatic and nontraumatic brain injuries, degenerative and metabolic brain disorders, and severe congenital malformations of the nervous system.

Recovery of consciousness from a posttraumatic persistent vegetative state is unlikely after 12 months in adults and children. Recovery from a nontraumatic persistent vegetative state after three months is exceedingly rare in both adults and children. Patients with degenerative or metabolic disorders or congenital malformations who remain in a persistent vegetative state for several months are unlikely to recover consciousness. The life span of adults and children in such a state is substantially reduced. For most such patients, life expectancy ranges from 2 to 5 years; survival beyond 10 years is unusual.

The term "persistent vegetative state" was coined by Jennett and Plum in 1972 to describe the condition of patients with severe brain damage in whom coma has progressed to a state of wakefulness without detectable awareness1. Such patients have sleep-wake cycles but no ascertainable cerebral cortical function. Jennett and Plum thought that patients in a persistent vegetative state could be distinguished clinically from those with other conditions associated with prolonged unconsciousness.

In 1983 the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research accepted the definition of persistent vegetative state proposed by Jennett and Plum and defined unconsciousness as the inability "to experience the environment." In the commission's judgment, a persistent vegetative state is only one form of permanent unconsciousness2. The others include coma after a traumatic or nontraumatic injury, with death occurring before the recovery of sufficient brain-stem function to allow a stable vegetative state; the end stages of degenerative neurologic conditions, such as Alzheimer's or Creutzfeldt-Jakob disease; coma from untreatable mass lesions such as neoplasms or vascular masses; and anencephaly in infants.

Because of the diagnostic, prognostic, and therapeutic uncertainties concerning the persistent vegetative state, several professional medical organizations began a comprehensive examination of their standards of medical care for patients with this condition3,4,5,6,7. In 1989, the American Academy of Neurology published a position paper that defined persistent vegetative state, classified artificial nutrition and hydration as forms of medical treatment, and stated that patients or their surrogates could decide to terminate treatment and that there were no medical or ethical distinctions between withholding and withdrawing treatment8. A 1990 survey by the American Neurological Association found that 88 percent of responding members agreed with this document9. In a 1991 survey by the Child Neurology Society, 92 percent of respondents agreed with the position paper as it related to adults, but only 72 percent thought that it was applicable to infants and children10. In addition, 75 percent of the respondents to this survey indicated that they would not withdraw nutrition and hydration from children in a persistent vegetative state.

In 1990, the Council on Scientific Affairs and the Council on Ethical and Judicial Affairs of the American Medical Association issued a report that provided clinical criteria for the diagnosis of a persistent vegetative state and discussed ethical and legal implications of decisions to withhold or withdraw life-prolonging medical treatment -- matters that were receiving widespread attention at the time11,12,13,14,15. In 1991, the United Kingdom's Institute of Medical Ethics Working Party on the Ethics of Prolonging Life and Assisting Death published a position statement indicating that a diagnosis of persistent vegetative state could usually be made with confidence three months after the acute insult but that in young children, the extent of damage and period of recovery were less predictable16. More recently, the British Medical Association's Medical Ethics Committee and the American Neurological Association have published position papers that define criteria for the clinical diagnosis of a persistent vegetative state and address several of the ethical issues concerning the care of patients in such a state17,18.

Because of the acceptance of recent consensus statements concerning guidelines for determining brain death in children19 and the medical aspects of anencephaly in infants,20 the Multi-Society Task Force on PVS was established in 1991 and charged with the creation of this document. Two representatives were appointed from each of the five societies, and an advisory panel of consultants was selected from the related fields of medicine, ethics, and law. The document was approved by the executive committee of each society.

Data reviewed by members of the task force were obtained from several sources, including a comprehensive literature review of all Medline references to the terms "vegetative state" and "persistent vegetative state," a "request for information" published in medical journals supported by the five sponsoring societies, a review of stories in the popular media concerning unexpected recovery from prolonged coma, and data from the National Institute of Neurological Disorders and Stroke Traumatic Coma Data Bank.

This statement by the task force summarizes the medical facts about the persistent vegetative state; it does not address associated ethical, legal, or other issues. The statement is divided into two parts. The first defines persistent vegetative state and related terms and conditions and discusses the epidemiology, causes, and pathological features, as well as ancillary diagnostic studies. The second part addresses the prognosis for recovery and long-term survival of patients in a persistent vegetative state and discusses issues related to pain and suffering and treatment.

Definition and Clinical Aspects

The vegetative state is a clinical condition of complete unawareness of the self and the environment, accompanied by sleep-wake cycles with either complete or partial preservation of hypothalamic and brain-stem autonomic functions. The condition may be transient, marking a stage in the recovery from severe acute or chronic brain damage, or permanent, as a consequence of the failure to recover from such injuries. The vegetative state can also occur as a result of the relentless progression of degenerative or metabolic neurologic diseases or from developmental malformations of the nervous system.

The vegetative state can be diagnosed according to the following criteria: (1) no evidence of awareness of self or environment and an inability to interact with others; (2) no evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile, or noxious stimuli; (3) no evidence of language comprehension or expression; (4) intermittent wakefulness manifested by the presence of sleep-wake cycles; (5) sufficiently preserved hypothalamic and brain-stem autonomic functions to permit survival with medical and nursing care; (6) bowel and bladder incontinence; and (7) variably preserved cranial-nerve reflexes (pupillary, oculocephalic, corneal, vestibulo-ocular, and gag) and spinal reflexes.

The distinguishing feature of the vegetative state is an irregular but cyclic state of circadian sleeping and waking unaccompanied by any behaviorally detectable expression of self-awareness, specific recognition of external stimuli, or consistent evidence of attention or intention or learned responses. Patients in a vegetative state are usually not immobile. They may move the trunk or limbs in meaningless ways. They may occasionally smile, and a few may even shed tears; some utter grunts or, on rare occasions, moan or scream. Some patients have acquired, nonhabitual startle myoclonus. Such activities are inconsistent, nonpurposeful, and coordinated only when they are expressed as part of a subcortical, instinctively patterned, reflexive response to external stimulation. These motor activities may misleadingly suggest purposeful movements, yet these responses have been observed in patients in whom careful study has disclosed no evidence of psychological awareness or the capacity to engage in learned behavior.

As a result of the relative preservation of brain-stem functions, most patients in a vegetative state retain good to normal reflexive regulation of vision and eye movement. Some patients have unequal or irregular pupils or limited responses to vestibulo-ocular stimulation. A few patients may have signs of mild internuclear ophthalmoplegia or other oculomotor abnormalities related to the brain stem. Occasionally, one or both third nerves are paralyzed.

Sustained visual pursuit is lacking in most patients in a vegetative state. They do not fixate on a visual target, track moving objects with their eyes, or withdraw from threatening gestures. When patients undergo a transition from the vegetative state to a state of awareness, one of the first and most readily observable signs of this transition is the appearance of sustained visual pursuit. However, patients in a vegetative state often have inconsistent primitive auditory or visual orienting reflexes, characterized by a turning of the head and eyes toward peripheral sounds or movements. In rare cases, patients who have no other evidence of consciousness over a period of months to years have some degree of briefly sustained visual pursuit or fixation, which is believed to be mediated through brain-stem structures. Nevertheless, one should be extremely cautious in making a diagnosis of the vegetative state when there is any degree of sustained visual pursuit, consistent and reproducible visual fixation, or response to threatening gestures.

The capacity for survival in a persistent vegetative state requires preservation of hypothalamic and brain-stem autonomic functions. Most patients who survive for a long time maintain normal body temperature, the ability to breathe spontaneously, and a functioning cardiovascular system. The prognosis is worse if there are hypothalamic disturbances producing central fever, excess sweating, disturbances in salt and water metabolism, and refractory pulmonary problems. In most patients, the gag, cough, sucking, and swallowing reflexes are preserved. Except for a lack of coordination in chewing and swallowing, gastrointestinal function remains nearly normal. As the prolonged survival of some patients in a persistent vegetative state suggests, autonomic function is sufficient to maintain long-term internal regulation so long as external needs receive constant attention.

Related Terms and Conditions

Unconsciousness, Coma, and the Vegetative State

The term "consciousness" was defined by William James in 1890 as awareness of the self and the environment. Consciousness has two dimensions: wakefulness and awareness. Normal consciousness requires arousal, an independent, autonomic-vegetative brain function subserved by ascending stimuli from the pontine tegmentum, posterior hypothalamus, and thalamus that activate wakefulness. Awareness is subserved by cerebral cortical neurons and their reciprocal projections to and from the major subcortical nuclei. Awareness requires wakefulness, but wakefulness can be present without awareness.

Unconsciousness implies global or total unawareness and is characteristic of both coma and the vegetative state. Patients in a coma are unconscious because they lack both wakefulness and awareness. Patients in a vegetative state are unconscious because, although they are wakeful, they lack awareness. In this report we use the terms awareness and consciousness interchangeably.

Persistent as Compared with Permanent Vegetative States

As originally defined by Jennett and Plum in 1972, the term "persistent," when applied to the vegetative state, meant sustained over time; "permanent" meant irreversible1. Notwithstanding Jennett and Plum's precise use of language, confusion has arisen over the exact meaning of the term "persistent." The adjective "persistent" refers only to a condition of past and continuing disability with an uncertain future, whereas "permanent" implies irreversibility. Persistent vegetative state is a diagnosis; permanent vegetative state is a prognosis.

A wakeful unconscious state that lasts longer than a few weeks is referred to as a persistent vegetative state. We define such a state operationally as a vegetative state present one month after an acute traumatic or nontraumatic brain injury or a vegetative state of at least one month's duration in patients with degenerative or metabolic disorders or developmental malformations. A permanent vegetative state, on the other hand, means an irreversible state, which like all clinical diagnoses in medicine, is based on probabilities, not absolutes. A patient in a persistent vegetative state becomes permanently vegetative when the diagnosis of irreversibility can be established with a high degree of clinical certainty -- that is, when the chance that the patient will regain consciousness is exceedingly small. We believe there are sufficient data on the prognosis for neurologic recovery to allow us to distinguish between persistent and permanent vegetative states. These data, in conjunction with other relevant factors in an individual patient, can be used by a physician to determine when the persistent vegetative state becomes permanent -- that is, when a physician can tell the patient's family or surrogate with a high degree of medical certainty that there is no further hope for recovery of consciousness or that, if consciousness were recovered, the patient would be left severely disabled.

Diagnostic Factors and the Limits of Certainty

By definition, patients in a persistent vegetative state are unaware of themselves or their environment. They are noncognitive, nonsentient, and incapable of conscious experience. There is, however, a biologic limitation to the certainty of this definition, since we can only infer the presence or absence of conscious experience in another person21. A false positive diagnosis of a persistent vegetative state could occur if it was concluded that a person lacked awareness when, in fact, he or she was aware. Such an error might occur if a patient in a locked-in state (i.e., conscious yet unable to communicate because of severe paralysis) was wrongly judged to be unaware. Thus, it is theoretically possible that a patient who appears to be in a persistent vegetative state retains awareness but shows no evidence of it. In the practice of neurology, this possibility is sufficiently rare that it does not interfere with a clinical diagnosis carefully established by experts.

Several individual signs of unconsciousness, as well as a small number of laboratory tests, are very closely correlated with the diagnosis of the condition of unconsciousness that characterizes a persistent vegetative state. At present, three lines of evidence based on careful clinical and laboratory studies support the conclusion that patients in a persistent vegetative state are unaware of themselves or their environment8,11,21. First, motor or eye movements and facial expressions in response to various stimuli occur in stereotyped patterns that indicate reflexive responses integrated at deep subcortical levels rather than learned voluntary acts. The presence of these responses is consistent with complete unawareness. Second, positron-emission tomographic studies of regional cerebral glucose metabolism show levels far lower than those in patients who are aware or in a locked-in state. These low metabolic rates are comparable to those reported during deep general anesthesia in normal subjects whom all would agree are unaware and insensate22. Finally, all available neuropathological examinations of the brains of patients with a clinical diagnosis of a persistent vegetative state show lesions so severe and diffuse that awareness would have been highly improbable, given our biologic understanding of how the anatomy and physiology of the brain contribute to consciousness23,24.

An accurate diagnosis is critical. Errors in diagnosis have occurred because of confusion about the terminology used to describe patients in this condition, the inexperience of the examiner, or an insufficient period of observation25. Physicians caring for such patients should be aware of these potential problems and be as precise and careful as possible when applying the suggested clinical criteria26.

Related Conditions

Other conditions of severe neurologic disability or altered consciousness include coma, brain death, the locked-in syndrome, and dementia (Table 1).

View this table:
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Table 1. Characteristics of the Persistent Vegetative State and Related Conditions.


Coma is deep, sustained pathologic unconsciousness that results from dysfunction of the ascending reticular activating system in either the brain stem or both cerebral hemispheres. The eyes remain closed, and the patient cannot be aroused. To be clearly distinguished from syncope, concussion, or other states of transient unconsciousness, coma must persist for at least an hour.

Brain death is the permanent absence of all brain functions, including those of the brain stem. Brain-dead patients are irreversibly comatose and apneic and have lost all brain-stem reflexes and cranial-nerve functions. The standard clinical criteria for the diagnosis of brain death in adults, children, and newborn infants are outlined elsewhere14,19,27,28,29,30.

The locked-in syndrome refers to a state in which consciousness and cognition are retained but movement and communication are impossible because of severe paralysis of the voluntary motor system28,31. This condition may result from abnormalities in the descending corticospinal and corticobulbar pathways at or below the pons. In such cases, breathing is possible. The locked-in syndrome can also be associated with diseases of the peripheral motor nerves or paralysis produced by the administration of neuromuscular blocking agents. Patients with this syndrome can usually establish limited communication through eye-movement signals. Diagnosis of the locked-in syndrome is established by clinical examination. Brain imaging may show isolated ventral pontine infarction, and nerve-conduction studies may demonstrate severe peripheral neuropathy. Positron-emission tomographic scans have shown higher metabolic levels in the brains of patients in the locked-in state than in patients in a persistent vegetative state. Electroencephalograms, evoked responses, and single-photon-emission computed tomograms do not distinguish reliably between the locked-in and vegetative states.

Dementia is a condition of progressive, multidimensional loss of cognitive functions in which arousal mechanisms are usually normal. Advanced dementia can progress until patients lose their self-awareness and all evidence of learned behavior. At this point, such patients are in a vegetative state.

Three other conditions deserve mention. Akinetic mutism is a rare syndrome characterized by pathologically slowed or nearly absent bodily movement and loss of speech28. Wakefulness and self-awareness may be preserved, but the level of mental function is reduced. The condition characteristically accompanies gradually developing or subacute bilateral damage to the paramedian mesencephalon, basal diencephalon, or inferior frontal lobes. Neocortical death is a term used by some authors to refer to a persistent vegetative state, but in addition to the characteristics of a persistent vegetative state, neocortical death is marked by an absence or substantial slowing of electrocortical activity on electroencephalography. Others equate neocortical death with the ostensible death of all neurons of the cerebral cortex. It is not clear, therefore, whether this term denotes a clinical syndrome or its electrical, pathologic, or anatomical features. Apallic syndrome is an archaic term for a condition that is now considered equivalent to a persistent vegetative state32. The terms "neocortical death" and "apallic state" have limited usefulness and should be abandoned, because they do not represent distinct clinical entities.

Epidemiology

The prevalence of persistent vegetative state is not known because of the lack of accepted diagnostic criteria and the fact that, until recently, neither the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), nor most health agencies included persistent vegetative state as a codable diagnosis. According to estimates, however, in the United States there are 10,000 to 25,000 adults and 4,000 to 10,000 children in a persistent vegetative state6,10,11,15,16,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47.

Causes and Clinical Course

The clinical course of a persistent vegetative state depends on the particular underlying disease process.

Acute Traumatic and Nontraumatic Injuries

The most common acute causes of the vegetative state in adults and children are head trauma and hypoxic-ischemic encephalopathy (Table 2). The clinical course after the acute insult usually begins with coma (with eyes closed) for several days to weeks, during which time the acute illness stabilizes and the stunned but ultimately viable brain stem and lower diencephalon resume function43,44,45. By this time, most patients are able to breathe spontaneously and no longer require ventilatory assistance. After the interval of coma, spontaneous opening of the eyes, random eye movements, blinking, and limb movements occur, along with sleep-wake cycles. In a few patients, the vegetative state occurs immediately after the insult, without an initial period of coma.

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Table 2. Causes of the Persistent Vegetative State in Adults and Children.


A persistent vegetative state develops in approximately 1 to 14 percent of patients in prolonged traumatic coma and in 12 percent of those in prolonged nontraumatic coma46,47,48,49,50,51. Although numerous studies have examined a wide variety of clinical and laboratory variables, no well-established criteria applied during the period of coma can, with certainty, predict a vegetative outcome52,53,54. Some evidence suggests a direct correlation between a post-traumatic vegetative outcome and the presence of ventilatory dysfunction, decorticate posturing, and extraneural trauma soon after the insult55. Other variables that are correlated with a poor outcome include an advanced age, pupillary abnormalities, and a low score on a test of motor responses47. In patients with nontraumatic coma, impairment of eye opening, the presence of abnormal oculocephalic or motor responses, and the inability to obey commands at two weeks are all correlated with a vegetative outcome56.

Degenerative and Metabolic Disorders

Many degenerative and metabolic nervous system disorders in adults and children inevitably progress to an irreversible vegetative state. The early stages of such disorders are marked by progressive impairment of intellect, memory, language, motor skills, and social behavior, yet many patients retain some degree of awareness of themselves and their environment. In later stages, awareness disappears, marking the start of a vegetative state.

In patients with degenerative diseases, a persistent vegetative state usually evolves over a period of several months or years57. Those who remain in a vegetative state may die of a superimposed infectious illness. Those who survive such an illness remain in a vegetative state or go into a coma. Patients with degenerative diseases who have severe impairment but retain some degree of awareness may lapse briefly into a vegetative state from the effects of medication, infection, superimposed medical or surgical illnesses, seizure activity, or decreased fluid and nutritional intake57. The possibility of such a temporary metabolic or toxic encephalopathy must be eliminated before establishing that the patient is in a persistent vegetative state21.

Developmental Malformations

Severe congenital malformations of the nervous system in infants and children may prevent the development of awareness or cognition. Among the malformations associated with the developmental vegetative state are anencephaly and hydranencephaly (Table 2). Diagnosis of the vegetative state in infants and children poses several problems related to the immaturity of the developing brain and the ongoing influences of development on the potential for reorganization of structure and function58.

On the basis of our understanding of development, the diagnosis of the vegetative state may be difficult to make in infants younger than three months, except in the case of infants with anencephaly. Newborns and young infants have a limited ability to show higher cognitive functions before this age59,60. Although they are capable of a variety of social responses, including visual and auditory orientation, cuddling, the ability to be consoled, and self-quieting behavior, these responses may be tenuous, inconsistent, and unsustained until three months of age61,62. The concept of the vegetative state cannot be applied to preterm infants because of developmental immaturity and, to a lesser extent, the lack of consistently recognizable sleep-wake cycles63,64.

Recognition of the vegetative state in infants and young children also depends on the ability to distinguish between voluntary and involuntary responses65,66. Differentiation of voluntary from involuntary responses may be unreliable until approximately three months of age. Voluntary behavior that can be elicited includes a consistent and sustained response of turning to or following visual or auditory stimuli, a growing awareness of social stimuli, cuddling in response to interactions experienced as comforting, and a preference for a specific behavior when several choices are presented. Involuntary behavior includes blinking or wandering, nonpurposeful eye movements; nonspecific sounds and grimace-like expressions in reaction to noxious stimuli; and primitive reflexes, including grasp, postural, startle, and alerting responses.

Some newborn infants with severe developmental malformations, such as hydranencephaly, have a minimal cerebral cortex or none. Such infants usually remain in a developmental vegetative state. Because some brain tissue is developing, these infants may have a limited awareness of their environment and minimal purposeful motor activity within the first several months of life67,68. However, only limited improvement has been reported in such children. Those with less extensive malformations (such as certain types of holoprosencephaly or lissencephaly) may appear to be in a vegetative state as infants but eventually show some evidence of awareness and responsiveness. Such infants generally continue to have severe disabilities. There are few reports describing the clinical course of such patients, but some degree of consciousness may emerge.

Pathologic Features

The anatomical basis for a persistent vegetative state differs somewhat from case to case, for several reasons. The interval between brain injury and death affects the nature and severity of pathologic changes. Patients in a vegetative state who die early of medical complications are unlikely to undergo neuropathologic changes that would be sufficient to cause chronic unconsciousness in long-term survivors. Furthermore, in patients with chronic neurologic conditions, other complicating factors, such as severe atherosclerotic disease, may independently injure the brain. In such patients, it may be difficult to determine at autopsy exactly which neuropathologic changes accompanied the initial failure to recover consciousness.

Allowing for the above limitations, two major patterns have characterized most detailed reports on the neuropathology of a persistent vegetative state due to acute traumatic or nontraumatic brain injury. We are not aware of any systematic investigation of the neuropathologic characteristics of patients in whom a persistent vegetative state was due to degenerative, metabolic, or developmental disorders.

Diffuse Laminar Cortical Necrosis

This pattern follows acute, global hypoxia and ischemia. The principal finding is extensive multifocal or diffuse laminar cortical necrosis with almost invariable involvement of the hippocampus. These abnormalities may be accompanied by scattered small areas of infarction or neuronal loss in the deep forebrain nuclei, hypothalamus, or brain stem23,69. Relatively selective thalamic necrosis may also follow acute global ischemia, although the specific anatomical boundaries for this uncommon pattern have not been well described70 (and see the report, elsewhere in this issue of the Journal, on studies of the brain of Karen Ann Quinlan)71.

Diffuse Axonal Injury

This abnormality is usually due to a shearing injury after acute trauma. An extensive subcortical axonal injury virtually isolates the cortex from other parts of the brain41. Sometimes a diffuse axonal injury is accompanied by small primary brain-stem injuries, as well as secondary damage to the brain stem that results from transtentorial herniation soon after the injury72,73,74. In patients with an axonal injury complicated by acute circulatory or respiratory failure, diffuse laminar necrosis may also be present.

Only a few pathological reports on the persistent vegetative state describe severe abnormalities of the brain stem. Those that do mainly concern patients in whom severe paramedian mesencephalic damage developed secondary to acute downward or upward transtentorial herniation during the early stage of illness. Lesions confined to the brain stem seldom, if ever, cause long-term unconsciousness, although there has been a report of four patients with severe secondary brain-stem damage in whom coma persisted for as long as six weeks before death75. We have found no well-described autopsy studies of patients in a persistent vegetative state who had severe damage confined to the hypothalamus.

Ancillary Diagnostic Studies

Neurodiagnostic tests alone can neither confirm the diagnosis of a vegetative state nor predict the potential for recovery of awareness53. However, when used in conjunction with a clinical evaluation, laboratory tests may provide useful supportive information.

Electroencephalography

In most patients in a persistent vegetative state, electroencephalograms (EEGs) show diffuse generalized polymorphic delta or theta activity76,77. This pattern is usually not attenuated by sensory stimulation, except occasionally by noxious stimulation78,79. In most patients, the transition from wakefulness to sleep is accompanied by some desynchronization of the background activity80. In some patients, very-low-voltage EEG activity is all that can be detected. In others, persistent alpha activity is the most remarkable feature. In approximately 10 percent of patients in a vegetative state, the EEG is nearly normal late in the course of illness but without evidence of vision-induced alpha blocking77. There have been occasional reports of isoelectric EEGs in patients in a vegetative state37,58,76,81,82. Most investigators have not reported this finding, however, nor has it been confirmed by reviews of the initial EEG records by other investigators. Typical epileptiform activity is unusual in patients in a persistent vegetative state, as is seizure activity.

The transition from coma to the vegetative state is not accompanied by notable changes in the EEG. However, clinical recovery from the vegetative state may be paralleled by diminished delta and theta activity and the reappearance of a reactive alpha rhythm76,78. This phenomenon is inconsistent and does not predict future recovery37,78.

Compressed spectral analysis of the EEG has been used to study patients with prolonged unconsciousness. Preliminary data suggest that patients with changeable or desynchronized spectrograms and abnormal evoked responses remain in a vegetative state83.

Infants and children have abnormalities on the EEG that are similar to those reported in adults, although in infants and children the EEG activity may be somewhat more discontinuous and of lower voltage66,84.

Evoked-Response Studies

Evoked-response testing is useful statistically, but not always clinically, in trying to assess the risk of a vegetative outcome in patients who are in a coma as a result of an acute neurologic injury85. Somatosensory evoked responses are the most sensitive and reliable markers in both adults and children86,87,88,89,90,91. The bilateral absence of such responses one week after the insult is highly predictive of failure to regain consciousness (i.e., of death or survival in a vegetative state). Patients without somatosensory evoked responses, however, may recover at least minimal cognitive activity, especially if the coma is traumatic rather than anoxic92,93. In contrast, patients with normal somatosensory responses may enter a vegetative state and remain in it88. Prolongation of the central conduction time of an evoked response is a less reliable finding than the absence of a response in predicting a poor outcome78,94,95.

Other evoked potentials, such as the brain-stem auditory evoked response, are of limited value. Numerous studies have shown that the brain-stem auditory evoked response is preserved when the somatosensory evoked response is absent, and the outcome is either survival in a vegetative state or death78,86,87. Multimodal evoked-response testing may be used to determine the outcome, but whether the results are of greater predictive value than the somatosensory evoked response alone remains uncertain. The presence of P300 evoked responses is not necessarily correlated with the outcome96.

Neuroimaging

Computed tomographic or magnetic resonance imaging in patients in a persistent vegetative state often reveals diffuse or multifocal cerebral disease involving the gray and white matter. Although there are no established correlations between the results of neuroimaging studies and the development of the vegetative state or the potential for recovery, most patients who do not recover consciousness have abnormal scans49,57,67,97,98. When studied during the first several months after a traumatic or nontraumatic brain injury, patients in a persistent vegetative state are more likely to recover consciousness yet remain severely disabled if serial neuroimaging scans are normal than if they are abnormal. Serial scanning usually documents progressive brain atrophy, which reduces the likelihood of neurologic recovery.

Cerebral Metabolic Studies

A substantial reduction in the cerebral metabolic rate has been reported in approximately 20 adults in a persistent vegetative state22,99,100,101. A 40 to 60 percent reduction in global cerebral oxidative metabolism was observed in six patients in a vegetative state after trauma or diffuse anoxia99. Positron-emission tomographic (PET) studies showed a 50 to 60 percent decrease in the glucose metabolic rate in the cerebral cortex, basal ganglia, and cerebellum in seven adults; no overlap in metabolic impairment was noted when these patients were compared with three patients who had the locked-in syndrome22. Using the same method, other investigators found a 50 percent reduction in cerebral glucose metabolism in patients in a vegetative state, as compared with a 25 percent reduction in metabolic activity in patients who had regained consciousness after anoxic cerebral injuries100. The parieto-occipital and mesiofrontal regions had the most consistent reduction in metabolic activity, whereas Levy et al. reported consistently low metabolic rates in all cortical areas22.

Although these studies demonstrate substantial reductions in the metabolism of glucose, there is not yet sufficient information to warrant the use of PET scanning to determine prognosis. Likewise, the lack of experience with cerebral metabolic studies in infants and children in a vegetative state precludes the use of such studies to assess prognosis in infants and children. Normal cerebral metabolic activity in this age group is substantially lower than that reported in adults102. Questions have been raised about the validity of cerebral metabolic studies to determine whether patients in a vegetative state are conscious or can experience pain and suffering. These questions remain unanswered and require further systematic investigation. Whether patients are conscious and have the potential to experience pain and suffering can best be assessed by careful and repeated neurologic examinations.

Cerebral Blood Flow

Measurement of cerebral blood flow immediately after an acute neurologic injury does not predict a vegetative outcome in either adults or children84,103,104,105. Once a vegetative state exists, however, cerebral blood flow is likely to be reduced. An early study using xenon-133 in four patients in a vegetative state found that cerebral blood flow was 10 to 20 percent of normal106. PET studies in seven patients in a persistent vegetative state who were studied 3 weeks to 68 months after acute injury showed a 50 percent decrease in cerebral blood flow22. More recent radionuclide-imaging studies using HM-PAO-single-photon-emission computed tomography showed a global reduction in cerebral blood flow 2 to 12 months after a head injury, as well as 3 years later107. Some studies, however, have found normal cerebral blood flow in patients in a persistent vegetative state108.

We are indebted to the following people who served as consultants to the task force and reviewed this document: George Annas, J.D., Richard Beresford, M.D., Elizabeth M. Boggs, Ph.D., Reinder Braakman, M.D., Arthur Caplan, Ph.D., John J. Caronna, M.D., Allen Childs, M.D., Peggy C. Ferry, M.D., Norman Fost, M.D., M.P.H., John Freeman, M.D., Robert G. Grossman, M.D., Deborah G. Hirtz, M.D., Bryan Jennett, M.D., Howard H. Kaufman, M.D., Arthur F. Kohrman, M.D., Robert L. Kriel, M.D., Nicholas J. Lenn, M.D., David E. Levy, M.D., Thomas G. Luerssen, M.D., Joanne Lynn, M.D., Lawrence F. Marshall, M.D., Robert L. McLaurin, M.D., Michael P. McQuillen, M.D., Jan M. Minderhoud, M.D., Patricia A. Murphy, R.N., Allan H. Ropper, M.D., Jay Rosenberg, M.D., Leon Sazbon, M.D., Alan Shewmon, M.D., David A. Stumpf, M.D., Francois Tasseau, M.D., H. Rutherford Turnbull III, Kenneth A. Vatz, M.D., and Deborah Webb, R.N.


Source Information

This statement has been approved by the American Academy of Neurology, Child Neurology Society, American Neurological Association, American Association of Neurological Surgeons, and American Academy of Pediatrics. The results of the literature search, as well as correspondence and other documents generated by the task force, are available through the American Academy of Neurology in Minneapolis.The members of the task force are Stephen Ashwal, M.D., cochairman (Loma Linda University School of Medicine, Loma Linda, Calif.), Child Neurology Society; Ronald Cranford, M.D., cochairman (Hennepin County Medical Center, Minneapolis), American Academy of Neurology; James L. Bernat, M.D. (Dartmouth Medical School, Hanover, N.H.), American Academy of Neurology; Gastone Celesia, M.D. (Loyola University Stritch School of Medicine, Maywood, Ill.), American Neurological Association; David Coulter, M.D. (Boston University School of Medicine, Boston), Child Neurology Society; Howard Eisenberg, M.D. (Maryland Institute of Emergency Medical Services Systems, Baltimore), American Association of Neurological Surgeons; Edwin Myer, M.D. (Medical College of Virginia, Richmond), American Academy of Pediatrics; Fred Plum, M.D. (New York Hospital-Cornell University Medical College, New York), American Neurological Association; Marion Walker, M.D. (Primary Children's Hospital and Medical Center, Salt Lake City), American Academy of Pediatrics; Clark Watts, M.D. (University of Texas Health Sciences Center, San Antonio), American Association of Neurological Surgeons; and Teresa Rogstad, project administrator, American Academy of Neurology.

Address reprint requests to the Multi-Society Task Force on PVS, American Academy of Neurology, 2221 University Ave. S.E., Minneapolis, MN 55414.

References

1. Jennett B, Plum F. Persistent vegetative state after brain damage: a syndrome in search of a name. Lancet 1972;1:734-737.[Medline]
2. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to forego life-sustaining treatment: a report on the ethical, medical, and legal issues in treatment decisions. Washington, D.C.: Government Printing Office, 1983:171-92.
3. Campbell AGM. Children in a persistent vegetative state. BMJ 1984;289:1022-1023.[Medline]
4. Feinberg WM, Ferry PC. A fate worse than death: the persistent vegetative state in childhood. Am J Dis Child 1984;138:128-130.[CrossRef]
5. Cranford RE. The persistent vegetative state: the medical reality (getting the facts straight). Hastings Cent Rep 1988;18:27-32.
6. Spudis EV. The persistent vegetative state -- 1990. J Neurol Sci 1991;102:128-136.[CrossRef][Medline]
7. Jennett B, Dyer C. Persistent vegetative state and the right to die: the United States and Britain. BMJ 1991;302:1256-1258.[Medline]
8. Position of the American Academy of Neurology on certain aspects of the care and management of the persistent vegetative state patient: adopted by the Executive Board, American Academy of Neurology, April 21, 1988, Cincinnati, Ohio. Neurology 1989;39:125-126.[Medline]
9. Daroff RB. The American Neurological Association survey results on PVS. Presented at the 115th annual meeting of the American Neurological Association, Atlanta, October 14-17, 1990.
10. Ashwal S, Bale JF Jr, Coulter DL, et al. The persistent vegetative state in children: report of the Child Neurology Society Ethics Committee. Ann Neurol 1992;32:570-576.[Medline]
11. Council on Scientific Affairs and Council on Ethical and Judicial Affairs. Persistent vegetative state and the decision to withdraw or withhold life support. JAMA 1990;263:426-430.[Abstract]
12. Cantor NL. The permanently unconscious patient, non-feeding and euthanasia. Am J Law Med 1989;15:381-437.[Medline]
13. Banja JD. Ethical aspects of treatment for coma and the persistent vegetative state. Phys Med Rehabil 1990;4:579-92.
14. Bernat JL. Ethical issues in neurology. In: Joynt RJ, ed. Clinical neurology. Vol. 1. Philadelphia: J.B. Lippincott, 1991:2-57.
15. Tasseau F, Boucand MH, LeGall JR, Verspieren P. Etats vegetatifs chroniques: repercussions humaines aspects medicaux juridiques et ethiques. Rennes, France: Editions Ecole Nationale de La Sante Publique, 1991.
16. Institute of Medical Ethics Working Party on the Ethics of Prolonging Life and Assisting Death. Withdrawal of life-support from patients in a persistent vegetative state. Lancet 1991;337:96-98.[CrossRef][Medline]
17. Dyer C. BMA examines the persistent vegetative state. BMJ 1992;305:853-854.
18. ANA Committee on Ethical Affairs. Persistent vegetative state: report of the American Neurological Association Committee on Ethical Affairs. Ann Neurol 1993;33:386-390.[Medline]
19. American Academy of Pediatrics Task Force on Brain Death in Children. Report of a special Task Force: guidelines for the determination of brain death in children. Pediatrics 1987;80:298-300.[Medline]
20. The Medical Task Force on Anencephaly. The infant with anencephaly. N Engl J Med 1990;322:669-674.[Medline]
21. Bernat JL. The boundaries of the persistent vegetative state. J Clin Ethics 1992;3:176-180.[Medline]
22. Levy DE, Sidtis JJ, Rottenberg DA, et al. Differences in cerebral blood flow and glucose utilization in vegetative versus locked-in patients. Ann Neurol 1987;22:673-682.[Medline]
23. Dougherty JH Jr, Rawlinson DG, Levy DE, Plum F. Hypoxic-ischemic brain injury and the vegetative state: clinical and neuropathologic correlation. Neurology 1981;31:991-997.[Abstract]
24. Graham DI, McLellan D, Adams JH, Doyle D, Kerr A, Murray LS. The neuropathology of the vegetative state and severe disability after non-missile head injury. Acta Neurochir Suppl (Wien) 1983;32:65-67.[Medline]
25. Childs NL, Mercer WN, Childs HW. Accuracy of diagnosis of persistent vegetative state. Neurology 1993;43:1465-1467.[Abstract]
26. Celesia GG. Persistent vegetative state. Neurology 1993;43:1457-1458.[Medline]
27. Guidelines for the determination of death: report of the medical consultants on the diagnosis of death to the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. JAMA 1981;246:2184-2186.[CrossRef][Medline]
28. Plum F, Posner JB. The diagnosis of stupor and coma. 3rd ed. Philadelphia: F.A. Davis, 1980.
29. Cranford RE. Neurologic syndromes and prolonged survival: when can artificial nutrition and hydration be forgone? Law Med Health Care 1991;19:13-22.[Medline]
30. Ashwal S, Schneider S. Brain death in the newborn. Pediatrics 1989;84:429-437.[Abstract]
31. Position statement: certain aspects of the care and management of profoundly and irreversibly paralyzed patients with retained consciousness and cognition: report of the Ethics and Humanities Subcommittee of the American Academy of Neurology. Neurology 1993;43:222-223.[Medline]
32. Dalle OG, Gerstenbrand F, Lucking CF, Peters G, Peters UH. The apallic syndrome. Berlin, Germany: Springer-Verlag, 1977.
33. Minderhoud JM, Braakman R. Het vegeterende bestaan. Ned Tijdschr Geneeskd 1985;129:2385-2388.[Medline]
34. Hellema H. "Life termination" in The Netherlands. BMJ 1991;302:984-985.[Medline]
35. Sazbon L, Costeff H, Groswasser Z. Epidemiological findings in traumatic post-comatose unawareness. Brain Inj 1992;6:359-362.[Medline]
36. Brule JF, Danze F, Vallee D. Etat vegetatif: problemes therapeutiques. Rev Fr Dommage Corpor 1988;14:191-5.
37. Higashi K, Sakata Y, Hatano M, et al. Epidemiological studies on patients with a persistent vegetative state. J Neurol Neurosurg Psychiatry 1977;40:876-885.[Medline]
38. Sato S, Imamura H, Ueki K, et al. Epidemiological survey of vegetative state patients in the Tohoku District, Japan -- special reference to the follow-up study after one year. Neurol Med Chir (Tokyo) 1979;19:327-33. (In Japanese).(86970)
39. Tresch DD, Sims FH, Duthie EH, Goldstein MD, Lane PS. Clinical characteristics of patients in the persistent vegetative state. Arch Intern Med 1991;151:930-932.[Abstract]
40. Ashwal S, Eyman RK, Call TL. Life expectancy of children in a persistent vegetative state. Pediatr Neurol 1994;10:27-33.[CrossRef][Medline]
41. Jennett B. Vegetative state: causes, management, ethical dilemmas. Curr Anaesth Crit Care 1991;2:57-61.
42. Higashi K, Hatano M, Abiko S, et al. Five-year follow-up study of patients with persistent vegetative state. J Neurol Neurosurg Psychiatry 1981;44:552-554.[Medline]
43. Levy DE, Knill-Jones RP, Plum F. The vegetative state and its prognosis following nontraumatic coma. Ann N Y Acad Sci 1978;315:293-306.[Medline]
44. Gillies JD, Seshia SS. Vegetative state following coma in childhood: evolution and outcome. Dev Med Child Neurol 1980;22:642-648.[Medline]
45. Bricolo A, Turazzi S, Feriotti G. Prolonged posttraumatic unconsciousness: therapeutic assets and liabilities. J Neurosurg 1980;52:625-634.[Medline]
46. Levy DE, Bates D, Caronna JJ, et al. Prognosis in nontraumatic coma. Ann Intern Med 1981;94:293-301.[Medline]
47. Braakman R, Jennett WB, Minderhoud JM. Prognosis of the posttraumatic vegetative state. Acta Neurochir (Wien) 1988;95:49-52.[Medline]
48. Berrol S. Persistent vegetative state. Phys Med Rehabil 1990;4:559-67.
49. Levin HS, Saydjari C, Eisenberg HM, et al. Vegetative state after closed-head injury: a Traumatic Coma Data Bank Report. Arch Neurol 1991;48:580-585.[Abstract]
50. Sazbon L, Groswasser Z. Outcome in 134 patients with prolonged posttraumatic unawareness: part 1: parameters determining late recovery of consciousness. J Neurosurg 1990;72:75-80.[Medline]
51. Sazbon L, Zagreba F, Ronen J, Solzi P, Costeff H. Course and outcome of patients in vegetative state of nontraumatic aetiology. J Neurol Neurosurg Psychiatry 1993;56:407-409.[Abstract]
52. Bates D. Defining prognosis in medical coma. J Neurol Neurosurg Psychiatry 1991;54:569-571.[Medline]
53. Shewmon DA, De Giorgio CM. Early prognosis in anoxic coma: reliability and rationale. Neurol Clin 1989;7:823-843.[Medline]
54. Childs A. The PLEXUS parameters: results of the `PLEXUS conference.' Brain Inj 1991;5:73-76.[Medline]
55. Sazbon L, Fuchs C, Costeff H. Prognosis for recovery from prolonged posttraumatic unawareness: logistic analysis. J Neurol Neurosurg Psychiatry 1991;54:149-152.[Abstract]
56. Levy DE, Caronna JJ, Singer BH, Lapinski RH, Frydman H, Plum F. Predicting outcome from hypoxic-ischemic coma. JAMA 1985;253:1420-1426.[Abstract]
57. Walshe TM, Leonard C. Persistent vegetative state: extension of the syndrome to include chronic disorders. Arch Neurol 1985;42:1045-1047.[Abstract]
58. Ashwal S. The persistent vegetative state in children. In: Fukuyama Y, Suzuki Y, Kamoshita S, Casaer P, eds. Fetal and perinatal neurology. Basel, Switzerland: S. Karger, 1992:357-66.
59. Jones DG. Brain birth and personal identity. J Med Ethics 1989;15:173-8, 185.[Abstract]
60. Korein J. Ontogenesis of the fetal nervous system: the onset of brain life. Transplant Proc 1990;22:982-983.[Medline]
61. Brazelton TB. Neonatal behavioral assessment scale. Clinics in developmental medicine no. 50. London: Spastics International Medical, 1973.
62. Knobloch H, Stevens F, Malone AF, eds. Gesell and Amatruda's manual of developmental diagnosis: the evaluation and management of normal and abnormal neuropsychologic development in infancy and childhood. 4th ed. Philadelphia: Harper & Row, 1980.
63. Smith SA. Sleep disorders in children. In: Swaiman KF, ed. Pediatric neurology: principles and practice. Vol. 1. St. Louis: C.V. Mosby, 1989:149-56.
64. Electroencephalography and evoked response. In: Fenichel GM. Neonatal neurology. 3rd ed. New York: Churchill Livingstone, 1990:225-52.
65. Coulter DL. Is the vegetative state recognizable in infants? Med Ethics Physician 1990,5:13-7.
66. Coulter DL. The vegetative state in infants: criteria and prognosis. Ann Neurol 1991;30:473-473.abstract
67. Aylward GP, Lazzara A, Meyer J. Behavioral and neurological characteristics of a hydranencephalic infant. Dev Med Child Neurol 1978;20:211-217.[Medline]
68. Shewmon DA, Holmes GL. Brainstem plasticity in congenitally decerebrate children. Brain Dev 1990;12:664-664.abstract
69. Ingvar DH, Brun A, Johansson L, Samuelsson SM. Survival after severe cerebral anoxia with destruction of the cerebral cortex: the apallic syndrome. Ann N Y Acad Sci 1978;315:184-214.[Medline]
70. Relkin NR, Petito CK, Plum F. Coma and the vegetative state associated with thalamic injury after cardiac arrest. Ann Neurol 1990;28:221-222.abstract
71. Kinney HC, Korein J, Panigrahy A, Dikkes P, Goode R. Neuropathological findings in the brain of Karen Ann Quinlan -- the role of the thalamus in the persistent vegetative state. N Engl J Med 1994;330:1469-1475.[Abstract/Full Text]
72. Strich SJ. Diffuse degeneration of the cerebral white matter in severe dementia following head injury. J Neurol Neurosurg Psychiatry 1956;19:163-185.
73. Strich SJ. Shearing of nerve fibres as a cause of brain damage due to head injury: a pathological study of twenty cases. Lancet 1961;2:443-448.
74. Adams JH, Graham DI, Murray LS, Scott LG. Diffuse axonal injury due to nonmissile head injury in humans: an analysis of 45 cases. Ann Neurol 1982;12:557-563.[Medline]
75. McClellan DR, Adams DI, Graham AE, et al. The structural basis of the vegetative state and prolonged coma after non-missile head injury. In: Papo I, Cohadon F, Massarotti M, eds. Le coma tramatique. Padova, Italy: Liviana Editrice, 1986:165-85.
76. Chatrian E. Coma and brain death. In: Daly DD, Pedley TA, eds. Current practice of clinical electroencephalography. 2nd ed. New York: Raven Press, 1990:463-8.
77. Danze F, Brule JF, Haddad K. Chronic vegetative state after severe head injury: clinical study; electrophysiological investigations and CT scan in 15 cases. Neurosurg Rev 1989;12:Suppl 1:477-499.[Medline]
78. Hansotia PL. Persistent vegetative state: review and report of electrodiagnostic studies in eight cases. Arch Neurol 1985;42:1048-1052.[Abstract]
79. Shuttleworth E. Recovery to social and economic independence from prolonged postanoxic vegetative state. Neurology 1983;33:372-374.[Abstract]
80. Oksenberg A, Cohen M, Sazbon L, Becker E. Sleep in prolonged comatose patients. In: Horne J, ed. Sleep '88. Stuttgart, Germany: Gustav Fischer Verlag, 1989:286-8.
81. Mizrahi EM, Pollack MA, Kellaway P. Neocortical death in infants: behavioral, neurologic, and electroencephalographic characteristics. Pediatr Neurol 1985;1:302-305.[CrossRef][Medline]
82. Brierley JB, Graham DI, Adams JH, Simpson JA. Neocortical death after cardiac arrest: a clinical, neurophysiological, and neuropathological report of two cases. Lancet 1971;2:560-565.[Medline]
83. Tsubokawa T, Yamamoto T, Katayama Y. Prediction of outcome of prolonged coma caused by brain damage. Brain Inj 1990;4:329-337.[Medline]
84. Ashwal S, Schneider S, Thompson J. Xenon computed tomography measuring cerebral blood flow in the determination of brain death in children. Ann Neurol 1989;25:539-546.[Medline]
85. Ahmed I. Use of somatosensory evoked responses in the prediction of outcome from coma. Clin Electroencephalogr 1988;19:78-86.[Medline]
86. Frank LM, Furgiuele TL, Etheridge JE Jr. Prediction of chronic vegetative state in children using evoked potentials. Neurology 1985;35:931-934.[Abstract]
87. White LE, Frank LM, Furgiuele TL, Montes JE, Etheridge JE. Prognostic value of BAEP with near- and far-field SSEP in childhood coma. Neurology 1985;35:Suppl 1:199-199.abstract[Abstract]
88. Brunko E, Zegers de Beyl D. Prognostic value of early cortical somatosensory evoked potentials after resuscitation from cardiac arrest. Electroencephalogr Clin Neurophysiol 1987;66:15-24.[Medline]
89. Sonnet ML, Perrot D, Bouffard Y, Floret D, Fournet A, Motin J. Les potentiels evoques somesthesiques et auditifs precoces dans les comas anoxiques: interet dans le bilan lesionnel et valeur pronostique. Presse Med 1990;19:166-169.[Medline]
90. Judson JA, Cant BR, Shaw NA. Early prediction of outcome from cerebral trauma by somatosensory evoked potentials. Crit Care Med 1990;18:363-368.[Medline]
91. Houlden DA, Li C, Schwartz ML, Katic M. Median nerve somatosensory evoked potentials and the Glasgow Coma Scale as predictors of outcome in comatose patients with head injuries. Neurosurgery 1990;27:701-708.[Medline]
92. Zegers de Beyl D, Brunko E. Prediction of chronic vegetative state with somatosensory evoked potentials. Neurology 1986;36:134-134.
93. Tsao CY, Ellingson RJ, Wright FS. Recovery of cognition from persistent vegetative state in a child with normal somatosensory evoked potentials. Clin Electroencephalogr 1991;22:141-143.[Medline]
94. Hume AL, Cant BR, Shaw NA. Central somatosensory conduction time in comatose patients. Ann Neurol 1979;5:379-384.[Medline]
95. Lindsay K, Pasaoglu A, Hirst D, Allardyce G, Kennedy I, Teasdale G. Somatosensory and auditory brain stem conduction after head injury: a comparison with clinical features in prediction of outcome. Neurosurgery 1990;26:278-285.[Medline]
96. Rappaport M, McCandles KL, Rand W, Kraft MC. Passive P response in traumatic brain injury patients. J Neuropsychiatry Clin Neurosci 1991;3:180-185.[Abstract]
97. Mutoh K, Nakagawa Y, Hojo H. CT appearance of children in a persistent vegetative state. Brain Dev 1987;9:605-609.[Medline]
98. Coulter DL. Neurologic uncertainty in newborn intensive care. N Engl J Med 1987;316:840-844.[Medline]
99. Shalit MN, Beller AJ, Feinsod M. Clinical equivalents of cerebral oxygen consumption in coma. Neurology 1972;22:155-160.[Medline]
100. DeVolder AG, Goffinet AM, Bol A, Michel C, de Barsy T, Laterre C. Brain glucose metabolism in postanoxic syndrome: positron emission tomographic study. Arch Neurol 1990;47:197-204.[Abstract]
101. Momose T, Matsui T, Kosaka N, et al. Effect of cervical spinal cord stimulation (cSCS) on cerebral glucose metabolism and blood flow in a vegetative patient assessed by positron emission tomography (PET) and single photon emission computed tomography (SPECT). Radiat Med 1989;7:243-246.[Medline]
102. Chugani HT, Phelps ME, Mazziotta JC. Positron emission tomography study of human brain functional development. Ann Neurol 1987;22:487-497.[Medline]
103. Jaggi JL, Obrist WD, Gennarelli TA, Langfitt TW. Relationship of early cerebral blood flow and metabolism to outcome in acute head injury. J Neurosurg 1990;72:176-182.[Medline]
104. Muizelaar JP, Marmarou A, DeSalles AAF, et al. Cerebral blood flow and metabolism in severely head-injured children: part 1: relationship with GCS score, outcome, ICP, and PVI. J Neurosurg 1989;71:63-71.[Medline]
105. Ashwal S, Schneider S, Tomasi L, Thompson J. Prognostic implications of hyperglycemia and reduced cerebral blood flow in childhood near-drowning. Neurology 1990;40:820-823.[Abstract]
106. Ingvar DH. Cerebral blood flow and metabolism in complete apallic syndromes, in states of severe dementia, and in akinetic mutism. Acta Neurol Scand 1973;49:233-244.[Medline]
107. Oder W, Goldenberg G, Podreka I, Deecke L. HM-PAO-SPECT in persistent vegetative state after head injury: prognostic indicator of the likelihood of recovery? Intensive Care Med 1991;17:149-153.[Medline]
108. Agardh CD, Rosen I, Ryding E. Persistent vegetative state with high cerebral blood flow following profound hypoglycemia. Ann Neurol 1983;14:482-486.[Medline]




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Haig A. J., McQuillen M. P., Whyte J., Zasler N. D., Giacino J., Sandel M. E., Ashwal S., Cranford R.
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"This has nothing to do with the sanctity of life"
The Rev. John Paris, professor of bioethics, says Terri Schiavo has the moral and legal right to die, and only the Christian right is keeping her alive.

- - - - - - - - - - - -
By Andrew Leonard

March 22, 2005 | The decision on whether to allow Terri Schiavo to die has sparked endless controversy over what is legal and ethical when patients are unable to make their own wishes. One observer who brings both legal and moral authority to the debate is the Rev. John Paris, the Walsh Professor of Bioethics at Boston College.

Paris has served as an expert witness on numerous cases involving patients who were being kept alive by artificial means. He is equally capable of discussing the legal details of the Schiavo case and the Catholic Church's view of it. According to Paris, every relevant legal issue has already been decided; the only thing keeping the case alive is the fact that the Christian right has made Schiavo a cause célèbre.

Paris did not serve as an expert witness in the Schiavo case. However, when the case was reviewed by the Florida Supreme Court, he signed an amicus brief on behalf of Michael Schiavo, who wants to take his wife off life support. Salon spoke to Paris by phone on Monday morning. "This case," he says, "is bizarre."

Why is the case bizarre?

In most cases, the court has a theory, you have an appellate review, and that's the end. But this case, the parents keep coming back with new issues -- every time that they lose, they come in with a new issue. We want to reexamine the case. We believe she's competent. We need new medical tests being done. We think she's been abused. We want child protective services to intervene. Finally, Judge George Greer denied them all. He said. "Look, we have had court-appointed neutral physicians examine this patient. You don't believe the findings of the doctors but the finding of the doctors have been accepted by the court as factual." There have been six reviews by the appellate court.

What did the appellate court find?

The Florida Court of Appeals found four very interesting things. And it found them by the highest legal standard you can have -- clear and convincing evidence. The appellate court said that Judge Greer found clear and convincing evidence that Schiavo is in a well-diagnosed, persistent vegetative state, that there is no hope of her ever recovering consciousness, and that she had stated she would not ever want to be maintained this way. The court said we have heard the parents saying she didn't [say that], and we heard the husband say she did, and we believe the husband's statement is a correct statement of her position. The court also found that the husband was a caring, loving spouse whose actions were in Terri's best interests. The court said, "Remove the feeding tube," and the family protested. Of course, the family has the radical, antiabortion, right-to-life Christian right, with its apparently unlimited resources and political muscle, behind them.

So what do you think this case is really about?

The power of the Christian right. This case has nothing to do with the legal issues involving a feeding tube. The feeding tube issue was definitively resolved by the U.S. Supreme Court in 1990 in Cruzan vs. Director. The United States Supreme Court ruled that competent patients have the right to decline any and all unwanted treatment, and unconscious patients have the same right, depending upon the evidentiary standard established by the state. And Florida law says that Terri Schiavo has more than met the standard in this state. So there is no legal issue.

Are there any extenuating circumstances?

The law is clear, the medicine is clear, the ethics are clear. A presidential commission in 1983, appointed by Ronald Reagan, issued a very famous document called "Deciding to Forgo Life-Sustaining Treatment." It talked about the appropriate treatment for patients who are permanently unconscious. The commission said the only justification for continuing any treatment -- and they specifically talked about feeding tubes -- is either the slight hope that the patient might recover or the family's hope that the patient might recover. Terri Schiavo's legitimate family -- the guardian, the spouse -- has persuaded the court that she wouldn't want [intervention] and therefore it shouldn't happen. Now you have the brother and sister, the mother and father, saying that's all wrong. But they had their day in court, they had their weeks in court, they had their years in court!

Isn't the underlying social issue here one that says the law doesn't have authority over this kind of life-or-death matter?

Let me give you a test that I've done 100 times to audiences. And I guarantee you can do the same thing. Go and find the first 12 people you meet and say to them, "If you were to suffer a cerebral aneurysm, and we were able to diagnose that with a PET-scan immediately, would you want to be put on a feeding tube, knowing that you can be sustained in this existence?" I have asked that question in medical audiences, legal audiences and audiences of judges. I'll bet I have put that question before several thousand people. How many people do you think have said they wanted to be maintained that way? Zero. Not one person. Now that tells you about where the moral sentiment of our community is.

Where do you think this case is headed?

It's headed to federal court today. I cannot imagine what the federal question is. Congress said, "All we are doing is asking to have a federal court examine this." I don't know what they thought the courts were doing in the last eight years. They are saying, "We're asking a court to review this, to be certain that due process has not been violated." I don't think there is a case in the history of the United States that has been reviewed six times by an appellate court. Remember, the United States Supreme Court refused to review this.

As a priest, how do you resolve questions in which the "sanctity of life" is involved?

The sanctity of life? This has nothing to do with the sanctity of life. The Roman Catholic Church has a consistent 400-year-old tradition that I'm sure you are familiar with. It says nobody is obliged to undergo extraordinary means to preserve life.

This is Holy Week, this is when the Catholic community is saying, "We understand that life is not an absolute good and death is not an absolute defeat." The whole story of Easter is about the triumph of eternal life over death. Catholics have never believed that biological life is an end in and of itself. We've been created as a gift from God and are ultimately destined to go back to God. And we've been destined in this life to be involved in relationships. And when the capacity for that life is exhausted, there is no obligation to make officious efforts to sustain it.

This is not new doctrine. Back in 1950, Gerald Kelly, the leading Catholic moral theologian at the time, wrote a marvelous article on the obligation to use artificial means to sustain life. He published it in Theological Studies, the leading Catholic journal. He wrote, "I'm often asked whether you have to use IV feeding to sustain somebody who is in a terminal coma." And he said, "Not only do I believe there is no obligation to do it, I believe that imposing those treatments on that class of patients is wrong. There is no benefit to the patient, there is great expense to the community, and there is enormous tension on the family."

How do you square that with the pope's comments last year, which seemed to indicate that people in Schiavo's situation should be kept alive?

The bishops of Florida did it very nicely when they said, "There is a presumption to use nutritional fluid, unless the continued use of it would be burdensome to the patient." So it's not an absolute. That statement is a recognition that the Vatican is inhabited by the same cross section of people that inhabit the United States

What do you mean?

I mean there are some radical right-to-lifers there, and they got that statement out. But it has to be seen in the context of the pope's 1980 declaration on euthanasia, and the pope's encyclical on death and dying, in which he repeats the long-standing tradition that I just gave you. His comment last year wasn't doctrinal statement, it wasn't encyclical, it wasn't a papal pronouncement. It was a speech at a meeting of right-to-lifers.

Again, this issue is not new. Every court, every jurisdiction that has heard it, agrees. So you'd think this issue would have ended. I thought it ended when we took it to the Supreme Court in 1990. But I hadn't anticipated the power of the Christian right. They elected him [George Bush]. And now he dances.

- - - - - - - - - - - -

About the writer
Andrew Leonard is a staff writer at Salon.

http://www.salon.com/news/feature/2005/03/...john/index.html

http://www.latimes.com/news/nationworld/na...-home-headlines
Frist's Medical Opinion of Schiavo Draws Criticism
By Richard Simon and Maura Reynolds
Times Staff Writers

7:57 PM PST, March 21, 2005

WASHINGTON -- As Senate Majority Leader Bill Frist pushed Congress to intervene in the Terri Schiavo case, he drew attention to a part of his resume many expect him to spotlight as he prepares for a likely 2008 presidential bid: He is a doctor.

Polls find that physicians rank among the most trusted professions, and most political experts say Frist's medical background will be an asset for him as a presidential candidate, separating him from the welter of lawyers and career politicians in Congress.

But critics say the Republican senator from Tennessee may have overplayed his hand by offering a medical opinion in the Schiavo case.

In a speech last week on the Senate floor, Frist said that "speaking more as a physician than as a U.S. senator," he believed there was "insufficient information to conclude that Terry Schiavo is in a persistent vegetative state."

Frist, who as a surgeon performed more than 150 heart and lung transplants, said his conclusion was based on a review of footage of the brain-damaged Florida woman whose parents are seeking to reconnect her feeding tube. He said he also consulted court documents and spoke to a neurologist who examined Schiavo two years ago.

Frist's comments raised some eyebrows in the medical community.

Although there are no official rules against the practice, ethicists said it is generally considered unprofessional for a doctor to make or question a diagnosis on the basis of incomplete information.

"In general, physicians would consider it unprofessional for doctors to take clinical stands on issues without adequate clinical data," said Dr. Neil Wenger, head of the ethics committee at UCLA Medical Center.

William J. Winslade, a bioethicist and law professor at the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston, was more direct. Frist "has no business making a diagnosis from a video," he said.

In his comments on the Senate floor, Frist said that based on the videotape of Schiavo and court records, she "does respond" to outside stimulus. "That footage, to me, depicted something very different than persistent vegetative state."

A Frist spokeswoman said Monday that the majority leader was not offering a diagnosis of Schiavo. "What he's saying is, it seems like there is a lot of gray area about whether she is in a persistent vegetative state," said Amy Call.

Michael Williams, chair of the ethics committee of the American Academy of Neurology, was among those taking exception to Frist's comments.

"For Dr. Frist to make a statement like that -- it's like me making an off-the-cuff statement about a heart transplant patient," said Williams, a neurologist at Johns Hopkins Medical Institution in Baltimore.

In the Senate, Frist is hardly shy about his medical credentials.

The front door to his Capitol Hill office has "William H. Frist, M.D." on the nameplate. He signs ordinary correspondence "Bill Frist, M.D." He keeps a doctor's bag in his office, and put it to real use in 1998 -- saving the life of a man shot after storming the Capitol building and killing two Capitol Police officers. Frist became a familiar face on television delivering public briefings after anthrax attacks on the Capitol in 2001. And he has cited his background in promoting legislation to fight bioterrorism, establish a prescription drug benefit under Medicare, and limiting payouts in medical malpractice cases.

Some analysts saw political dividends for Frist in his high-profile efforts to bring the federal courts into the fight over whether Schiavo's feeding tube should be reconnected.

David Carney, who served as White House political director for President George H.W. Bush, said Frist generally has been linked more to the fiscal conservative wing of the GOP than its social conservative wing.

"With social conservatives, this certainly helps," Carney said of Frist's involvement in the Schiavo case.

Carney, a political consultant based in New Hampshire, noted that Frist has been making trips to the state, home of the nation's first presidential primary. Frist has visited the state twice this month, including attending a Republican Party dinner on Saturday in the midst of the controversy over the Schiavo case.

Some Democrats resent Frist's use of his medical background during debates. He projects the attitude that, "He's a doctor, and he knows best," said an aide to a senior Democratic senator, who asked not to be named.

Frist, 53, was elected to the Senate in 1994, becoming the first practicing doctor in the chamber since the late 1930s. Although he has been noncommittal about presidential aspirations, he has said he does not intend to seek reelection in 2006, sparking speculation he would then focus on seeking his party's nomination.

In a 2003 speech at Princeton University, Frist said some people found it confusing that "William H. Frist, majority leader, M.D., can be merged together." He added: "But at the end of the day, it allows me to address things with a perspective that's just different."

That could prove especially beneficial in a presidential run, political analysts say.

"When you can say you saved probably hundreds of lives in your career before you got to Congress, that's not something the average run-of-the-mill elected official can say," said Michael Franc, a former GOP congressional aide who now works at the Heritage Foundation, a conservative think tank. Carney, the political consultant, said, "In the primary, there will be one doctor and a bunch of politicians. Dr. Frist can go make house calls."

John J. Pitney Jr., a former GOP strategist who is now a professor of government at Claremont McKenna College, noted there's a potential downside to Frist's background: his family founded a hospital company, HCA.

"While people like doctors, they dislike corporate medicine," Pitney said.

And ultimately, voters will be more interested in Frist's politics than his medical practice, said Keith Appell, a public relations consultant who worked on Republican Steve Forbes' presidential campaign.

"Folks ... will only care if you're a doctor if you're on the right side of the issues they care about," Appell said.

http://www.latimes.com/news/nationworld/po...litics-national
CALIFORNIA VOICES
State Physicians Group Condemns Involvement by Congress
A resolution by doctors expresses outrage over lawmakers' intervention in medical decisions.
By Jean O. Pasco and Rachana Rathi
Times Staff Writers

March 22, 2005

The California Medical Assn. moved nearly unanimously Monday to condemn federal legislation signed by President Bush allowing Terri Schiavo's parents to ask a federal judge to order her feeding tube reconnected.

Only a single "no" rose in voice vote of about 450 doctors attending the group's annual medical convention in Anaheim responding to an emergency resolution calling on the CMA to "express its outrage at Congress' interference with medical decisions."

Members of the group said they would ask the American Medical Assn. to approve the same resolution at its national convention in June in Chicago.

"Many of us are appalled at what's going on in Washington, D.C.," said George P. Susens, an internist who wrote the resolution on behalf of the San Francisco Medical Society. Legislators, he said, are neither doctors nor experts.

"They're doing this for political gain…. We hope physicians all over the country will rise up in opposition to what Congress has done," Susens said.

Several doctors urged the group to reject what they called improper political influence on medical decisions best left to patients and their families. To intervene in the Schiavo case is tantamount to torture, said William Andereck, an internist and the director of a program in medicine and human values at the California Pacific Medical Center in San Francisco. He said Schiavo was in a persistent vegetative state from which she could not recover and has responded only reflexively to the infliction of pain.

Melvyn L. Sterling, an internist in Orange, said he would urge the AMA to condemn the congressional action when he attends the convention as a delegate.

"To say a husband has no right to save his wife from a horrible existence is intolerable," said Sterling, who also practices hospice care. "This is a golden-rule issue, and we feel it is an important national issue."

The issue galvanized physicians because of the political implications, not necessarily the medical facts of Schiavo's case, said Robert E. Hertzka, a former president of the CMA. If the delegates were polled, he predicted they would split over whether to reconnect Schiavo's feeding tube. "Congress is inserting themselves into a situation best left to a healthcare team," Hertzka said.

Other doctors said Congress had no right to intervene in a state issue already decided by the Florida Supreme Court.

Denise Greene, a Fresno resident physician whose specialty is pain management, said the resolution was fitting given the CMA's long opposition to political interference in medical issues.

Four other resolutions dealing with so-called right-to-die issues were raised by doctors Monday, but only one passed. It called for guidelines for the appropriate use of hospice care. The failed measures called for support of a pending "California Death With Dignity Act" before the state Legislature, encouraged legislative approval of physician-assisted suicides for the terminally ill and supported creating laws for "making end-of-life decisions."

Lies Terri Schiavo's parents told me

The Terri Schiavo case has transfixed the right wing media while attracting comparatively little attention from the left. This is discrepancy is understandable. Once you know the facts, there's very little to argue about. The case is literally a no brainer.

The Schiavo case presents no intricate medical, ethical, or legal dilemmas. Abstract Appeal's comprehensive legal chronology shows just how straightforward this case should have been. Michael Schiavo is Terri's legal guardian, the courts have determined that Terri wouldn't want a feeding tube, and Michael asked the doctors to take the tube out. That's really all there is to it.

The Terri Schiavo appeal is a vicious and lavishly-funded propaganda campaign. Terri's parents and their allies are using pseudoscience and character assassination to destroy Michael Schiavo. The right wing is eating it up.

If progressives don't counter these blatant misrepresentations now, the Terri Schiavo myths will be used against us for years to come.

Myths about the Terri Schiavo case

1. Terri is conscious

Court-appointed, government-appointed, and private physicians have confirmed that Terri Schiavo is in a persistent vegetative state (PVS). Schiavo suffered massive brain damage as a result of a cardiac arrest 15 years ago, and ongoing neurological degeneration interim.

Patients in a PVS have no higher cognitive function and no chance of recovery.

Terri is neither comatose, nor brain dead. She is in a vegetative state because her higher brain centers have been destroyed and replaced by fluid.

1.' A recent study showed that patients like Terri are more conscious than we thought

A recent fMRI by study found that two patients in a minimally conscious state (MCS) showed slightly more brain activity during speech recognition tasks than would have been predicted based on the severity of their injuries and behavioral observations (Schiff ND, Rodriguez-Moreno D, Kamal A, et al, 2005). When the study was released, some commentators inappropriately cited this result as evidence that Terri Schiavo's level of consciousness might have been underestimated.

Terri Schiavo is not in an MCS. According to the authors of the study, a diagnosis of MCS is reserved for a subset of patients who demonstrate "unequivocal, but intermittent, behavioral evidence of awareness of self or their environment." Unfortunately, Terri is even more severely disabled than the patients in this study.

2. There are new treatments that might help Terri

Despite what Terri's parents say, there are no new treatments that could help their daughter. Anyone who claims that he can improve Terri's level of consciousness is a quack. You can't treat a brain that isn't there.

3. Terri's collapse is unexplained and/or suspicious

In an attempt to discredit Michael Schiavo, Terri's parents and their supporters are circulating unsubstantiated rumors of abuse and even accusations of attempted murder.

Former chief medical examiner for the city of New York and co-director of the Medicolegal Investigation Unit of the New York State Police, Dr. [Michael] Baden is often quoted in news reports and interviewed on television. [...] Dr. Baden, who has written three books on forensic pathology, told [Greta]van Susteren: "It's extremely rare for a 20-year-old to have a cardiac arrest from low potassium who has no other diseases . . . which she doesn't have. . . . The reason that she's in the state she's in is because there was a period of time, maybe five or eight minutes, when not enough oxygen was going to her brain. That can happen because the heart stops for five or eight minutes, but she had a healthy heart from what we can see." [Village Voice]

Terri Schiavo was not a healthy young woman. Her heart stopped because of a potassium imbalance induced by severe bulimia nervosa.[AP]

Hypokalemic cardiac arrests are rare in the population at large, but they all too common in young women with severe eating disorders. Michael Schiavo successfully sued Terri's doctors for failing to diagnose her condition. If there had been an alternate explanation for Terri's condition--like attempted murder by the plaintiff--you would think the doctors Schiavo sued would have brought it up.

Here's a transcript of the Greta van Susteren's interview with Dr. Baden on FOX News.

In the interview Baden alludes to Terri's alleged "history of trauma" and suggested that her brain damage might have been caused by a "head injury." Dr. Baden's insinuations don't hang together. Both Terri's bulimia and her potassium imbalance are well-documented. Whereas there is no evidence that Terri Schiavo's brain was destroyed by any kind of trauma.

BADEN: Yeah, your staff has provided me with a bone scan that you guys obtained ah from her initial admission in 1991 to the hospital. And that bone scan describes her as having a head injury. That’s why she’s there, that’s why she’s getting a bone scan. And a head injury can cause, lead to the vegetative state that Ms. Schiavo is in now, and it does show evidence that there are other injuries, other bone fractures, that on healing-stage, so that...

Dr. Baden says that the bone scan describes Terri as having a head injury. The implication is that the bone scan reveals that she suffered a head injury. The paperwork requesting the bone scan describes Schiavo as having had a head injury, but the bone scan didn't show any evidence of head or neck trauma.

The head injury hypothesis is utterly far-fetched. Believe me, if Terri had been bleeding into her brain on the night in question, the ER would have noticed.

An even crazier theory of Terri's collapse is phantom strangulation. This one got a sympathetic hearing from both Hannity and Colmes. The evidence is that Terri was admitted with a rigid neck. So far, no one has claimed that Terri had any of the classic signs of manual strangulation. Patients who have been strangled tend to have bruises on their necks, petechiae in the whites of their eyes (blood spots), and bits of their assailant's flesh under their fingernails. Manual strangulation doesn't always leave marks, but why attribute to phantom stranglers what can be explained by hypokalemia?

4. Michael Schiavo abused Terri

There is no firm evidence that anyone abused Terri. A judge ruled the abuse allegation irrelevant years ago, but Terri's "supporters" are determined to keep meme alive just to destroy Michael Schiavo's reputation.

Dr. Baden alleges that a bone scan taken in 1991 showed that Terri had suffered trauma. Here is the deposition of the radiologist who analyzed Terri's bone scan, Dr. William Campbell Walker.

During the deposition, Walker acknowledges that the abnormalities on the bone scan could have been caused by Schiavo's collapse, vigorous CPR, an earlier car accident, prolonged immobility, or aggressive physiotherapy. Contrary to Dr. Baden's insinuation, the scan revealed no abnormalities in the head or neck.

By the time the scan was taken, Terri had already been in the care of a nursing home for several months. For all anyone knows, Terri's bones may have been damaged by neglect or abuse at the nursing facility.

5. Terri's brain damage was caused by a closed head injury

The head injury claim has been repeated over and over in the right wing media. Here's the only evidence I was able to find for this bold claim: In his deposition, Dr. Walker says that Dr. James Carnahan, Terri's rehabilitation physician, wrote "closed head injury" on a form requesting a radiological trauma work up. Maybe Schiavo has a history of closed head injuries, but it is absurd to think that a closed head injury caused her current vegetative state.

6. Michael Schiavo just wants to inherit Terri's fortune

What fortune? Even the pro-tube Terri Schiavo Foundation reports that of the nearly one million dollar malpractice settlement earmarked for Terri's future medical care, less than $50,000 is left.

The TSF is righteously indignant that a fair chunk of that money has gone to attorneys' fees. A judge authorized Michael Schiavo to spend that money on legal representation for himself and his incapacitated wife. It's odd that the TSF is so indignant, seeing as they picked the legal fight that depleted the account.

The TSF also acknowledges that Schiavo offered to donate whatever money he stood to inherit to charity if Terri's parents would stop trying interfere with his right to make medical decisions on behalf of his wife.

I just hope that these character assassins can be discredited before they ruin another person's life. Michael Schiavo has suffered enough.

http://majikthise.typepad.com/majikthise_/...king_lies_.html

In Schiavo case, Congress trespasses on private tragedy
Political grandstanding ignores 12 years of state court rulings.

Congress suddenly seems intent on practicing medicine without a license. Or is it just practicing politics?

No member of the House or Senate has ever examined Terri Schiavo, the Florida woman who has been in a persistent vegetative state with no hope of recovery since suffering severe brain damage 15 years ago.

Schiavo's husband and two other witnesses have testified that she had said that she would never want to be kept alive artificially.

Courts have reviewed the case for 12 years and ruled consistently that the husband should be entrusted with her care and that his decision to remove the feeding tube that sustains her life should stand.

But Congress thinks it knows better. Early Monday, President Bush signed a special bill opening the federal courts for a rerun of the family fight over whether Schiavo should be allowed to die. The latest round began with a hearing Monday in Tampa and seemed destined for appeals.

It is shameful political grandstanding. It also is an appalling precedent for political interference in the most painful decisions any family can face. An estimated 14,000 to 35,000 Americans are in persistent vegetative states. Does Congress plan to meddle in the medical and legal judgments on each one?

The Schiavo case is certainly sad and extraordinary. Her parents, pained and unable to let her go, have fought for custody so they could keep her feeding tube in place. Anyone can sympathize with their plight. But pro-life activists and their political allies long ago hijacked the case for their own purposes.

They previously persuaded Florida's Legislature to intervene, much as Congress has now. Last fall, the Florida Supreme Court ruled the Legislature had exceeded its authority. The U.S. Supreme Court declined to intervene, which should have settled the dispute. There was no need for intervention by politicians in some far-off capital preening for the next election or trying to distract attention from other issues.

In a nationwide poll conducted Sunday for ABC News, the public appeared to see it that way: 70% said Congress' action was inappropriate. In a USA TODAY/CNN/Gallup Poll Friday-Sunday, 61% said they would also have a spouse's feeding tube removed in similar circumstances.

Two-thirds of those in the ABC poll also said they thought elected officials were getting involved more for political reasons than for any devotion to principle. They have good reason to be suspicious. The case is a rallying point for religious conservatives who now play a dominant role in Republican politics, and their influence is clear.

Those most active in politicizing the case are Republicans who typically proclaim their devotion to reducing the interference of the federal government in people's lives. These include Senate Majority Leader Bill Frist and Florida Gov. Jeb Bush, both potential candidates for a future Republican presidential nomination.

Frist, a heart surgeon and one of the few physicians in Congress, even presumed to offer his own optimistic diagnosis of Schiavo's prospects based on viewing a few clips from a family-provided videotape. That's a dubious method for practicing medicine. Medical specialists say the occasional eye movements and reflex actions that Schiavo's parents and their supporters see as encouraging are common signs of false hope.

For House Majority Leader Tom DeLay, whose professional expertise is in pest control, not terminal-care decisions, the issue is a convenient distraction from allegations about ties to unsavory lobbyists and a Texas fundraising scandal.

DeLay says Schiavo is being starved to death. President Bush said Monday it's “wise to always err on the side of life.” There's no reason to doubt the sincerity of their beliefs or that of others who voted for the bill. But it is not their judgment to make.

It is a judgment for the family, certainly, with input from doctors familiar with the case. And for the courts, unavoidably, if family members disagree. But not for politicians, who have too little knowledge and too many motives.

When the Founders wrote the Constitution, they devoted the largest section to spelling out the powers of Congress. Nowhere did they include the right to play doctor. Terri Schiavo's story is tragic enough without political malpractice.



Find this article at:
http://www.usatoday.com/printedition/news/.../edit22.art.htm

Posted on Tue, Mar. 22, 2005

RIGHT-TO-DIE LAWS
President's move contradicts law signed in Texas
President Bush's actions in the Terri Schiavo case brought cries of hypocrisy based on a right-to-die law he signed as Texas governor.
BY WILLIAM DOUGLAS
bdouglas@krwashington.com

WASHINGTON - The federal law that President Bush signed early Monday in an effort to prolong Terri Schiavo's life appears to contradict a right-to-die law that he signed as Texas governor, prompting cries of hypocrisy from congressional Democrats and some bioethicists.

In 1999, then-Gov. Bush signed the Advance Directives Act, which lets a patient's surrogate make life-ending decisions on his or her behalf. The measure also allows Texas hospitals to disconnect patients from life-sustaining systems if a physician, in consultation with a hospital bioethics committee, concludes that the patient's condition is hopeless.

Bioethicists familiar with the Texas law said Monday that if the Schiavo case had occurred in Texas, her husband would be the legal decision-maker and, because he and her doctors agreed that she had no hope of recovery, her feeding tube would be disconnected.

''The Texas law signed in 1999 allowed next of kin to decide what the patient wanted, if competent,'' said John Robertson, a University of Texas bioethicist.

TESTED IN TEXAS

Meanwhile, Bush's Texas law faced its first high-profile test. With the permission of a judge, a Houston hospital disconnected an ill infant from his breathing tube last week against his mother's wishes after doctors determined that continuing life support would be futile.

''The mother down in Texas must be reading the Schiavo case and scratching her head,'' said Dr. Howard Brody, the director of Michigan State University's Center for Ethics and Humanities in the Life Sciences. ``This does appear to be a contradiction.''

Brody said that Bush and Congress had shattered a body of bioethics law and practice. ``This is crazy. It's political grandstanding.''

Bush's apparent shift on right-to-die decisions wasn't lost on Democrats. During debate on the Schiavo case, Rep. Debbie Wasserman Schultz, a Democrat from Weston in Broward County, accused Bush of hypocrisy.

''It appears that President Bush felt, as governor, that there was a point which, when doctors felt there was no further hope for the patient, that it is appropriate for an end-of-life decision to be made, even over the objection of family members,'' she said. ``There is an obvious conflict here between the president's feelings on this matter now as compared to when he was governor of Texas.''

`UNINFORMED'

White House press secretary Scott McClellan termed Wasserman Schultz's remarks ''uninformed accusations'' and denied that there was any conflict in Bush's positions on the laws.

''The legislation he signed [Monday] is consistent with his views,'' he said. ``The [1999] legislation he signed into law actually provided new protections for patients . . . prior to the passage of the '99 legislation that he signed, there were no protections.''

Wasserman Schultz stuck by her remarks when told of McClellan's comments.

''It's a fact in black and white,'' she said. ``It's a direct conflict on the position he has in the Schiavo case.''

Tom Mayo, a Southern Methodist University Law School associate professor who helped draft the Texas law, said he saw no inconsistency in Bush's stands.

''It's not really a conflict, because the [Texas] law addresses different types of disputes, meaning the dispute between decision-maker and physician,'' he said. ``The Schiavo case is a disagreement among family members.''

http://www.miami.com/mld/miamiherald/news/...on/11197083.htm

http://www.latimes.com/news/printedition/a...-news-a_section
POLITICAL AFTERMATH
Some in GOP Fear Effort May Alienate Voters
Advocates of smaller government could be turned off, analysts say. But others insist the action will inspire religious conservatives.
By Janet Hook
Times Staff Writer

March 22, 2005

WASHINGTON — T