"Starvation and Dehydration"

This is an interesting point..
Today I got into a heated but friendly argument with a co-worker who compared it to the suffering of the Jewish people in Nazi Germany! I was arguing that his comparison was going a little too far..even if you took away the conscious/incapacitated factor you are still left thinking of the horrors inflicted on millions of people in Nazi concentration camps.
Terri was in a climate contolled, comfortable room with a bed & constant care. It wasn't like she was forced into standing/working outside in the bitter cold wearing nothing more than rags, seeing friends & family die around you in the most brutal way imaginable..no need to say more.
I told him to do a little reading before he even dares to make such a comparison.

That's also one part of the arguement that I never got. I've seen quite a few people die from terminal cancer, my grandmother included. None of these individuals ate or drank anything over the last week or two of their lives, other than maybe the occasional ice chip or wash cloth drippings. It was very clear that they were not being tortured in any way. It's a part of the natural process of dying. None of them had any interest in eating or drinking and wouldn't have been able to hold food regardless. I think that dying in itself is what scares most people. They have a difficult time dealing with the realities of death and assume it has to be this horrible, painful experience to die naturally. The last thing that my grandma ate was exactly what she wanted to eat- vanilla ice cream! She wasn't very responsive in that last week, but she did manage to request ice cream at the beginning of it. She was only able to eat about a tablespoon of it, but she definately enjoyed it. That will probably be me

And from my own experience, it's not that they are hungry or thirsty -- we made my Mom try to eat and drink -- but that the washcloth drippings or the ice chips is because of the tongue drying out. So not so much hunger and thirst, but dryness.

My Mom hardly ate or drank before she passed away. From what my Dad said was that she passed peacefully -- falling asleep.

My grandma died rather peacefully, too, after going for quite a while without eating or drinking (cancer).
Thank you so much for starting this thread; it was great to read what the bioethicists had to stay about thirst vs. dehydration, etc. Enforces what I was already feeling about the Schaivo case.
Thanks Amy

I second that. I think that some of the people who didn't want the feeding tube removed were "over emotionalizing" the issue.

I almost didn't click on this thread for fear of more depressing thoughts. I'm glad I did. It is a relief that these people are suffering less than we perceive. Thanks for the info, AmyDHH

I dont really know how my grandmother passed away.
APparently it was peacefully she said something and was looking up to the ceiling and calling my grandpas name.
2 weeks beforehand i got to see her she was only able to eat 2 pieces of chips and a very small sandwhich, she couldnt even drink all of her tea so my aunt's had to make it extra small for her.
My mother couldnt stand it so we left earlier. My grandma had lung cancer so she was due to go in any minute.
We were still on our ship cruise when she passed away.

My mother felt it and i have to admit it that she went all strange she went all cold and drank 3 cappuccinos to get warm and she was very pale for half an hour. In that half an hour i found out as soon as i got home thats the time she had passed.
She was the only grandmother i had, and i wish i got to know her a bit more. I was her only grandchild that she had never seen. I vowed to my mum that my grandma would get to see me married and she would get to see my kids.
She was already a great grandmother of 3.

Well i know that when the time comes she will be there because she will be watching over me even though she isnt in her body with us.

As i get older death is harder to compromise.
I watched my uncle die and i didnt shed a tear and i really dont know how im going to cope when my parents pass.

I'm very suspicious about studies like this because they are extremely advantageous to Health Insurance companies who don't want to subsidize the outrageous costs of feeding bags/tubes. My father died of cancer in 1994 and was on TPN/ feeding tube for much of 1993-1994. At that time, his insurance covered it. I don't think it would cover it today.

Honestly, I really don't think he would have wanted to go without the food or the hydration. I think he would have felt ten times worse without it.

As for myself, I would much prefer my caretakers gave me an overdose of morphine before they decided to let me dehydrate or starve to death.

The day we stop "over emotionalizing" the removal of a feeding tube from a person who is NOT dying, will be a sad day for our country. Too many of us have already stopped doing that.

As Amy pointed out, and this is important to remember, these are merely *opinions* of a particular group of bioethicists. For all the medical literature that claims dehydration is a "peaceful process", you'll find literature refuting that conclusion. Opinions like this provide balm to people who thought Terri should be "let go" (nice euphemism) but were worried that dehydrating to death might actually be terrible.

There is a difference between people who are terminally ill and refuse food and people who are not dying but need to be tube fed. Many terminally ill people will refuse food and water as a natural part of the dying process. End stage cancer will often cause a distorted sense of hunger and/or thirst. In this situation, being deprived of UNWANTED food/water by someone whose body is shutting down doesn't cause a painful death. Most of these people will pass away within hours or a few days after refusing food and water. Several members have told their personal stories about this experience with a dying loved one. There is a distinction, though, between removing food from people in this situation, and discontinuing feeding a person who though brain damaged, is not dying and cannot feed themself.

Consider the associations that many bioethicists have. Dr. Cranford, a medical doctor and bioethicist, who was instrumental in Terri being put to death, is on the board of directors of the Choice in Dying Society which promotes doctor assisted suicide and euthanasia. He's also been a featured speaker for the Hemlock Society. He's stated that people diagnosed as PVS lack "personhood" (a position that was criticized by many of his colleagues). Alzheimers patients also fit this category, according to Dr. Cranford, and feeding tubes for them "make no sense". Following his line of logic, if someone is diagnosed PVS, and therefore, not a person, pulling the feeding tube is of no consequence. They're not a person, they don't feel pain or discomfort, so there's no moral issue to fret over.

Some bioethicists categorize newborn infants as "human non-persons" or "potential persons". Do we really want to follow where these so-called "ethicists" are leading?

Some of us are relieved when "experts" assure us that Terri felt no pain. It makes the horror we've inflicted on this helpless woman a little easier to bear. Yet why were doctors prescribing pain meds for Terri each month for her menstrual cycle if she couldn't feel pain? If, in fact, "it is physiologically impossible for a patient in a vegetative state to feel anything at all" why was Terri given morphine as she lay dying of dehydration?

In the February 8, 2005 edition of The New York Times, Benedict Carey wrote an article titled "Signs of Awareness Seen in Brain-Injured Patients". He writes: "Thousands of brain damaged people who are treated as if they are almost completely unaware may register what is going on around them but be unable to respond, a study suggests."

Another excerpt from this article quotes Dr.Joseph Fins, chief of the Medical Ethics Division of New York Presbyterian Hospital - Weill Cornell Medical Center: "This study gave me goose bumps because it shows the possibility of this profound isolation, that these people are there, that they've been there all along, even though we've been treating them as if they're not".

If Terri was able to feel pain, and administration of morphine tells me she was, dehydrating to death was anything but peaceful.

Most people who are in the dying process are administered morphine. In fact my grandmother was given morphine and oxycontin even up to the point of her death. Out of the several dozen people that I've been present at the deaths of none, including those who had died at home, died without the aid of pain management.

If "it is physiologically impossible (for those with PVS) to experience anything at all", including hunger, thirst or pain, why was Terri given pain meds?

I agree that there is a distinction on a certain level but I come from a different perspective. That is the basis of both decisions are grounded on the right to accept or reject medical treatment.

That of course brings up another point which has been raised in another thread. If the complaint is with regards to the putative pain suffered then should not the response be to allow active euthanasia, that of the doctor giving an injection that leads to instant death?

Who exactly describes newborn infants as "potential persons?"

Finally, with regards to the NYT it should be pointed out that in this article that the term brain-injured patients is used as a catch all phrase to include those in PVS and those that are minimally conscious.

Regarding the morphine administered to Terri: George Felos, Michael Schiavo's attorney, told the press on March 29 that "Terri was exhibiting light moaning, facial grimacing and tensing of arms" as noted by nurses present during the dehydration process. It was due to the observation of these nurses that morphine was administered, not for "the comfort of the family". To the contrary, Terri's father expressed concern that any morphine given might hasten his daughter's death.

Wesley Smith, in an article written about a debate he had with Bill Allen, a bioethicist, mentions that some bioethicists categorize infants as "human non-persons", but does not specifically name them.

As far as the New York Times article, I believe you may only have seen the abstract, not the article in its entirety. Rather than being "used as a catch all phrase", the term "brain injured" in this article refers specifically to "minimally conscious" patients and how the findings could possibly impact those diagnosed as PVS or minimally conscious. Dr. Joy Hirsch is the senior author of the study, and the Director of the Functional MRI Research Center at Columbia University Medical Center. Dr. Hirsch's brain-imaging study appeared in the journal "Neurology".

From the article: "The research showed that brain imaging technology, Magnetic Resonance Imaging (MRI), can be a powerful tool to help doctors and family members determine whether a person has lost all awareness or is still somewhat mentally engaged..."

A quote from the article by Dr. Joseph Fins, Chief of the Medical Ethics Division of New York Presbyterian Hospital-Weill Cornell Medical Center: "A better understanding of brain pattern in minimally conscious patients should also help cut down on misdiagnosis by doctors. One study had found that as many as 30% of patients identified as being unaware, in persistent vegetative state, were not. They were minimally conscious."

Judge Greer refused to allow an MRI for Terri. Dr. Cranford, the "expert" and bioethicist people often cite as the last word on Terri's condition, dismissed an MRI as "unnecessary".

I am not too sure if you people recall the English case of Diane Pretty, which perhaps sums up my feelings on cases such as this. While the nature of the cases are different, the battle is between the right to choose for oneself versus the right of the state to act on one's behalf.
http://news.bbc.co.uk/1/hi/health/1983457.stm

On the point of personhood and infants. Unless he provides names it is difficult to know whether he is just saying to bolster his position by setting up a strawman argument. But in any event, there are two possibilities for personhood begining after infant but in both interpretations it is not what you think it is.

The first position is a religious position taken by some Jewish Rabbis that personhood or to be precise the "ensoulment" begins only when the baby first speaks. So that is a religious position that may aid one's decision if one is of such a faith and believes such an interpretation but it does not aid the rest.

The second position is on the definition of personhood. This I see as more of a legal definition. That is the right to legally choose a course of action that will be supported by the law. Therefore having the law recognise the control of a parent over a child would impact on the child's personhood. Thus a court who orders medical treatment for a child despite the child's outright objection to it is impacts on the child's personhood because if that person was not a child but an adult, the court cannot make such an order.

Since this is not exactly a thread on Terri, I shall keep my response to it really short. No MRI because it would not change the fundamental of CT scan. Second, perhaps if I was not clear, but the question to ask is whether the misdiagnosis is on people with activities in their upper brain but was diagnosed as PVS and not when the only thing left is the stem. Note that people that are minimally conscious still have significant activities in their upper brain.

KTLynn, thank you for your balanced and informative report. I regret that I too was hoping to believe that Terri had an easy passing, but was nagged that it may very well have not been so. It would have been useful if Terri had been examined by other experts in the field, including those from other top medical centers nationwide. The differences in the states' considerations of brain-damaged, retarded, and otherwise "useless human beings"is pretty amazing, although not surprising, considering how animals can be mistreated legally in some states - just check out the posts in "Ask Animal Control". I hope this case got people thinking; I myself keep flip-flopping on the "human euthanasia" issue.

Not having a background in radiology, I can't interpret nor draw conclusions from the CT scans that are posted.

However, I was able to find the opinion of a radiologist whose job it is to read such scans. He begins by saying that he was directed to the University of Miami Ethics Program website, where these images were posted. The sentence attached to the pictures says that the images are from scans done in 1996 of Ms. Schiavo's brain, and show extensive cortical regions filled with spinal fluid. The radiologist, Dr. Boyle, says this is inaccurate. Cortical regions are not, and cannot be filled with spinal fluid.

He states: "The most alarming thing about this image, however, is that there is *certainly cortex left*. It is severely thinned, especially for Terri's age, but I would be nonplussed if you told me this was a scan of a 75 year old female who was somewhat senile but fully functional. I defy a radiologist anywhere to contest that".

He continues: "I have seen many walking, talking, fairly coherent people with worse cerebral/cortical atrophy. Therefore, this is in no way prima facie evidence that Terri Schiavo's mental abilities and/or capabilities are completely eradicated. I cannot believe such testimony has been given on the basis of this scan...this is an atrophied brain, yes, but there is cortex remaining, and where there's cortex, there's hope".

"If you starve this woman to death, it would be, in my professional and experienced medical opinion, the equivalent of starving to death a 75-85 year old person. I would take that to the witness stand".

His opinion and other information about Terri's records can be found at www.codeblueblog.blogs.com.

The implant in Terri's head (thalmic stimulator) was to have been a *temporary* treatment from therapy done in 1992. Doctors who placed the implants told Michael Schiavo that they needed to be removed since they could possibly cause infection if left in place long term. Schiavo refused to have the implant removed. Had this been done, as per the doctors' advice, there would be no obstacle to having an MRI.

There are many neurologists who would disagree with the assertion that "an MRI would not show anything further" and "it's quite accepted in this case that the CT scan was absolutely detailed enough". Dr. Robert Morin,for one, of Boston University disagrees with those statements. When interviewed for an article in National Review Online, he asked about the MRI results and was told that test was never done. He was astounded and asked how a definitive diagnoses of PVS could possibly be made without one.

There's an interesting site, www.braininjury.com/diagnostichtml, which explains the advantages and disadvantages of MRI and CT scans. It makes clear how the tests complement each other and are necessary to be done in conjunction to arrive at as clear a diagnosis as possible.

If Terri had left legal documentation as to her wishes regarding medical treatment in the event of a catastrophic medical condition, this case wouldn't exist. Her wishes would have been carried out. The only person who seems to "know" Terri's wishes is Michael Schiavo, who needed 7 years to remember what they were. Judge Greer made a "best guess" ruling on this single piece of "evidence". If you're going to sentence someone to die by dehydration, you need to do better than that.

It is inconsequential whether or not I or 98% of Americans would want "to live in Terri's condition". That's a decision we can make only for ourselves, no one else. We cannot and should not extrapolate that because "80% of people said let me go...it isn't a stretch to think Terri would have wanted to be let go as well". Terri was an individual with private thoughts and feelings that none of us have any idea about, and can only guess at. Guessing doesn't cut it when you're going to kill someone by dehydration.

As for polls - the polls leading up to Terri's death made it appear Americans had formed a consensus in favor of ending her life. A new Zogby poll (published April 1) with *fairer* questions (read the questions in the original polls; you'll understand why people answered as they did) shows Americans clearly supporting Terri and her parents and wanting to protect the lives of other disabled patients.

The poll found that 79% of Americans were not in favor of starving/dehydrating Terri to death.

Did you note the disclaimer on that site?
"DISCLAIMER This is a personal web site, reflecting the opinions of its author. It is not a production of my employer, and it is unaffiliated with ANY hospital, medical center, medical practice or other physicians. Statements on this site do not represent the views or policies of anyone other than myself. The information on this site is provided for discussion purposes only, and are not medical recommendations. I offer no guarentee as to the accuracy of anything stated and the information here is at times, highly speculative and does not constitute advice to/not to diagnose or treat. Any personal medical issues the reader may have should be referred immediately to the reader's private physician and under no circumstances should anyone delay, change, or alter any medical treatment or planned treatment or diagnosis based on anything read on this site. Under no circumstances does any herein contained information represent a medical recommendation."

That hardly compares with an expert medical opinion accepted in court.

The second site, http://braininjury.com/ ,which I see is one operated by attorneys specializing in brain injury suits, states, "The MRI and CAT scan slice the brain radiographically into slabs. The MRI does this with magnetic fields; the CAT scan uses x-rays. The MRI provides more detail than the CAT scan. Hence, brain damage seen on an MRI - as small as 1-2mm in size -- may escape detection by a CAT scan." That statement alone seems to imply that had an MRI been done, even more extrensive damage would have been revealed, so I fail to see what difference it would have made.

Why? Why continue to rehash these same arguments? It doesn't matter how many doctors saw her, how many experts viewed or will view the medical records. They will have differing opinions. Some opinions will be based on experience, some based on "moral" judgements in this high profile case. But in the end, none of it matters. She's dead now. She's dead because the courts found that regardless of her condition, she had expressed to her husband and others that she would not have wanted artificial means keeping her alive. And on what were ruled to be HER wishes, the PEG tube was removed. The rest of this is totally irrellevant.

And you know what? No one would have given this a second thought if her parents hadn't found a benefactor to finance 8 years and 20+ appeals. Quite frankly, if they cared so damn much about her and believed that she knew what was happening, then maybe they should have spent some time with her in the last 2 weeks of her life instead of going to courtroom after courtroom and giving press conferences villifying her husband, the courts, the legislators and other politicians whose hands were tied by the LAW.

Not everyone is imputing their own belief. Personally I am unsure whether do I want to be kept alive for eternity (or until death do me part). But one question to ask is are you yourself imputing your belief on the her in question?

Secondly, the burden of proof is on the person (husband) seeking the petition and he has succeeded in showing the decision of Terri was that she did not want to live in such a condition.

One could validly argue that for such a situation one needs to be 100% certain that is if she left an express will, bearing in mind that even in criminal cases 100% certainty is not required nor actual video footage of the event.

Furthermore, one could even argue base on the above that we should do nothing (meaning to keep the status quo and leep her alive). But that is not doing "nothing" because such a decision is an action that is violating her choice. It cannot be considered doing "nothing" when the nothing in effect is a course of action that is the antithesis of her choice.

Finally, here is the important crux of the issue. What is your underlying position on this general issue of the right to die. If your position is that of the parents whereby even if there is an express clear will by the person one will still be against such an action, then it is obvious your decision cannot be reconciled with the position on those that support the right to die. That would be what I call the primary concern. Thus every other argument is merely to support that primary concern whether or not one actually believes in them. Then if that is so then there really is no point arguing about the secondary arguments since those are not really addressing one's key concern.

You're right. Not everyone, and certainly not all of those who are or claim to be "experts", are imputing their own belief system into the conclusions they draw. But I do believe that some of the "experts" are, particularly the ones who are not testifying in court and have limited access to the records, but still choose to comment on it.

We should keep "re-hashing" this case because it represents issues that will affect the lives of almost *everyone* at some point, when either they themselves or a loved one becomes incapacitated.

Personally, I'm not aligned with either right-to-live or right-to-die agendas. Every person should decide for themselves what is right. There is no clear and convincing evidence of what Terri wanted for herself. If there were, there would be no reason not to follow through with her wishes, despite her parents' feelings about it. Terri should have gotten the benefit of the doubt, and if you look at this case with an unprejudiced eye, it's obvious she didn't.

To this day:

There is no definitive explanation for her collapse in 1990.

There is no consensus on exactly what her condition is nor why and how it was caused.

There is no explanation as to why all therapy and treatment for Terri stopped other than that is what Michael Schiavo wanted.

There is no documented legal proof of her wishes should she become incapacitated with the exception of *hearsay* evidence from Michael Schiavo, 7 YEARS into her condition. Aside from only this hearsay *evidence*, Schaivo was living with another woman (with whom he had two children), a clear conflict of interest.

Doctors and judges are not God. They are fallible human beings. It seems to me that there were many mistakes made here all with devastating consequences for Terri. This woman never had a chance being surrounded as she was by people with agendas and conflicts of interest (both Felos and Dr. Cranford are right-to-die advocates, Judge Greer and Attorney Felos are both on the board of directors of the company which runs Woodside Hospice where Terri was dehydrated to death - that alone should have been enough to make Greer recuse himself from this case.)

Where was the harm in having the MRI done, or having Terri examined by an independent, unbiased neurologist? Didn't Terri deserve that last chance? How long would it have taken, another few weeks, or months? Couldn't that have been spared for her, since her life was at stake? What if it was found that PVS had been misdiagnosed after all? Was that the fear?

I noted the disclaimer on the codeblueblog, and I don't take that to mean that what is written there is fiction, merely that they are protecting themselves legally since the subject matter is medicine. People are litigation-happy these days and they'd be foolish not to have a disclaimer.

The blog aside, what's difficult to dismiss is that many neurologists are also of the opinion that Terri was not given the type of thorough testing and examination necessary to arrive at the conclusion that she was PVS.

A writer for National Review Online spent 10 days interviewing (unbiased) neurologists who were willing to come forward and offer affidavits or declarations concerning additional and new testing for Terri. Almost 50 neurologists said the same thing: "Terri should be reevaluated, re-examined and there are grave doubts as to the accuracy of the diagnoses of PVS". All of these neurologists are board-certified, a number are fellows of the prestigious American Academy of Neurology and are professors of neurology at major medical schools. Among them: Dr. William Bell, professor of Neurology at Wake Forest University Medical School who has stated that a CT scan doesn't give much detail, thus the necessity for an MRI. Dr. Thomas Zabiega, who trained at the University of Chicago said "Any neurologist who is *objective* would say 'Yes' to the question 'Should Terri be given an MRI?'"

Dr. Peter Morin, neurologist and researcher specializing in degenerative brain disease, when told Michael Schiavo had refused both MRI and PET scans for Terri said "That's criminal. How can he continue as guardian? He refused a non-invasive test? People are deliberating over this woman's life and death and there's been no MRI or PET? These people don't want the information."

He continued: "People trying to do the right thing want the best and most complete information available. We don't have that in Terri's case."

Various factors played a role in my acceptance of removal of Terri Schiavo's feeding tube:
Personal experience with terminally ill family members: twin brother (leukemia), father ( multiple strokes, organ failure), grandmother (breast cancer), great-uncle (ALS), cousin (also ALS), in addition to friends (AIDs, testicular cancer, pancreatic cancer) and pets (2 with kidney cancer, one with pancreatic cancer, one with leukemia).
Conversations with family members in the medical field: 3 RNs (sister with 24 years' experience, primarily in ERs, transplants, AIDs, oncology, and hospice care); husband (geriatrics and hospice since 1993), cousin (all fields), and brother (operating room tech, then EEG tech, who had to establish "brain death".)
As a lapsed Catholic who attended an RC high school and Jesuit university, I'm very much aware of the "right-to-life" movement. However, I feel that the Schindlers allowed themselves to be instrumentalized by the "pro-lifers" who wish to change all legislation regarding procreation, etc., and then by legislators who fear that their efforts to mobilize the "religious conservatives" will be undermined by so-called "activist judges". I question their backers' motives, to put it quite simply, and feel they they twisted the truth to appeal to human emotions.
I prefer to make my own value judgments, rather than to be swayed by people with a political agenda, and to only quote their reading recommendations.
Since Terri Schiavo is now dead, and has been cremated, there's little point in continuing this discussion. Thousands of people die after the removal of feeding tubes worldwide every day; most family members manage to reach an agreement by compromise. The majority of the states in the U.S. allow the surviving spouse to make medical decisions when no "living will" exists. In Pennsylvania,(much like Texas and Colorado). where both the Schindlers and Schiavos lived before moving to Florida, a "survivors' compromise" is the norm. Since both the Schindler family and Michael and Terri Schiavo reside(d) in Florida, they can hardly expect to have PA laws applied there. In Florida, the legal spouse is the decision maker.
I personally don't want to see the separation of powers, i.e., a division of powers among the executive, legislative, and judicial branches, undermined to any extent. Those who advocate it should ask themselves if they'd like to live in Iran, or Afghanistan in the Taliban days.