Lecture 6 Forgoing Life-sustaining Treatments And the Conflict of Values

扁鹊 病有六不治 驕恣不論於理，一不治也； 輕身重財，二不治也； 衣食不能適，三不治也； 陰陽并藏氣不定，四不治也； 形羸不能服藥，五不治也； 信巫不信醫，六不治也；有此一者，則重 難治也 《史记 · 扁鹊列传》 《 古今圖書集成醫部全錄卷五百四 醫術名流列傳 》

Karen Ann Quinlan coma since 1975 Died: 1986

Should we operate on Baby Doe?

This oft-published photograph, taken in the late 1980s, shows Terri in her mid- 20s alive and well. (St. Petersburg Times)

On Feb. 25, 1990, Terri collapsed from an apparent cardiac arrest. She was deprived of oxygen for five minutes, suffering the brain damage that left her in what the courts later ruled was a persistent vegetative state. She was 26 years old.

In early 1990, Mr. Schiavo says he awoke to a thud in the dead of night and found his wife passed out on the floor. Together, the Schindlers and Mr. Schiavo learned that Ms. Schiavo's heart had stopped and that she had suffered drastic brain damage before the paramedics arrived. Doctors say a potassium deficiency, possibly caused by an eating disorder, led to her collapse. Here, in November 1990, Mr. Schiavo visits with his wife at College Harbor Nursing Home. (NYTImes)

The Schindlers used this undated photo of Terri, her hair styled, eyes outlined by mascara, as evidence to counter Michael Schiavo's contention in 2003 that she was in a persistent vegetative state.

Response or reflex? In this image taken from four hours of videotape, the Schindlers argued that Terri was able to respond to her mother.

Ms. Schiavo with her mother, Mary Schindler, in late 2001.

Court verdict n Michael Schiavo asked a court’s permission to remove his wife’s feeding tube, 1998 n A court in Florida determined that Terri Schiavo had wished not to be kept alive artificially, 2000 n Further legal battles n Feeding tube removed, March 18, 2005

Examples of physiologic futility Performing CPR in terminal patients with disseminated malignancy Performing CPR in a patient with multi- trauma or sepsis who is in severe shock with multi-organ failure despite maximally intensive therapy.

CPR: Why Not? (Dr. Jane Chan, QMH) More harm than good Patient autonomy Medical futility  Harmful effects of CPR –Bodily injury –Take away the dignity of dying. –Prolong the dying process.  Patient refusal by living will or advance directive –President Nixon  Terminal conditions for which CPR is thought to be futile

Benefits of withholding CPR (Dr. Jane Chan, QMH) Avoid unnecessary bodily injury and prolongation of life. Allow the patient the dignity and peacefulness of dying. Allow family and friends to gather at the bedside during the final moments.

Choice for the patient and family: “Hi-tech” dying vis-à-vis natural dying when the hi-tech intervention is not going to alter the dying process (Dr. Jane Chan, QMH)

The hi-tech dying process (Dr. Jane Chan, QMH) Family’s access to the patient is limited by ongoing bedside activities. Patient is subjected to the trauma of CPR. The dying process may be temporarily halted by life-sustaining devices. Patient connected to tubes and lines.

The natural dying process (Dr. Jane Chan, QMH) Family gathering around HandholdingGriefing The patient’s last breath is the patient’s last breath

2002

2003

終於得享安息

p.v.s. and euthanasia n Issue 1: Is a patient in p.v.s. a dying patient? (NB: persistent ≠ permanent) n Or is s/he only temporarily incapacitated? n Issue 2: is artificial hydration and nutrition a medical treatment? n Or is it a humane support to a temporarily disabled person?

Persistent Vegetative State n A persistent vegetative state, which sometimes follows a coma, refers to a condition in which individuals have lost cognitive neurological function and awareness of the environment but retain noncognitive function and a perserved sleep-wake cycle.

n It is sometimes described as when a person is technically alive, but his/her brain is dead. n However, that description is not completely accurate. In persistent vegetative state the individual loses the higher cerebral powers of the brain, but the functions of the brainstem, such as respiration (breathing) and circulation, remain relatively intact. n Spontaneous movements may occur and the eyes may open in response to external stimuli, but the patient does not speak or obey commands. n Patients in a vegetative state may appear somewhat normal. They may occasionally grimace, cry, or laugh.

Response or reflex? In this image taken from four hours of videotape, the Schindlers argued that Terri was able to respond to her mother.