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Sunday, April 03, 2005

Rest in Peace - Last Remarks

   As we know, Terri Schiavo has finally found relief from the prison of her severely damaged mind and body. I rarely find joy in a person's death, nor do I at her's; but I am relieved for her and her family. Perhaps her parents can find another cause to rally around. Her husband, having already moved on; perhaps can have a more peaceful life outside of the camera eye.

   There are a lot of things about Terri's case that people are confused about, some details that, although as readily available as the misinformation; not available in the sheer volume as the repeated misconceptions. A glib example: I always prefer the local grocery store's 'store brand' peanut butter to Jif and Peter Pan because they are not overly sweet as those heavily advertised brands, as is my preference. Have you ever heard of 'Great Value' brand peanut butter?

   Back on point, Terri's husband did not beat her into her brain-damaged condition, the court case was not simply to defend his right to decide for her, and the judge that had decided it was Terri's intent not to live under the conditions she was forced to all these years had not based that decision solely on her husband's testimony or his wishes, nor had his opinion or wishes been the locus of the case. A chopped, condensed bit, taken from here: http://abstractappeal.com/schiavo/infopage.html
(For more info go there.)


What happened to Terri?

The Second District's opinion in the first appeal in this case explains:

On February 25, 1990, . . . Theresa, age 27, suffered a cardiac arrest as a result of a potassium imbalance. Michael called 911, and Theresa was rushed to the hospital. She never regained consciousness.

I've heard Michael beat or strangled her nearly to death and that he wants her to die to cover up his abuse. What really happened?

The cause of the cardiac arrest was adduced to a dramatically reduced potassium level in Theresa's body. Sodium and potassium maintain a vital, chemical balance in the human body that helps define the electrolyte levels. The cause of the imbalance was not clearly identified, but may be linked, in theory, to her drinking 10-15 glasses of iced tea each day. While no formal proof emerged, the medical records note that the combination of [Theresa's] aggressive weight loss, diet control and excessive hydration raised questions about Theresa from Bulimia, an eating disorder, more common among women than men, in which purging through vomiting, laxatives and other methods of diet control become obsessive.

But isn't there a bone scan that shows Terri was beaten?

I honestly don't know. What I understand is that a bone scan was taken in 1991 and that the doctor who read it saw on it evidence of past trauma at various places on Terri's body. Some consider that evidence of a severe beating by her husband, others consider it evidence consistent with bulimia, a fall, and CPR by paramedics. Whether trauma really happened, or what kind, or when, are all unclear.

The bone scan was not raised in the original trial regarding Terri's wishes. The issue was raised by the Schindlers in a November 2002 emergency motion. Judge Greer rejected the matter as being irrelevant to the issue of Terri's wishes. See the order linked in the timeline above.

What's happened to Terri since her collapse?

The Second District's first opinion in this case explained:

Since 1990, Theresa has lived in nursing homes with constant care. She is fed and hydrated by tubes. The staff changes her diapers regularly. She has had numerous health problems, but none have been life threatening.

Over the span of this last decade, Theresa's brain has deteriorated because of the lack of oxygen it suffered at the time of the heart attack. By mid 1996, the CAT scans of her brain showed a severely abnormal structure. At this point, much of her cerebral cortex is simply gone and has been replaced by cerebral spinal fluid. Medicine cannot cure this condition. Unless an act of God, a true miracle, were to recreate her brain, Theresa will always remain in an unconscious, reflexive state, totally dependent upon others to feed her and care for her most private needs.
In a later opinion in the same case, the Second District further explained:

Although the physicians are not in complete agreement concerning the extent of Mrs. Schiavo's brain damage, they all agree that the brain scans show extensive permanent damage to her brain. The only debate between the doctors is whether she has a small amount of isolated living tissue in her cerebral cortex or whether she has no living tissue in her cerebral cortex.

Why didn’t Terri’s parents get a chance to prove that Terri wouldn’t want her feeding tube to be removed?

They did. As explained above, the trial judge held a trial on this issue and determined that the evidence clearly and convincingly showed that Terri would not want to continue life-prolonging measures in her current state.

Can't the parents appeal the trial judge's decision, and shouldn't conflicting evidence be judged in favor of continuing life?

The Schindlers did appeal, and the Second District determined that while a surrogate decision-maker should err on the side of life, the trial judge had sufficiently clear and convincing evidence to determine that Terri would not wish to continue the life-prolonging measures she needs to live. The appellate court explained:

[T]he Schindlers argue that the testimony, which was conflicting, was insufficient to support the trial court's decision by clear and convincing evidence. We have reviewed that testimony and conclude that the trial court had sufficient evidence to make this decision. The clear and convincing standard of proof, while very high, permits a decision in the face of inconsistent or conflicting evidence. See In re Guardianship of Browning, 543 So. 2d at 273.

In Browning, we stated:

In making this difficult decision, a surrogate decisionmaker should err on the side of life… In cases of doubt, we must assume that a patient would choose to defend life in exercising his or her right of privacy.
In re Guardianship of Browning, 543 So.2d at 273. We reconfirm today that a court's default position must favor life.

The testimony in this case establishes that Theresa was very young and very healthy when this tragedy struck. Like many young people without children, she had not prepared a will, much less a living will. She had been raised in the Catholic faith, but did not regularly attend mass or have a religious advisor who could assist the court in weighing her religious attitudes about life-support methods. Her statements to her friends and family about the dying process were few and they were oral. Nevertheless, those statements, along with other evidence about Theresa, gave the trial court a sufficient basis to make this decision for her.

In the final analysis, the difficult question that faced the trial court was whether Theresa Marie Schindler Schiavo, not after a few weeks in a coma, but after ten years in a persistent vegetative state that has robbed her of most of her cerebrum and all but the most instinctive of neurological functions, with no hope of a medical cure but with sufficient money and strength of body to live indefinitely, would choose to continue the constant nursing care and the supporting tubes in hopes that a miracle would somehow recreate her missing brain tissue, or whether she would wish to permit a natural death process to take its course and for her family members and loved ones to be free to continue their lives. After due consideration, we conclude that the trial judge had clear and convincing evidence to answer this question as he did.

Was Michael the only person who testified about Terri's supposed statements on her views about living on life support?

No, others did as well, and when making the decision in the case, the trial judge took into account all of that testimony and additional evidence. As the Second District explained:

We note that the guardianship court's original order expressly relied upon and found credible the testimony of witnesses other than Mr. Schiavo or the Schindlers. We recognize that Mrs. Schiavo's earlier oral statements were important evidence when deciding whether she would choose in February 2000 to withdraw life-prolonging procedures. See § 765.401(3), Fla. Stat. (2000); In re Guardianship of Browning, 568 So. 2d 4, 16. Nevertheless, the trial judge, acting as her proxy, also properly considered evidence of Mrs. Schiavo's values, personality, and her own decision-making process.

Why has this case become such a controversy?

This case has become such a controversy because of Terri's parents' insistence that their daughter would not wish to die under these circumstances and their claim that Terri is conscious and responsive to stimulation.

The case has also become controversial because, for years, Terri's parents have publicly questioned Michael's motives for wanting to discontinue Terri's life support. Specifically, they have charged that Michael remains Terri's husband and is working to end her life so he can inherit whatever money remains from a $1 million 1993 medical malpractice settlement Michael recovered on behalf of himself and Terri. Presumably, if Michael divorced Terri, then he would not have access to Terri's portion of the money, and upon her death her parents would inherit it. News reports also indicate that Michael is engaged to another woman.

What about the Schindlers' claims that Terri is conscious and responds to stimulation?

When the Second District first reviewed the trial court's decision that Terri would choose not to live under her present circumstances, the appellate court expressed no reservations when it explained that Terri was and "will always remain in an unconscious, reflexive state, totally dependent upon others…" In October, 2002, as a result of Terri's parents' claims that treatment options offered promise to restore some of Terri's cognitive functioning, the Second District ordered the trial court to hold a trial on that issue. The trial court did so, and in the course of that trial the parties litigated whether Terri is in a persistent vegetative state.

The trial court heard testimony from five experts: two selected by Michael, two selected by the Schindlers, and one independent expert selected by the trial court. The two experts selected by Michael and the independent expert agreed that Terri was in a persistent vegetative state and that her actions were limited to mere reflexes. The two experts chosen by the Schindlers disagreed, but the trial court found their positions not credible. For instance, the trial court explained:

At first blush, the video of Terry Schiavo appearing to smile and look lovingly at her mother seemed to represent cognition. This was also true for how she followed the Mickey Mouse balloon held by her father. The court has carefully viewed the videotapes as requested by counsel and does find that these actions were neither consistent nor reproducible. For instance, Terry Schiavo appeared to have the same look on her face when Dr. Cranford rubbed her neck. Dr. Greer testified she had a smile during his (non-videoed) examination. Also, Mr. Schindler tried several more times to have her eyes follow the Mickey Mouse balloon but without success. Also, she clearly does not consistently respond to her mother. The court finds that based on the credible evidence, cognitive function would manifest itself in a constant response to stimuli.
The experts also disagreed about whether any treatment could improve Terri's condition. The two experts selected by the Schindlers each proposed a potential therapy method, but the trial court rejected both of them based on "the total absence of supporting case studies or medical literature."

Affirming those decisions, the Second District explained that it, too, reviewed the videotapes of Terri in their entirety as well as Terri's brain scans. The appellate court explained that it not only affirmed the decision but that, were it to review the evidence and make its own decision, the court would reach the same result reached by the trial court.

Were the Schindlers' doctors given an opportunity to examine Terri?

Yes. As the Second District explained:

Through the assistance of Mrs. Schiavo's treating physician, Dr. Victor Gambone, the physicians obtained current medical information about Theresa Schiavo including high-quality brain scans. Each physician reviewed her medical records and personally conducted a neurological examination of Mrs. Schiavo. Lengthy videotapes of some of the medical examinations were created and introduced into evidence. Thus, the quality of the evidence presented to the guardianship court was very high, and each side had ample opportunity to present detailed medical evidence, all of which was subjected to thorough cross-examination. It is likely that no guardianship court has ever received as much high-quality medical evidence in such a proceeding.

What about the video clips that show Terri reacting to her mother?

The court opinions indicate that similar videos were viewed in their entirety by the trial court, which found that Terri's actions were no more than reflexive and could not be reproduced with any consistency. The Second District affirmed that decision.