Tuesday, May 03, 2005

Neurologist and Terri Schiavo

THE TERRI SCHIAVO CASE: A CATHOLIC NEUROLOGIST’S PERSPECTIVE
Over the past several weeks, it has come to my attention that significant debate has developed regarding the Terri Schiavo case. I have read various e-mail messages between Cathy Beal, Father Cekada, Father Dardis, Bishop Sanborn, and two letters appearing in the St. Gertrude the Great Church bulletin.
Let me begin by stating that I do not feel I have either the theological expertise (mine is limited to a minor in theology at Xavier University, a Jesuit college in Cincinnati) or moral authority to adequately address the theological aspects of this case. However, I do feel that my background as a neurologist with additional specialized “fellowship” training in both neurological critical care (the subspecialty of neurology which deals with patients in comas and other critical neurological illnesses) and stroke, at the Cleveland Clinic and University of Cincinnati respectively, put me in a position to contribute some thoughts on the medical
aspects of her case. Since completing medical school, I have over 15 years of experience training, practicing, and doing research in these areas. I have also had the opportunity as the result of my trainingand expertise in these areas to testify as an expert witness in such matters in medical malpractice and pharmacological product liability lawsuits. I state the above not to be prideful, but to give you some tangible appreciation of the fact that, simply speaking, there are few people in the country with any better training background or practical expertise to understand in detail the scientific and medical aspects of the care of patients like Terri Schiavo, whom I deal with on literally an almost daily basis.

I have reviewed the CT scan images of Terri Schiavo’s brain, watched the video of her taken by her family members, and also reviewed some summary comments/ excerpts regarding testimony given in deposition transcripts in her medical malpractice case. These again are all things I do on a very frequent basis. They are, to be frank, part of how I make my living. Having clarified the context in which I share my thoughts with you, I offer the following thoughts on this matter:

1) Terri Schiavo was NOT in a persistent vegetative state. The video taken of her clearly and unequivocally demonstrates that, at least at times, she is in a minimally conscious state and capable of interacting in a rudimentary way with her family and environment, which by definition excludes her from being medically classified as comatose or in a persistent vegetative state.

2) The parts of Terri Schiavo’s brain which would allow her to perceive pain, her thalami, were clearly intact and visible on her CT scan images shown by her husband, Michael Schiavo, on national television (which I rarely watch, and by the way, I have never voluntarily watched “Oprah”)

3) The parts of Terri Schiavo’s brain which would allow her to perform complex cognitive function, or which would enable her to speak or understand speech, were clearly damaged.

4) The parts of Terri Schiavo’s brain which would allow her to swallow on her own were intact and, in fact, she did not suffer from medically significant dysphagia (swallowing difficulty). If she had, she would have been dead long ago from a condition known as aspiration pneumonia, an infection in the lungs which is the result of inhaling one’s own saliva.

5) The parts of Terri Schiavo’s brain which would allow her to move her arms and hands to feed or hydrate herself were clearly damaged.

6) The parts of Terri Schiavo’s brain which would allow her to experience discomfort and/or pain due to hunger were undamaged.

7) Other tests were available to better clarify the full extent of Terri Schiavo’s awareness or lack thereof, such as MRI scanning of her brain ( a more detailed picture of the brain than a CT (CAT) scan, EEG (a brainwave test), and evoked potential studies, which could decipher the extent to which she could hear or see. These studies were refused by her husband, Michael Schiavo.

8) Terri Schiavo did not receive or require intravenous hydration or nutrition (so-called “TPN” or total parenteral nutrition.

9) Oral or stomach tube feeding via an “NG” (nasogastric tube) (a tube put down one’s throat to the stomach) or (more commonly) via a “G-tube” are routinely used to feed stroke victims, both temporarily and indefinitely in patients with stroke or other brain injuries who cannot feed themselves, whether due to swallowing problems (which occur at least temporarily in most stroke victims). Such feeding and hydration are by modern medical standards considered as ordinary and unburdensome as eating and drinking on one’s own. Such feedings are, in fact, less expensive than what an average American spends on food and water, and are easily administered a few times a day by a family member, requiring much less effort than cooking three meals a day. Terri Schiavo’s husband, parents, or siblings could easily administer such
feedings. They are by no logical measure extraordinary or unduly burdensome by any reasonable standard (moral, medical, or economic).

10) Terri Schiavo could have been cared for at home with some home health care assistance at modest to at most moderate expense which would not by any common sense standard be deemed economically burdensome.

11) Terri Schiavo’s stomach and intestines were fully functional and capable of digesting food, even normal food if it was placed in her G-tube.

12) Terri Schiavo could have received sequential neurostimulation therapy to her throat muscles, which may have further improved her swallowing function to the point that she may have been able to chew or swallow at least some types of normal food and/or liquid if placed in her mouth. This and other similar available measures were denied to her by her husband.

13) Terri Schiavo’s brain, while severely damaged, had not “failed.” When someone’s brain “fails” i.e. is irreparably and totally damaged, they are, by definition, dead. While we can keep people alive when other vital organs such as the liver, kidneys, lungs, and even heart fail (via dialysis, organ transplantation, etc.), not even 2005 era medicine can keep one alive if one’s brain has failed, because all other organs shut down within 5 days when this occurs, even when every maximal effort possible is made.

14) Terri Schiavo did not require, nor to the best of my knowledge did she ever receive intravenous nutrition (TPN), as was suggested in one of Father Cekada’s e-mail messages. Lifelong TPN, in contrast to tube feeds, is widely considered to be an extraordinary, burdensome, and expensive means of prolonging life, and are comparable to a respirator in that regard.

15) Terri Schiavo’s doctors did, in my opinion, probably commit malpractice by failing to order routine pre-procedure labs which would have disclosed severe electrolyte disturbances secondary to her bulimia.

16) Medical malpractice care awards/settlements are often grossly overinflated due to plaintiff’s attorneys hiring so-called “life care planners” who add up every conceivable convenience and treatment imaginable as “necessary” for the rest of the patient’s life. Their overestimates are typically further compounded by overestimating the patient’s life expectancy. Furthermore, all the money is paid in advance at today’s dollars, meaning the real money value of the award is much higher than the actual cost of such care in the vast majority of such cases. Terri Schiavo’s true care needs would certainly be far less than 750,000 or
1,000,000 dollars.

17) Attorneys representing patients and defendants in medical malpractice and other medicolegal matters often “shop around” for expert witnesses until they find experts who will give an opinion which suits their client’s needs. Thus, it is no surprise that George Felos, a well-connected euthanasia advocate, was able to find three physicians to testify that Mrs. Schiavo was in a persistent vegetative state. In fairness, likewise it is no surprise that Terri Schiavo’s parents and siblings’ attorneys found expert witnesses who testified that she was not. One should certainly be suspect of the testimony of an expert witness who has spoken to the
Hemlock Society and concludes that Terri Schiavo is in a persistent vegetative state.

18) Terri Schiavo died of dehydration, not starvation. Dehydration kills one much faster than starvation, barring the exception of extreme malnourishment, which was not the case here.

19) Terri Schiavo had an average life expectancy despite her brain injury, and would not have died were it not for her being deprived of nutrition and hydration. The proximate legal and medical cause of her death in my opinion was dehydration.

20) Laws regarding who has legal authority over health care decisions vary greatly by state. In Pennsylvania, for instance, children and siblings have as much right to make medical decisions as spouses, unless a pre-specified durable power of attorney designating one of them pre- exists the illness, or unless a living will was written by the patient. Other states require a durable power of attorney to be obtained no matter what. Ex- spouses, unless they are made durable power of attorney, have no legal right to make medical care decisions in any state.

21) Discontinuation of tube feeds or any form of food in general causes intense hunger pains for 2-3 days, which Terri Schiavo would have had the capacity to feel and suffer.

22) Death by dehydration occurs slowly, eventually causing hyperosmolarity often resulting in shriveling, cracking, and bleeding of the mucous membranes. This causes pain, nosebleeds, and as consciousness begins to wane, patients often begin aspirating blood from the nosebleeds, thickened, mucus or saliva, or both, causing aspiration pneumonitis. The aspiration along with accumulation of unsecreted organic acids results in progressive shortness of breath which further compounds the mucus membrane injury. Observing this struggling to breath and choking is often very disconcerting to family members as well as potentially painful and discomforting to the patient. This is why such patients are often administered
morphine, which both relieves pain and suppresses this so- called “air hunger.” This is also I suspect why the judge in the Terri Schiavo case barred pictures or video of her being taken while she dehydrated and starved. Much as those who are pro- abortion most detest the one thing which actually shows people what happens in the case of abortion (pictures of aborted babies), euthanasia advocates do not want people to see the visible suffering which often occurs in cases like Terri Schiavo’s.

23) Cases like Terri Schiavo’s are, thankfully, rare. This is why when they occur and ultimately result in legal battles, we hear about them on the media. Collectively, even if one were to assume each and every one of them were to result in a lifetime of tube feedings, would be far less of an economic burden on society than a new football stadium.

Cases like Terri Schiavo’s understandably evoke a wide range of emotional responses and theological arguments. Unfortunately, the Catholic Church, theologians, and bioethicists in general lag far behind in their scientific understanding of the rapid and increasingly complex advances in medical care, which often occur literally even prior to our ever having the opportunity to contemplate their moral and theological implications. It is in the spirit of attempting to help simplify and clarify some of the medical aspects of the Schiavo case that I share the above thoughts with those who are inclined to read them. Finally, I would
advise each and every person to prepare a living will as you would a normal will so that your families might be spared the pain and anguish of having to decide what care measures you would want should a grave or terminal illness occur. Had Terri Schiavo done so, her family and many others would have been spared from the bitter, divisive, and expensive series of legal battles which followed, which were the real extraordinary burden to society in her case.

Respectfully,
James M. Gebel Jr., M.D., M.S., F.A.H.A.

1 Comments:

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10:17 AM, May 03, 2005  

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