An M.D.'s perspective

I received an email response to my Schiavo's End post from an M.D. in northern Wisconsin. I liked it a lot, because I'm not often privy to the professional irritants manifest in medicine, which apparently extend past the "does this look infected?" standard query. (Engineers get that question too, but only in the context of personal computers).

So I'm happy to have obtained permission to post the email here (with minor changes for readability and to obscure identities). My email response will be reproduced in a subsequent post.

First of all, no offense to any of you or the beliefs of others; but as a physician, I see this case as cut and dried.

I was about to write a commentary in that blog-whatever forum but I changed my mind for now. I will write to all of you on a medical point of view. This was done in voice recognition, so there may be a few typos:

One of the greatest vagaries that I know of is medical ethics. Here you have medical experts, who present factual information, and this factual information gets contorted by the legal system and by the emotions of the general public, and then the know-it-all government gets involved and mucks things up even further.

T. Schiavo has been in a persistent vegetative state for 15 years. The persistent vegetative state means that the patient is in a coma but has active sleep-wake cycles. The sleep-wake cycles are non-cognitive and represent the most primitive portions of the brain.

Fact: a coma is a state of unarousable unresponsiveness. It can be caused by diffuse insults to the cerebral hemispheres (the cognitve higher functioning parts of the brain which separates humans from bacteria) or damage to the reticular activating system in the brainstem, which is necessary to maintain cortical operations.

Here is the CT scan of a healthy brain, left, and T. Schiavo's brain, right [image not posted]:

The entire parenchyma (brain tissue) is gone as the low oxygen (anoxic) insult caused permanent cortical cell death. Cerebral spinal fluid has replaced the void where brain tissue once was.

Fact: "Patients in a vegetative state have complete unawareness of self and the environment and show no evidence of purposeful responses to stimuli, but continued to have sleep wake cycles and preserved brainstem function" - MKSAP 13 American College of Physicians.

To see a summary of the Shiavo case, here is a web link, but I am sure you know the case details better than I.

Therefore:

All we have is the verbal request, as stated by her husband and friends, that she did not want to have any extraordinary measures (tubes, etc.) and that she essentially declared herself as a do not resuscitate.

The parents of T. Schiavo somehow were able to get tube feedings started and apparently there's been an ongoing battle for the last 15 years to have these tube feedings withdrawn.

Ethically/legally, the husband is the guardian. It makes no difference what her parents ask to be done or anyone else other than her husband. Ethical law, our medical teachings, provide a hierarchy for decision making and responsibilities in situations such as these. If the patient is not autonomous then the husband is next in line, then parents, siblings, close friends, etc.

One might argue that T. Schiavo's husband has things to gain by her death. If she had a mere stroke, but still had some cognitive function to provide quality of life this would be a more difficult case. One would expect a true guardian to do everything possible to provide quality care and treatments to maximize her quality of life and one would think there were ulterior motives if the guardian did not fulfill the obligation on behalf of the patient.

This is not the case here: this person is one fraction away from pure brain death and has been so for 15 years. She will never wake up, never hear, see, smell, taste, feel, or even have the ability to acknowledge existence as the entire cortical area of her brain is irreversibly destroyed.

[Kwik2Jujj], your statement I feel is incorrect: "Such painstaking agency for the disabled is not usually necessary, but this is not a 'normal' case like siblings quibbling over grandma's intravenous drip during her last month of Alzheimer's. What is being discussed is authorization to kill someone who was not dying, and in such extraordinary circumstances the lack of independent consideration on behalf of the person to be killed is bewildering."

Removing the feeding tube is not killing someone (medical ethics 101), and until society understands the medical profession with both its extraordinary capabilities of extending natural life and shortcomings of failing to provide immortality, we will continue to have discussions like these.

I therefore would be a murderer because I have removed tube feeds, ventilatory support, and IV fluids many times -- and in circumstances that were more "gray" than this one.

Schiavo died 15 years ago. Modern medicine has given her nutrition to sustain a few brainstem (not brain) cells that govern respiration and non-cognitive function, with no hope of her ever reaching consciousness. Withdrawal of the feeding tube is allowing her to truly die peacefully. If she is truly alive then she needs to feed herself, communicate needs, experience happiness, sorrow, grief, anger, interact and show awareness to the world. Medicine provided prolonged unnatural existence, so removing the unnatural means of existence is not killing.

Society is very quick to say that doctors are killing their loved ones.

I have been there. I have coded people back to life and I have failed at bringing people back to life. Families were thrilled that I saved their loved one's life -- treating me like God -- and a week later were threatening to sue my ass because their loved one was cognitively impaired or like Schiavo. I have coded persons where I did not have a directive, only to find the family barging into the room at the end of the code stating that their loved one is a DNR and they are going to call their attorneys. "Gee I'm really sorry that I tried to save your loved one's life, and I really would have tried to call; but if I did take an extra ten seconds to contact you he would have surely died and then you-all would have told me he was to be resuscitated and my ass still would be sued!"

Physicians play God because society wants it and we extend life by unnatural means -- so to take away extraordinary measures such as tube feeds is not killing, but merely allowing the patient to pass on. Which is what would have happened 15 years ago.

By the way... who was paying the tens of thousands of dollars per day for Schiavo to receive her care when there is no hope of her ever regaining consciousness or meaning of self?

Imagine the cases similar to this nationwide and the amount of funds spent in futility. Society needs to change its values. We need to provide the appropriate care to those in need, where there is reasonable chance of obtaining cognitive function. Millions of dollars are wasted on futile cases, and this money could provide care for hundreds or thousands of individuals who either don't have insurance or the finances to treat curable illnesses. We need a multifaceted team approach to allocate resources. Imagine funneling this money into Medicare... problem solved!

Morals of the bit** session:

1. Today over lunchtime demand to meet immediately with your attorneys to get your living will/power of attorney stuff drafted. It doesn’t matter that they can’t see you on short notice! You are an American and the Constitution says you can see any doctor and any lawyer at any time and get whatever you want, because medical and legal counsel are your God Given Right -- and by the way demand they don’t dare charge you a fee for this God Given Right!

2. Support legislation which allocates monies in futile cases to other areas of need, like research for cancer, deadly-but-curable diseases, and the Medicare problem!

3. Society -- including government, the legal and medical professions -- need to collaborate to set guidelines as to how to handle these ethical dilemmas.

4. Whether you or I or anyone else hold differing opinions on this, it comes down to this: money!! And availability of resources. If this husband were Bill Gates, he could pay for the hospital bed and feeds and there’s no financial strain on the system. But a bed is being tied up that could be used to save someone’s life.

Well, I did get a little emotional near the end. But then again [colleague] (as chief of the northern Wisconsin medical ethics department) and I deal with this every day, and it is extremely frustrating.

No hard feelings.

Any of you... feel free to reply.