Terri Schiavo case

File:TerriSchiavo2.jpg

Terri Schiavo before her 1990 collapse.

Theresa Marie Schiavo (December 3, 1963–March 31, 2005), commonly known as Terri Schiavo (pronounced SHY-voh, IPA: /'ʃaɪvoʊ/), was an American woman from St. Petersburg, Florida.

On February 25, 1990, Schiavo suffered severe brain damage from cerebral hypoxia caused by bulimia-induced cardiac arrest. She went into a coma for two and a half months, and later awoke from her coma to a profoundly disabled condition that was variously diagnosed as a Minimally Conscious State (MCS) or a a persistent vegetative state (PVS), a condition that lasted until her death 15 years later.

Schiavo's medical diagnosis was a subject of major dispute between her blood family (parents Bob and Mary Schindler, and her two siblngs) and her husband (Michael Schiavo, who was her legal guardian, despite having started another family with another woman). Two doctors selected by Michael after he began legal action to end his wife's life diagnosed her to be in a persistent vegetative state. A doctor selected by the court reported that it was more likely that she was in a persistent vegetative state than conscious. But two doctors selected by Terri Schiavo's parents diagnosed her to be in a minimally conscious state, and a doctor selected by the Florida Department of Children and Families reported that she was most likely in a minimally conscious state, and several dozen other physicians (mostly neurologists) likewise questioned or disputed the PVS diagnosis. However, the trial court judge, George Greer, ruled that Schiavo was indeed in a PVS, and this ruling was upheld on appeal.

The judicial and legislative battles to prevent the disconnect of her gastric feeding tube generated tremendous media coverage during the last few weeks of her life and sparked a fierce debate over bioethics, legal guardianship, federalism, euthanasia and civil rights. Michael Schiavo contends that he carried out his wife's wishes not to be kept alive in a state such as a persistent vegetative state. This became another source of major dispute between Michael Schiavo and the Schindlers. Mrs. Schiavo had no living will, and both sides brought their case before the courts. Mrs. Schiavo's parents, Bob and Mary Schindler, vigorously appealed the judicial decisions, leading to the reinsertion of the feeding tube on two separate occasions after its removal. The courts all ruled in favor of Schiavo's husband, and the feeding tube was removed a third and final time. On March 18, 2005, with the Schindlers having exhausted their legal options in 2005, they brought their dispute to Florida Governor Jeb Bush, the U.S. Congress, President George W. Bush, and the mass media as her feeding tube was removed a third and final time. Schiavo died on March 31, 2005 at around 9:05 a.m. EST. [1] An autopsy has been performed, but the results have not yet been released.

Related article: Terri Schiavo timeline

Early life

Schiavo was born Theresa Marie Schindler. Her parents named her after Saint Teresa of Avila. She grew up in the Huntingdon Valley area of Lower Moreland Township, Pennsylvania, a suburb of Philadelphia, as the eldest of three children; her younger siblings are Robert Jr. (Bobby) and Suzanne.

By her senior year in high school, Schiavo was overweight, with a height of 5'3" (1.57 m) and a weight of around 200 pounds. Schiavo went on a NutriSystem diet and lost about 55 pounds (25 kg). [2] Schiavo may have developed an eating disorder around this time in order to cope with her perceived weight problem. [3] In 1981, she graduated from Archbishop Wood High School, a private Catholic school in nearby Warminster.

She met Michael Schiavo in 1982 in a sociology class at Bucks County Community College in Newtown, Pennsylvania, where they were both students. He was her first boyfriend. After dating for five months, the couple got engaged and were married on November 10, 1984, at Our Lady of Good Counsel Church in Southhampton. They moved to St. Petersburg, Florida in April 1986. Schiavo's parents also moved to St. Petersburg three months later. In Florida, Schiavo worked as an insurance claims clerk for the Prudential insurance company, and her husband was a restaurant manager. Schiavo's friends began to have suspicions about her eating habits. After meals out, she would immediately excuse herself to go to the bathroom. Michael Schiavo was aware of her unusual eating patterns, but did not realize their potential danger. [4]

In 1989, the Schiavos began visiting an obstetrician and receiving fertility services and counseling in the hopes of having a child. At this time, Schiavo's weight had dropped to 120 pounds, and she had stopped menstruating. However, the physician who examined Schiavo did not take a complete medical history, which would have indicated an eating disorder. [5]

Initial medical crisis

On the morning of February 25, 1990, at about 5:30 a.m. EST, Schiavo collapsed in the hallway of the St. Petersburg apartment she shared with her husband. The noise awoke Michael Schiavo and he immediately called his wife's parents and 911 emergency services. The cause of the collapse was determined to be cardiac arrest. While waiting for the paramedics to arrive she experienced a loss of oxygen to the brain, causing catastrophic brain damage and total loss of cognitive function, resulting in a persistent vegetative state (PVS). The collapse also left her partially blind.

Firefighters and paramedics found Schiavo face down and unconscious, in the hallway outside her bathroom. There were no signs of violence or a struggle. Attempts were made to resuscitate Schiavo, but she remained unconscious and slipped into a coma. She was taken to the Humana Northside Hospital, and in order to keep her alive, she was intubated, ventilated, and given a tracheotomy; she also received a percutaneous endoscopic gastrostomy (PEG), a feeding tube inserted through the abdominal wall. Schiavo emerged from her coma two and a half months later at Humana Northside Hospital, but never fully recovered or exhibited any evidence of higher cortical function.

The St. Petersburg police report revealed that no illegal drugs or alcohol were found in Schiavo's system; a physical inspection did not find any sign of trauma to her head or face.

According to her discharge summary from Humana Hospital, Schiavo suffered a cardiac arrest and anoxic brain damage, accompanied by seizures, respiratory failure, and an injured knee from the fall. Her cardiac arrest is believed to have been caused by bulimia-induced hypokalemia (abnormally low levels of potassium in the blood). At the time of her hospital admission, her blood potassium level was 2.0 mEq/L; the normal range for adults is 3.5-5.0. Medical records noted that "she apparently has been trying to keep her weight down with dieting by herself, drinking liquids most of the time during the day and drinking about 10-15 glasses of iced tea." [6]

Rehabilitation efforts

On May 12, 1990, Schiavo was discharged to the College Park Skilled Care and Rehabilitation Facility. On June 18, the court appointed Michael Schiavo as his wife's legal guardian, without objection from the Schindlers. Schiavo was transferred to Bayfront Hospital for further rehabilitation efforts on June 30. She came home to her family in September; however, after becoming overwhelmed with her needs, the family sent her back to the College Park facility. In November, Mr. Schiavo took his wife to the University of California, San Francisco for an experimental procedure involving the placement of a thalamic stimulator implant in her brain. The experimental treatment took several months but was unsuccessful. Mr. Schiavo returned to Florida with her in January 1991 and admitted his wife to the Mediplex Rehabilitation Center (specializing in brain injuries) in Bradenton, often "taking her to parks and public places in hopes of sparking some recovery." There she recieved 24-hour care. On July 19, 1991, Schiavo was transferred to the Sable Palms Skilled Care Facility, where she neurological testing and regular speech and occupational therapy are done until 1994.

Around this time, Mr. Schiavo began studying nursing at St. Petersburg College to better care for his wife; eventually, he became a respiratory therapist and emergency room nurse. [7]

Family relationship and malpractice suit

From 1990 to 1993, Mr. Schiavo and the Schindlers enjoyed an amicable relationship. [8] The Schindlers even allowed Mr. Schiavo to live rent-free in their condominium for several months. On June 18, 1990, the court appointed Mr. Schiavo as Mrs. Schiavo's legal guardian, without objection from the Schindlers. During this time, the Schindlers actively encouraged Mr. Schiavo to "get on with his life." He was encouraged by the Schindlers to date, and he introduced his in-law family to women he was dating. [9]

In 1992, Mr. Schiavo, on behalf of Schiavo and himself, brought a medical malpractice lawsuit against the obstetrician who had been treating Schiavo for infertility, claiming that the doctor's failure to diagnose Schiavo's eating disorder caused her current condition. At the conclusion of the trial, the jury found that Schiavo was bulimic and that the obstetrician's failure to diagnose this condition caused her hypokalemia and subsequent cardiac arrest. While on appeal, the case was settled (May 1992) and provided that Mrs. Schiavo receive $700,000 in damages and Mr. Schiavo receive $300,000 for loss of consortium [10]. The court placed Mrs. Schiavo's award in a trust fund, which was controlled by a third party and covered her medical and legal expenses.

Legal disputes

On February 14, 1993, Mr. Schiavo and the Schindlers had a falling-out. Mr. Schiavo claims the argument arose because he refused to share the settlement money with the Schindlers. The Schindlers claim that he failed to honor commitments he had previously made to seek aggressive treatments for his wife's condition. [11] The amicable relationship ended, and Mr. Schiavo and the Schindlers literally stopped speaking to each other. [12] Mr. Schiavo placed limits on how much time the Schindlers could spend with Schiavo.

In July 1993, the Schindlers began their first challenge to Mr. Schiavo's guardianship and attempted to remove him as legal guardian.

In 1994, after three years of trying traditional and experimental therapies, Mr. Schiavo accepted the diagnosis of an irreversible persistent vegetative state. At this point, he began to accept the idea of allowing his wife to die naturally, rather than remaining in a persistent vegetative state. In consultation with his wife's physician, he halted most therapy for his wife and entered a "do-not-resuscitate" order, which he later rescinded after the Schindlers and the nursing home protested. Wolfson wrote in his report that:

In early 1994 Theresa contracted a urinary tract infection and Michael, in consultation with Theresa's treating physician, elected not to treat the infection and simultaneously imposed a do-not-resuscitate order should Theresa experience cardiac arrest. When the nursing facility initiated an intervention to challenge this decision, Michael cancelled the orders. Following the incident involving the infection, Theresa was transferred to another skilled nursing facility...

Michael's decision not to treat was based upon discussions and consultation with Theresa's doctor, and was predicated on his reasoned belief that there was no longer any hope for Theresa's recovery. It had taken Michael more than three years to accommodate this reality and he was beginning to accept the idea of allowing Theresa to die naturally rather than remain in the non-cognitive, vegetative state.

On March 1, 1994, guardian ad litem John H. Pecarek submitted his report, writing that Mr. Schiavo had acted appropriately and attentively toward Schiavo. Michael remained his wife's guardian. In May 1998, Mr. Schiavo filed a petition to discontinue life support for Schiavo. Her parents opposed it. Richard Pearse was appointed as a second ad litem.

The same year, Dr. Jeffrey Karp and Dr. Victor Gambone, Schiavo's primary care physician, determined that she was in an irreversible persistent vegetative state (PVS). On December 29, 1998, Pearse concluded that Schiavo was legally in a persistent vegetative state as defined by State Law 765.101, section 12:

(12) "Persistent vegetative state" means a permanent and irreversible condition of unconsciousness in which there is:

(a) The absence of voluntary action or cognitive behavior of any kind.

(b) An inability to communicate or interact purposefully with the environment.

Pearse found that there was no possibility of improvement and that Mr. Schiavo's decisions may have been influenced by the potential to inherit what remains of Schiavo's estate. Due to a perceived lack of evidence for Schiavo's wishes, and questions regarding Mr. Schiavo's credibility, Pearse recommends denying his petition to remove her feeding tube. According to Jay Wolfson, one of Schiavo's court-appointed guardians, due to the attention Schiavo has received in the 15 years she has been bedridden, she has never developed any bedsores.

Dr. Ron Cranford, a neurologist at the University of Minnesota, assessed Schiavo's brain function in 2001 as part of a court-ordered examination. His exam showed that Schiavo's cerebral cortex had been completely destroyed and replaced by cerebrospinal fluid. The upper brain was about 80 percent destroyed, and there was also damage to the lower brain. The only part of the brain that remained intact was the brain stem, which controls involuntary functions such as breathing and heartbeat—allowing Schiavo to survive (with a feeding tube) even though she no longer had any cognitive function. He was quoted in Florida Today as saying, "[Schiavo] has no electrical activity in her cerebral cortex on an EEG (electroencephalogram), and a CT (computerized tomography) scan showed massive atrophy in that region." [13]

In 2002, a trial was held to determine whether new therapy treatments would help Schiavo restore any cognitive function. A new computed axial tomography scan (CAT scan) was done, and showed severe cerebral atrophy. An EEG showed no measurable brain activity.

Five doctors were selected to provide their expert testimony to the trial: two by Schiavo's parents, two by Mr. Schiavo, and one by the court. The Schindler family selected Dr. William Maxfield (the Schindlers' family doctor, who was a radiologist) and Dr. William Hammesfahr (who made claims about vasodilation therapy that the court found spurious, [14] and who later falsely claimed to be a Nobel Prize nominee, being "nominated" by someone who was ineligible to nominate him. [15]). Michael Schiavo selected Dr. Cranford and Dr. James Barnhill. The court selected Dr. Peter Bambakidis. These five doctors examined Schiavo's medical records, brain scans, the videos, and Schiavo herself. Cranford, Barnhill, and Bambakidis said Schiavo was in a PVS. Maxfield and Hammesfahr said Schiavo was in a "minimally conscious state." Greer ruled that Schiavo was in a PVS and was beyond hope of significant improvement. [16] Florida's Second District Court of Appeal reviewed all the evidence and upheld the trial court's decision, saying had they heard the case themselves they would have ruled the same as Greer. Judge Greer reviewed a six-hour tape of Schiavo and concluded that her vegetative condition was factual and not subject to legal dispute.

Schiavo's condition in 2005

Left: Scan of normal 25-year-old's brain; Right: Schiavo's 2002 CT scan at age 38.

Persistent vegetative state (PVS)

Patients in a persistent vegetative state have severe brain damage and are in a state of "wakefulness without awareness." In many cases, the persistent vegetative state occurs after a coma, which is consistent with Schiavo having been in a coma following her collapse. Patients in a persistent vegetative state are usually considered to be unconscious and unaware. They may experience sleep-wake cycles or be in a state of chronic wakefulness. They may exhibit some behaviors that can be construed as arising from partial consciousness, including reflexive or random behaviors such as grinding of teeth, swallowing, smiling, shedding tears, grunting, moaning or screaming without any apparent external stimulus. They are unresponsive to external stimuli, except, possibly, painful stimuli.

The prognosis for recovery of awareness in PVS has been quantified. In general, the prognosis depends on the cause and duration of PVS. It is worse after cardiac arrest and after a long duration of PVS. Patients remaining in PVS for greater than three months after cardiac arrest have only a slight chance of recovery of awareness. Recovery of awareness is unprecedented after two years. With head injury causing PVS, the times necessary to show these levels of prognostic certainty are one year and five years, respectively. [17] [18]

Nonetheless, some dispute exists over the reliability of a PVS diagnosis. One British study found that 43 percent of patients in the study classified as being in a PVS were misdiagnosed and another 33 percent were able to recover while the study was underway. [19]

Three Florida neurologists viewed 12 of Schiavo's CT scans on March 22, 2005. [20] After viewing the scans, Dr. Leon Prockop (a professor and former chairman of the neurology department at the University of South Florida's College of Medicine) was quoted by the Sun-Sentinel as saying that Schiavo's scan exhibits the "most severe brain damage as I've ever seen." Dr. Walter Bradley, the chairman of neurology at the University of Miami's Miller School of Medicine, said that he "doubts there's any activity going on in the higher levels of her brain." Dr. Michael T. Pulley said, "The chance that this person is going to recover is about zero." [21]

On March 23, 2005, Dr. William Cheshire Jr., a neurologist and consultant at the Mayo Clinic in Jacksonville and Assistant Professor of Neurology at Mayo Clinic College of Medicine, [22] filed an affidavit [23] in which he explains that he had been asked by the Florida Dept. of Children and Families [24] to investigate allegations of abuse of Schiavo. Although no such abuse was found, Cheshire goes on to say that he believed he had found reason to doubt the PVS diagnosis and to prefer a diagnosis of "minimally conscious state" or MCS. He notes that the MCS diagnosis is recent, and cites a 2002 article to show its recent establishment. Of note is that one of the authors of that article ("The minimally conscious state: definition and diagnostic criteria," Neurology 58 (2002): 349-353) [25] is Ronald Cranford, who, in his testimony in the 2002 trial on Schiavo's medical condition, had rejected the MCS diagnosis in favor of re-affirming the PVS diagnosis which had stood for 12 years. Of further note is that in reviewing Schiavo's medical records, Cheshire does not mention the EEG tests that had played a role in establishing and re-affirming the PVS diagnosis. Cheshire visited Schiavo five days after her feeding tube had been removed. His visit lasted 90 minutes and consisted only of visual observation, not a formal medical exam. During his visit, he observed what he interpreted to be purposeful behavior, as when Schiavo appeared to be watching him for "about half a minute."

He noted that her hospice records suggested that she exhibited what might have been discomfort during menstruation. He notes that "three years have passed since Schiavo has had the benefit of neurologic consultation." Because her early brain examinations had been structural, not functional, he recommended functional examinations using new technologies, and in light of current research. He argues that a diagnosis of MCS would make "an enormous difference in making ethical decisions on Terri's behalf." If she were in an MCS, his judgment is that "it would be wrong to bring about her death by withdrawing food and water." Based on Cheshire's affidavit, Governor Jeb Bush filed a petition to have Schiavo's feeding tube restored. [26] Criticism of Dr. Cheshire includes his writing of opinion articles on stem-cell research and other scientific debates that reveal a conservative Christian viewpoint. [27]

See also: Persistent vegetative state

Issues of dispute

Schiavo's parents contend that her behavior in this image from one of the videos released by her parents showed that she was aware of the people around her. Neurologists who examined Schiavo disagree, saying that her level of brain damage made responsiveness impossible and that her behavior represented reflex or instinctive actions.

Patients in a PVS may exhibit some behaviors that can be construed as arising from partial consciousness—reflex or random behaviors such as grinding of teeth, swallowing, smiling, shedding tears, grunting, moaning or screaming without any apparent external stimulus. They are unresponsive to external stimuli, except, possibly, painful stimuli.

Schiavo's parents claim that their daughter did not meet the definition of a persistent vegetative state and was in a "minimally conscious state" instead. Her parents argue that at times her actions were indicative of responses to external stimuli, not reflex or instinctive behavior. For example, the Schindlers claim that their daughter smiled, laughed, cried, moved, made childlike attempts at speech, and attempted to say "Mom" or "Dad"; or "yeah" when they asked her a question. They claim that when they kissed her she looked at them and sometimes puckered her lips.

Schiavo's parents videotaped her for four and a half hours and produced six video segments totaling four minutes and twenty seconds. Her parents cite the testimony and affidavits of 33 physicians and therapists (including 15 neurologists) who, after reviewing these four and a half minutes of video segments, believe that Schiavo should have received further tests and/or would have likely responded to therapy. Some of these physicians have claimed that there was a "strong likelihood that Mrs. Schiavo is in a "minimally conscious state." None of the physicians saw the full four and a half hours of video. (The six video segments have been released publicly. The rest of the recorded video has not been released by Schiavo's parents.) [28]

An emergency motion to restore the feeding tube was filed by Barbara Weller, the Schindlers' co-attorney who stated that 20 minutes before the tube was removed on March 18, 2005, and in response to their attempts to coach her, "she managed to articulate the first two vowel sounds, first articulating AHHHHHHH and then virtually screaming WAAAAAAAA." Schiavo had been unable to speak since her heart attack in 1990. Weller asserted that she had told Schiavo that she would die unless she said, "I want to live." The alleged incident occurred only in the presence of family members and has not been independently confirmed; the police officer stationed outside the room said she could not recall hearing the vocalization. Judge George Greer said that Schiavo's utterances came only after being touched, which was consistent with evidence presented in 2002. "All of the credible medical evidence this court has received over the last five years is that this is not a cognitive response, but rather something akin to a person jerking his/her hand off a hot stove long before he/she has thought about it," Greer wrote. [29]

According to a December 29, 1998 report submitted by the second guardian ad litem, Richard Pearse, nursing home staff members observed the same reactions claimed by the Schindlers, except the staff noted that Schiavo's responses were random, coincidental, and unrelated to any external stimuli. However, the report did note two consistent responses: Schiavo responded to deep pain stimuli by moaning, and she opened her eyes in response to noise.

Life-prolonging procedures

Under Florida law, every person—competent and incompetent—has the right to refuse medical treatment.[30] When a person is in a persistent vegetative state and there is no living will, the decision to withhold or withdraw life-prolonging procedures may be made by another. [31] Life-prolonging procedures are defined to be, "any medical procedure, treatment, or intervention, including artificially provided sustenance and hydration, which sustains, restores, or supplants a spontaneous vital function or functions." [32] Thus, a feeding tube would be considered a life-prolonging procedure (also known as life support), while feeding by hand would not. Clinical records indicate that that Schiavo was not responsive to swallowing tests and required a feeding tube. [33]

Schiavo did not have a living will; therefore, in May 1998, Mr. Schiavo petitioned the Pasco-Pinellas Circuit Court for authority to remove her feeding tube. The case, In re Guardianship of Theresa Marie Schiavo, Schiavo v. Schindler, was randomly assigned to probate judge George Greer. The court appointed a guardian ad litem, Pearse, who produced a report concluding that Schiavo was in a permanent vegetative state. Pearse also noted that neither side was exempt from possible conflicts of interest, as Mr. Schiavo would be the sole inheritor of her money and the Schindlers hoped that they would be granted guardianship, that Mr. Schiavo would divorce their daughter, and that they would become Schiavo's "heirs-at-law." A trial was held and testimony was heard from eighteen witnesses, with evidence pertaining to her medical condition and to her end of life wishes. Judge Greer issued his order granting Mr. Schiavo’s petition for authorization to discontinue artificial life support for his wife in February 2000. In this decision, the court found that Schiavo was in a persistent vegetative state and that she had made reliable oral declarations that she would have wanted the feeding tube removed. [34] (This decision would be upheld by nineteen separate judges.)

On February 23, the Schindlers filed an expedited motion for "Relief from Judgement Pending Contemporary Medical-Psychiatric-Rehabilitative Evaluation." [35] The Schindlers wanted to reinsert Schiavo's feeding tube so that she could be tested with an fMRI and given a swallowing therapy called VitalStim. They included the affidavits of doctors and speech therapists to support their case.

On February 28, the Schindlers filed an "Expedited Motion for Permission to Provide Terri with Food and Water by Natural Means." This second motion asked for permission to "attempt to feed" Schiavo by mouth. [36]

On March 8, Judge Greer denied the second motion, saying "it has become clear that the [second] motion is part and parcel of [the previous] motion on medical evaluation. The same declarations are being used for both motions and the motion appears to be an alternative pleading to the [previous] motion. Both are asking for an experimental procedure." The first motion requests that Schiavo be given VitalStim swallowing therapy, which had never been performed on a patient who was in a PVS. The second motion simply asked permission to attempt to feed her by mouth, asserting that she might be able to swallow naturally. Greer then explained that if the first motion is approved, then the second one isn't needed, and if the first one is denied, the second one would be denied as well. [37]

On March 9, Judge Greer denied the first motion by the Schindlers, for the experimental testing and swallowing therapy. He denied the motion because an affiant doctor for Mr. Schiavo cautioned that fMRI was an experimental procedure that should be conducted in an academic setting, because Schiavo had already undergone swallowing tests and failed, and because VitalStim had only been performed on patients who were not in PVS. Greer noted that "most of the doctor affidavits submitted are based on their understanding of Schiavo's condition from news reports or video clips they have seen. Many are obviously not aware of the medical exams undertaken for the 2002 trial.... The Court cannot see how the [Schindlers] have met the burden established by Schiavo III... They are not alleging that any new treatment exists that would significantly improve the quality of her life so that [Schiavo] would reverse the prior decision to withdraw life-prolonging procedures." [38]

The court-appointed guardian ad litem, Dr. Jaw Wolfson, however, did feel that swallowing tests would be appropriate to get to the bottom of the dispute. In his report, he stated:

"Is there feasibility and value in swallowing tests and swallowing therapy given the totality of circumstances? a. Yes. There is feasibility and value in swallowing tests and swallowing therapy being administered if the parties agree in advance as to how the results of these tests will be used with respect to the decision about Theresa’s future." [39]

On March 25, Mr. Schindler told the media that his daughter's lips and eyes were "bleeding" from lack of hydration, that her skin was "peeling," and that she was "fighting like hell to stay alive." [40] In a news conference the following day, Mr. Schiavo's attorney, George Felos, described her differently, saying "she looked beautiful. In all the years I've seen Mrs. Schiavo, I've never seen such a look of peace and beauty upon her." [41]

Neurologists have noted that if Schiavo was indeed in a persistent vegetative state, she did not experience pain, hunger or thirst due to the removal of the feeding tube. [42] Perry G. Fine, the vice president of medical affairs at the National Hospice and Palliative Care Organization, was quoted in the Los Angeles Times as saying: “What my patients have told me over the last 25 years is that when they stop eating and drinking, there's nothing unpleasant about it. In fact, it can be quite blissful and euphoric... the word 'starve' is so emotionally loaded. People equate that with the hunger pains they feel or the thirst they feel after a long, hot day of hiking. To jump from that to a person who has an end-stage illness is a gigantic leap.” [43] [44]

On March 30, Mr. Schindler told reporters, "I was pleasantly surprised by what I saw and encouraged that she's still fighting" [45] and that Schiavo was "failing" but "doing darn good under the circumstances." [46]

On March 31, 13 days after her feeding tube was removed, Schiavo went into cardiac arrest and died.

Bone scan

A bone scan [47] performed in March 1991 showed, according to the radiologist who evaluated it, that Schiavo had suffered prior traumatic injuries to multiple ribs (on both sides), to both sacroiliac joints, both knees, both ankles, several thoracic vertebrae, and to her right thigh, in addition to a minor compression fracture of the L1 vertebra. Schiavo's parents did not know of the existence of this scan until November 2002, twelve years after her brain damage and entry into an incapacitated state. Forensic pathologist Dr. Michael Baden, provided with the scan but not with her history, suggested that physical trauma, specifically a head injury, probably caused Schiavo's collapse [48], though in a later interview [49], after learning her history, he agreed that the bulimia/hypokalemia explanation was also possible. Others argue that the trauma is consistent with her cardiac arrest, fall, CPR attempts and eventual resuscitation.

Schiavo's parents and Dr. William Hammesfahr, a neurologist they hired to examine her in 2002, claim that she had been battered by her husband. Upon becoming aware of the bone scan report possibly suggesting previous abuse, the Schindlers petitioned the Pinellas-Pasco Circuit Court for a full evidentiary hearing to evaluate the new evidence.

Matt Conigliaro comments that "[t]o believe that Michael caused Terri's collapse by beating her requires that Michael initiated a medical malpractice lawsuit against a doctor for causing her collapse, opening the whole matter to serious inquiry and greatly increasing the risk that someone would discover his role as abuser. No evidence of abuse was presented by the obstetrician in the 1992 malpractice lawsuit even though the bone scan had been performed one year earlier." [50] On November 22, 2002, probate judge George Greer denied the motion, stating that the issue of trauma 12 years earlier was irrelevant to the current case. [51]

Florida's Department of Children and Families investigated 89 complaints of abuse dating back to 2001, when Schiavo's feeding tube was removed for the first time. In a report released on April 15, 2005, state investigators concluded that "there is no evidence to support allegations of any neglect or abuse." [52]

2003 petition

On September 11, 2003, the Schindlers petitioned the Pinellas County Circuit court for the Sixth District. The petition asked the court to forestall any removal of the feeding tube for "eight weeks' therapy." Accompanying the petition were five affidavits: four from members of the Schindler family (presumably her mother, father, brother, and sister) and one from Dr. Alexander T. Gimon. At the hearing in which the petition was presented, Patricia Fields Anderson was the attorney for the Schindlers and Felos was the attorney for Mr. Schiavo. During the hearing, Anderson read into the record affidavits from three "speech professionals" and two nurses, Heidi Law and Carla Sauer Iyer.

Iyer claimed in her affadavit that her initial training in 1996 consisted solely of the instruction "Do what Michael Schiavo tells you or you're terminated." She also claimed that Mr. Schiavo said "When is that bitch gonna die?" and that he made many other similar statements. She states that on five different occasions, she tested Schiavo's blood sugar levels after Mr. Schiavo visited her, and she found that that her blood sugar levels were so low it wouldn't even register a number. She stated that it was medically possible that Michael injected his wife with insulin in an attempt to kill her. Iyer states that standing orders were not to contact the Schindler family, but that she "would call them anyway." Iyer states that she eventually called the police and was fired the next day. Despite her claims that she called the Schindlers multiple times in 1996, there is no evidence the Schindlers did anything at the time to demand that the nursing home or police investigate the supposed incidents. Nor did they subpoena Iyer during their 2000 court battle with Mr. Schiavo. However, to date there have been no records found of any police reports filed in Iyer's name, and none of the other workers at Palm Garden or any medical staff reported any wrong-doing, and were shocked to learn of Iyer's accusations.

On September 17, Judge Greer issued a nine-page court ruling, rejecting the petition. Greer wrote that "the Petition is an attempt by Mr. and Mrs. Schindler to relitigate the entire case. It is not even a veiled or disguised attempt. The exhibits relied upon by them clearly demonstrate this to be true." Regarding Iyer's claims, Greer wrote that they were "incredible to say the least" and that "Ms. Iyer details what amounts to a 15-month cover-up (April 1995 through July 1996) which include the staff of Palm Garden of Largo Convalescent Center, the Guardian of the Person, the guardian ad litem, the medical professionals, the police, and believe it or not, Mr. and Mrs. Schindler. It is impossible to believe that Mr. and Mrs. Schindler would not have subpoenaed Ms. Iyer for the January 2000 evidentiary hearing had Iyer contacted them (in 1996) as her affidavit alleges." (PDF)

Family dispute

Michael Schiavo

Under Florida law and supported by rulings of State and Federal courts, Michael Schiavo, Schiavo's husband, was her legal guardian. Michael says his wife would not have wanted to live in a persistent vegetative state and that he was fighting for her right to die.

In 1991, Michael began studying nursing at St. Petersburg Community College to better care for his wife. He eventually became a respiratory therapist and an emergency room nurse.

In March 1994, guardian ad litem John H. Pecarek was appointed by the court to determine if there had been any abuse by Michael Schiavo. Pecarek's report found no evidence for any inappropriate actions and indicated that Michael had been very attentive to his wife.

In addition to Pecarek, a number of guardians ad litem as well as hospital staff members have described Michael Schiavo as a supportive husband who berated nurses for not taking better care of his wife; in 1994, the administration of one nursing home attempted, unsuccessfully, to get a restraining order against him because he was demanding more attention for his wife at the expense of other patients' care. [53] According to Jay Wolfson, one of Schiavo's court-appointed guardians, due to the attention Schiavo has received in the fifteen years she has been bedridden, she has never developed any bedsores.

On June 18, 2000, Michael signed an agreement stating he would not withdraw or terminate his wife's medical care or treatment for potential fatal infections, without prior notice to the court.

In an appearance on ABC News's Nightline on March 15, 2005, Michael Schiavo cited the willingness that Schiavo's parents expressed to keep her alive by multiple extreme measures, including quadruple amputation if needed, as an important reason for denying transfer of guardianship to them or other parties with similar desires. [54]

Raising the issue of a possible conflict of interest is the claim that Michael Schiavo stood to inherit the remainder of Schiavo's malpractice settlement upon her death. However, the December 2003 Wolfson GAL report, [55]submitted to Governor Jeb Bush pursuant to Florida's "Terri's Law," notes that Michael had, prior to his 1998 request to the court to determine Schiavo's wishes, "formally offered to divest himself entirely of his financial interest in the guardianship estate" (p. 12). In 2005, Michael publicly responded to the alleged conflict of interest by claiming that less than $50,000 of the original award from the suit is left, the rest having been spent under a judge's supervision on medical care for Schiavo and the ongoing legal battle. He also had a contract drafted stating that, should the Schindlers refrain from any further legal action, he would donate whatever his inheritance might be to charity. The Schindlers refused the offer.

On March 11, 2005, media tycoon Robert Herring (who believes that stem cell research could have cured Schiavo's condition) offered $1 million to Michael Schiavo if he agreed to waive his guardianship to his wife's parents [56]. The offer was rejected. George Felos, attorney for Michael, described the offer as "offensive." He also stated that Michael had rejected other monetary offers, including one of $10 million.

Michael Schiavo has been criticized by the Schindlers and their supporters for entering into a relationship with another woman, Jodi Centonze, while still legally married to Terri. Michael and Jodi Centonze have had two children together. Michael denies wrongdoing in this matter, stating that the Schindlers actively encouraged him to "get on with his life" and date since 1991. Michael said he chose not to divorce Schiavo and relinquish guardianship because he wanted to carry out her final wishes not to be kept alive in a persistent vegetative state.

Schindler family

Schiavo's parents and siblings had been battling her husband over her fate since 1998. Even though the courts consistently upheld the ruling that Schiavo would choose to have her life support discontinued, her parents used every legal measure available to them to prevent the disconnection of her feeding tube. The Schindlers stated that even if Schiavo had told them of her intention to have artificial nutrition withdrawn, they would not do it. [57]

The Schindlers took videos of Schiavo that purportedly show her responding to them. They enlisted the services of Galaxywave, Inc., "psychic healers" who claim to possess "Remote Healing ADAM Technology." On several occasions, the Schindlers put Schiavo in contact with these psychics via cell phone during their visits with her. [58]

Her parents claimed that Schiavo was a devout Roman Catholic who did not wish to violate the Church's teachings on euthanasia by intentionally starving or dehydrating herself to death, and that she had never expressed such a desire to anyone in her birth family or circle of friends. The Schindlers' legal fight was funded by a variety of sources on the political right. [59]

Schiavo's father, Bob Schindler, criticized Judge Greer because he never called her into the courtroom or visited her to observe her condition firsthand. Schindler called the court order to remove the feeding tube "judicial homicide."

On March 28, 2005, The New York Times reported that the Schindlers planned to sell a list of people and organizations who have contributed financially to their legal fight to a direct-marketing organization that will solicit money from these people for anti-abortion and conservative groups. [60]

Public opinion

Two polls showed that a large majority of Americans believed that Michael Schiavo should have had the authority to make decisions on behalf of his wife and that the United States Congress overstepped its bounds with its intervention in the case. [61]

According to an ABC News poll from March 21, 70 percent of Americans believed that Schiavo's death should not be a federal matter, and were opposed to the legislation transferring the case to federal court. In the same poll, when ABC said "Terri suffered brain damage and has been on life support for 15 years. Doctors say she has no consciousness and her condition is irreversible," 63 percent said that they support the removal of Schiavo's feeding tube. Sixty-seven percent agreed with the statement that "elected officials trying to keep Schiavo alive are doing so more for political advantage than out of concern for her or for the principles involved." [62]

A poll by CBS News reported on March 23 showed that 82 percent of respondents believed Congress and the President should stay out of the matter, while 74 percent thought it was "all about politics." Only 13 percent thought Congress acted out of concern for Schiavo. Furthermore, the approval ratings of Congress sank to 34 percent, its lowest since 1997. [63]

A poll commissioned by the Christian Defense Coalition and completed by Zogby International after the Schiavo's death found that, among likely voters, 44 percent said the tube should remain in place when asked, "[w]hen there is conflicting evidence on whether or not a patient would want to be on a feeding tube, should elected officials order that a feeding tube be removed or should they order that it remain in place?" Thirteen percent said the tube should be removed. Forty-four percent said the person should be allowed to live when asked, "[i]f a person becomes incapacitated and has no written statement that expresses his or her wishes regarding health care, should the law presume that the person wants to live, even if the person is receiving food and water through a tube?" (23 percent disagreed). These results were featured in many newspapers. Critics of the poll contend that the questions were leading and that the questions were not related to the Schiavo case. [64][65] The raw poll data is available online. [66]

All of these polls have been criticized for being push polls. [67]

One of the effects of this case is that Americans are showing an increased interest in living wills. Some legal experts say that many of the court battles could have been avoided if Schiavo had had one. Many newspapers ran editorials on the importance of having a living will.

Activism and protests

Protesters in front of Schiavo's Pinellas Park, Florida hospice, March 27, 2005.

Vatican officials, U.S. President George W. Bush, Florida Governor Jeb Bush, many Republicans, and several Democrats in the Florida Legislature and U.S. Congress have sided with Schiavo's parents. Other groups and individuals, including the American Civil Liberties Union as well as many Democratic and several Republican legislators, have expressed support for the position of Michael Schiavo.

Various Christian organizations demanded that Schiavo's feeding tube be reinserted. Most of these groups are affiliated with the Christian right, but the Reverend Jesse Jackson, a Democrat and civil rights activist, also called for Schiavo's feeding tube to be reinserted. On March 29, Jackson prayed with the Schindler family outside of Schiavo's Florida hospice. Some groups, such as Not Dead Yet, also protested the removal of the feeding tube because they felt it violated the rights of the disabled.

Forty-seven protesters, including many children, were arrested outside the hospice where Schiavo was located. Most of these were non-violent, staged arrests for trespassing, made when protestors crossed a police line in a symbolic attempt to bring water to Schiavo. One man ran past police and reached the front door of the hospice; he was stunned with a Taser and was apprehended.

Arrests have been made in two separate murder plots against Michael Schiavo: one in which a North Carolina man is accused of offering $250,000 for the murder of Michael Schiavo and $50,000 for the murder of Judge Greer, and the other in which Michael Mitchell of Rockford, Illinois, robbed a Florida gun store as part of an effort to "rescue Terri Schiavo." Additionally, the wife of one of Michael Schiavo's brothers has been targeted; a white car drove by her home three times over the course of several hours, and on the last pass the driver shouted to her, "If Terri dies, I'm coming back to shoot you and your family." Another of Michael Schiavo's brothers says that he receives death threats every time the case is in the news. [68]

On the day Schiavo died, House Majority Leader Tom DeLay criticized the legal system and said, "The time will come for the men responsible [the judges] for this to answer for their behavior." He also threatened to impeach the judges who refused to intervene on Schiavo's behalf. "We will look at an unaccountable, arrogant, out-of-control judiciary that thumbed their nose at Congress and the president," DeLay said. On April 14, 2005, DeLay held a news conference and issued an apology for his comments. He stated, "I said something in an inartful way, and I shouldn't have said it that way, and I apologize for saying it that way."

Judge Greer and his family are under protection from U.S. Marshals due to death threats for having ruled against restoring Schiavo's feeding tube. Additionally, he has been asked to leave his Southern Baptist congregation, Calvary Baptist Church, in Clearwater, a move some might see as excommunication. [69]

Government involvement

Terri's Law

Main article: Government involvement in the Terri Schiavo case

Both the state and federal government made use of extraordinary measures to support the Schindlers. In October 2003, when the Schindlers' final appeal was exhausted, the Florida Legislature passed "Terri's Law," giving Governor Jeb Bush the authority to intervene in the case. Bush immediately ordered the feeding tube reinserted, but Judge Baird and the Florida Supreme Court both overturned the law as unconstitutional.

Congressional subpoenas

In March 2005, after the order to remove the feeding tube was given by Judge Greer, Republicans in Congress subpoenaed Schiavo to testify at two separate congressional inquiries (it is a federal crime to prevent congressional witnesses from testifying). Greer opted to ignore the subpoenas, telling congressional attoneys over a conference call that "I have had no cogent reason why the (congressional) committee should intervene." Although Senate Majority Leader Bill Frist, Senator Rick Santorum, and Representative Tom Delay, brought the possibility of sanctioning Greer on charges of contempt of Congress, Congress did not attempt to enforce the subpoenas or take any action against Greer.

"Palm Sunday Compromise"

Despite a lack of a quorum, Congress also passed and President George W. Bush signed the so-called "Palm Sunday Compromise," transferring jurisdiction of the Schiavo case to federal court. Like in state court, all of the Schindlers' federal appeals were denied, and the U.S. Supreme Court declined to grant certiorari, effectively quashing the Schindlers' legal options.

Potential conflict between law enforcement agencies

On March 24, 2005, three hours after cancelling an automatic stay on his order as a result of another Schindler appeal, Greer directed "each and every and singular sheriff of the state of Florida" enforce his order. If Governor Bush (or the Florida Legislature) had ignored Greer's order by attempting to remove Schiavo from the hospice, a confrontation between the Pinellas Park Police Department and the Florida Department of Law Enforcement agents could have ensured. It has been speculated that this could have led to a Mexican standoff or a constitutional crisis. In jest, one official said local police discussed, "...whether we had enough officers to hold off the National Guard." Governor Bush decided to obey the court order despite enormous pressure from the protesters' side.

Final stages

On March 26, 2005, Bob and Mary Schindler announced that their legal options had been exhausted. Paul O'Donnell, a Franciscan monk and the spiritual adviser to the Schindler family, announced to those holding a vigil outside the hospice in Pinellas Park, "The family would request that everyone go home, be with your children, hold them close and share every moment you have with them."

On March 27, Schiavo was given the Anointing of the Sick ("Last Rites"). In accordance with the Catholic ritual of Viaticum, a drop of consecrated wine was applied to her tongue, but a small piece of the host was unable to be offered. She had also been given Holy Communion through the feeding tube just before it was removed.

Schiavo died at 9:05 a.m. EST on Thursday, March 31. According to Michael Schiavo's attorney, George Felos, she died a "calm, peaceful and gentle death," cradled in her husband's arms.

Michael Schiavo had arrived at 8:45 a.m. EST that day. Schiavo's brother, Bobby Schindler, was visiting Schiavo with his sister, Suzanne Vitadamo, but they were asked to leave ten minutes before Schiavo's death. Hospice officials asked the pair to leave so that Schiavo could be examined. Bobby challenged the decision, but Michael Schiavo decided not to allow him to stay. Schiavo's parents, who had been denied access to her during her last hours, traveled to the hospice to visit her when they were informed that she may be approaching death, arriving half an hour after her death. The Schindler family was allowed into the room after Michael Schiavo had left it. [70] [71] [72] [73]

Autopsy

Schiavo's body arrived at the office of the medical examiner within three hours of her death. The autopsy was completed on April 1 by Pinellas County's medical examiner's office [74]. Supporters of the Schindlers had contended that the autopsy was required by Florida law, as the body was to be cremated, but the strict wording of the statute states only that the medical examiner has the authority to conduct an autopsy before a cremation if he or she deems it necessary. [75]

The examiner's office has said it would conduct examinations on Schiavo's body and look for any evidence of what might have caused her 1990 collapse. A neuropathologist was also to conduct an exam. [76]

The results of the autopsy have yet to be released.

Burial

Schiavo's body was cremated following the autopsy. Her parents offered a memorial Mass in her honor at the Holy Name of Jesus Catholic Church in Gulfport on April 5. Father Frank Pavone, an activist with Priests for Life, [77] delivered the main sermon. [78]

On May 7, 2005 the parents of Terri Schiavo made public a complaint that they had not been informed if, when, and where the ashes of their daughter were (or are to be) buried by Michael Schiavo. He was ordered by the court to provide this information to them.

See also

• Individuals who played significant roles in debates or legal actions regarding the removal of life support:
  • Nancy Cruzan
  • Sun Hudson
  • Spiro Nikolouzos
  • Karen Ann Quinlan
• Rhetorical terms used during the public and political debates
  • Culture of death
  • Culture of life
  • Right to die
  • Right to life
  • Separation of Powers
• Parodies
  • South Park's "Best Friends Forever" (season 9, episode 4)

Sources

Compilations

• Findlaw's compilation (legal documents relating to the Schiavo case)
• The New York Times's compilation (113 articles relating to the Schiavo case, dating from April 28, 2001; requires free registration)
• Tampa Bay Online's compilation
• Abstract Appeal's compliation (weblog) (by Matt Conigliaro)
• The University of Miami Ethics Programs' compliation

Articles

• "Before fight over death, Terri Schiavo had a life." CNN. October 25, 2003. [79]
• Breed, Allen G., and Matt Crenson. "Doctors: Schiavo tapes don't tell story." Associated Press. March 26, 2005. [80]
• Carey, Benedict, and John Schwartz. "Schiavo's condition holds little chance of recovery." The New York Times. March 26, 2005.
• "Excerpts from diagnoses of six Schiavo doctors." Associated Press. March 24, 2005. [81]
• Fackelmann, Kathleen. "Schiavo not likely to experience a painful death, neurologists say." USA Today. March 23, 2005. [82]
• Graham, Judith. "Schiavo's expressions misleading, experts say." Chicago Tribune. March 25, 2005. [83]
• Kumar, Anita. "The Terri Schiavo case: Before the circus" St. Petersburg Times. April 3, 2005. [84]
• Lamendola, Bob. "Neurologists see little sign of activity in Schiavo's brain." South Florida Sun-Sentinel. March 23, 2005. [85]
• Rufty, Bill. "Doctors lament misuse of proper terminology in Schiavo debate." The Ledger. March 23, 2005. [86]
• Schwartz, Jerry. "Friends remember Schiavo before maelstrom." Associated Press. March 31, 2005. [87]

Legal documents

• Report of guardian ad litem, Richard Pearse, Jr. (PDF file). Circuit Court for Pinellas County, Florida Probate Division. December 28, 1998.
• Executive Order Number 02-201. Office of Jeb Bush, Governor of the State of Florida. October 21, 2003. (Subsequently ruled as unconstitutional).
• Report of guardian ad litem, Jay Wolfson (PDF file). Sixth Judicial Circuit of the State of Florida. December 1, 2003.
• Jeb Bush v. Michael Schiavo, SC-04925 (PDF file). Supreme Court of Florida. September 23, 2004.
• Affidavit of Dr. William Polk Cheshire, Jr. (PDF file). State of Florida, County of Duval. March 23, 2005.
• Schiavo ex rel Schindler, et al. v. Schiavo, et al. (PDF file). United States Court of Appeals for the Eleventh Circuit. March 23, 2005. (A panel on the 11th Circuit rules 2-1 to deny a motion to reverse lower courts and reinsert a feeding tube).
• Schiavo ex rel Schindler, et al. v. Schiavo, et al. (PDF file). United States Court of Appeals for the Eleventh Circuit. March 23, 2005. (Court order denying a motion for a rehearing en banc).
• Schiavo ex rel Schindler, et al. v. Schiavo, et al. (PDF file). Supreme Court of the United States. March 23, 2005. (The Schindler's emergency request to the Supreme Court for a stay).
• Schiavo ex rel Schindler, et al. v. Schiavo, et al. (PDF file). Supreme Court of the United States. March 24, 2005. (Michael Schiavo's detail of opposition to application of injunction).
• Schiavo ex rel Schindler, et al. v. Schiavo, et al. (PDF file). Supreme Court of the United States. March 24, 2005. (Supreme Court order denying injunction pending the decision whether to grant the petition for writ of certiorari).
• Schiavo ex rel Schindler, et al. v. Schiavo, et al. (PDF file). United States District Court for the Middle District of Florida (Tampa Division). March 25, 2005. (Court order denying motion to reinsert feeding tube).
• Schiavo ex rel Schindler, et al. v. Schiavo (PDF file). United States Court of Appeals for the Eleventh Circuit. March 30, 2005. (Court order denying motion for rehearing).

Advocacy and commentary

• Abstract Appeal
• Blogs For Terri
• Terri Schindler-Schiavo Foundation
• Compassion in Dying, End of Life Choices
• End-of-Life Choices