Terri Schiavo case

File:TerriSchiavo2.jpg

Terri Schiavo before her 1990 collapse.

Theresa Marie "Terri" Schiavo (December 3, 1963–March 31, 2005), was a St. Petersburg, Florida woman whose medical circumstances and attendant legal battles led to landmark court decisions, historic legislative initiatives, and intense media attention.

Introduction

On February 25, 1990, Schiavo (pronounced SHY-voh, IPA: ʃaɪvoʊ) suffered severe brain damage from cerebral hypoxia, after experiencing cardiac arrest from an undetermined cause. She briefly lapsed into a coma, then passed into a persistent vegetative state (PVS), according to seven neurologists who examined her, or a minimally conscious state (MCS), according to one other. She remained in that condition for the last 15 years of her life.

Schiavo's parents opposed many decisions made by her husband and legal guardian. The topics of dispute included guardianship, level of care, end of life wishes, life support, level of consciousness, and even charges of physical abuse and neglect. Litigation went on for several years, and some issues reached the United States Supreme Court. During the last few weeks of her life, heightened public awareness spawned vigorous debate and judicial and legislative initiatives.

The most recognizable issue was her feeding tube, which was twice removed and, pending appeal, reinserted. The courts ultimately upheld each removal. It was removed a third and final time on March 18, 2005, and Schiavo died of dehydration on March 31 at around 9:05 a.m. EST. An autopsy report was released on June 15, 2005. The pathologists found "massive celebral atrophy" with a brain weight of 615 grams, roughly half that of the expected weight, and "cortical blindness," indicating she had been unable to see. Regarding the diagnosis of PVS, the report stated: "PVS is a clinical diagnosis arrived at through physical examination of living patients. Postmortem correlations to PVS with reported pathologic findings have been reported in the literature, but the findings vary with the etiology of the adverse neurological event." [1] (pdf)

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 feet, 3 inches (160 cm) and a weight of around 200 pounds (91 kg). Schiavo went on a NutriSystem diet and lost about 55 pounds (25 kg). [2] She may have developed an eating disorder around this time in order to cope with the weight problem. [3] In 1981, she graduated from Archbishop Wood High School, a private Catholic school in 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 became engaged, and married on November 10, 1984, at Our Lady of Good Counsel Church in Southampton. They moved to St. Petersburg, Florida in April 1986. Schiavo's parents 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. Her friends began to have suspicions about her eating habits. After meals out, she would excuse herself to go to the bathroom. Michael Schiavo was aware of her unusual eating patterns, but did not realize their potential danger.

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 was 120 pounds. She had also stopped menstruating. The physician who examined Schiavo allegedly failed to take a complete medical history, which might have indicated an eating disorder.

Initial medical crisis

On the morning of February 25, 1990, at approximately 5:30 a.m. EST, Schiavo experienced cardiac arrest and collapsed in the hallway of the St. Petersburg apartment she shared with her husband. The noise awoke Michael Schiavo, and he called 911 emergency services.

Firefighters and paramedics found Schiavo face down and unconscious in the hallway outside her bathroom. Attempts were made to resuscitate her, and she was defibrillated several times while being transported to the Humana Northside hospital. There, in order to keep her alive, she was intubated, ventilated, and eventually given a tracheotomy. She remained comatose for two and a half months. When she emerged from the coma, she exhibited no evidence of higher cortical function. The long period of anoxia she sustained had led to profound brain injury, termed "anoxic-ischemic encephalopathy". While initially fed by means of a naso-gastric feeding tube, she eventually received a percutaneous endoscopic gastrostomy (PEG) feeding tube, which was inserted through her abdominal wall.

The St. Petersburg police found nothing unusual inside the apartment, nor any signs of a struggle or a crime. No illegal drugs or alcohol were found in Schiavo's blood; a physical inspection did not find any sign of trauma to her head or face. [4]

The discharge summary from the Humana hospital stated that Schiavo had suffered a cardiac arrest and anoxic brain damage, accompanied by seizures, respiratory failure, and an injured knee from the fall.

For a time, it was believed that her cardiac arrest had been caused by an imbalance of electrolytes in her blood. On admission to hospital, her serum potassium level was noted to be very low, at 2.0 mEq/L; the normal range for adults is 3.5–5.0 mEq/L. There was speculation that her low potassium level had been caused by an eating disorder: her medical chart contained a note 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." However, there has never been any hard evidence that Schiavo had an eating disorder, and furthermore, the low potassium could very well have been a spurious result caused by the intravascular administration of fluids during the attempt to resuscitate her.

Rehabilitation efforts

On May 12, 1990, Schiavo was transferred to the College Park Skilled Care and Rehabilitation Facility, and on June 30, to Bayfront Hospital for further rehabilitation. She returned home to her family in September 1990 but, overwhelmed by the care she needed, 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 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 in Bradenton, Florida, which specializes in brain injuries and where she received 24-hour care. On July 19, 1991, she was transferred to the Sable Palms Skilled Care Facility, where she received neurological testing and regular speech and occupational therapy until 1994.

PVS, family relationship, and malpractice suit

On emerging from coma some two and a half months after her cardiac arrest, Mrs. Schiavo entered an unusual state of altered consciousness. She regained a sleep-wake cycle, but appeared not to exhibit awareness of herself or her environment. This peculiar state is a recognized sequelae of coma following acute brain injury, and was diagnosed by the physicians taking care of Schiavo as a persistent vegetative state. Dr. Garcia J. Desousa, a board-certified neurologist in St. Petersberg, Florida, cared for Schiavo during her initial admission to hospital; both he and Dr. Victor Gambone, an internist and Schiavo family physician, independently made the diagnosis within approximately one year after Schiavo's cardiac arrest. Other neurologists — Dr. Jeffery M. Karp, Dr. James H. Barnhill, and Dr. Thomas H. Harrison — also examined Schiavo over the years and made the same diagnosis, which entailed a poor prognosis.

No objections regarding Mrs. Schiavo's condition or the PVS diagnosis were raised by any parties at this point.

From 1990 to 1993, Mr. Schiavo and the Schindlers enjoyed an amicable relationship, with Mr. Schiavo living rent-free in their condominium for several months. [5] (pdf)During this time, the Schindlers allegedly encouraged Mr. Schiavo to get on with his life, and he introduced them to women he was dating. [6] On June 18, 1990, the court appointed Mr. Schiavo as his wife's legal guardian, without objection from the Schindlers.

In 1992, Mr. Schiavo, on behalf of Schiavo and himself, brought a medical malpractice lawsuit against the obstetrician, Dr. G. Stephen Igel, who had been treating Schiavo for infertility, claiming that the doctor's failure to test for an eating disorder led to her current condition. At the conclusion of the trial, the jury found for the Schiavos and awarded Schiavo $1,600,000 in damages and Mr. Schiavo $600,000 for loss of consortium. While on appeal, the case was settled, in May 1992, for $700,000 and $300,000, respectively. [7] (pdf) The court placed Schiavo's award in a trust fund, which was controlled by a third party and covered her medical and legal expenses.

During the malpractice trial, Michael testified that he began studying nursing at St. Petersburg College around 1991. When asked why, he said:

"Because I enjoy it and I want to learn more how to take care of [Terri]. I see myself hopefully finishing school and taking care of my wife. ... I want to bring my wife home. ... I married my wife because I love her and I want to spend the rest of my life with her. I'm going to do that. [8]

Eventually, he became a qualified respiratory therapist and emergency room nurse. [9]

On February 14, 1993, Mr. Schiavo and the Schindlers had a falling-out; Mr. Schiavo said the argument arose due to his refusal to share the settlement money with them. The Schindlers said that he failed to honor commitments he had previously made to seek aggressive treatments for his wife's condition. [10] (pdf) The amicable relationship ended, and Mr. Schiavo and the Schindlers stopped speaking to each other. [11] Mr. Schiavo placed limits on how much time the Schindlers could spend with Schiavo.

The Schindlers accused Mr. Schiavo of going back on his word that he wanted to spend the rest of his life with Schiavo once he decided to withdraw life-support. However, according to Schiavo's guardian ad litem in his 1998 report, Mr. Schiavo said he "essentially gave up hope that [Terri] would recover about four years after the accident." [12] 9pdf)

In his decision in the 2000 trial to determine Terri's wishes, Judge Greer wrote:

It has been suggested that Michael Schiavo has not acted in good faith by waiting eight plus years to file the Petition which is under consideration. That assertion hardly seems worthy of comment other than to say that he should not be faulted for having done what those opposed to him want to be continued." [13]

Judge Greer also noted in that 2000 decision that " ... the unrebutted evidence remains that Terri Schiavo remains in a persistent vegetative state."

Guardianship challenged

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

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. Michael remained his wife's guardian.

Michael Schiavo

In addition to Pecarek, a number of guardians ad litem and 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 unsuccessfully attempted to get a restraining order against him because he was demanding more attention for his wife at the expense of other patients' care. [14] According to Jay Wolfson, one of Schiavo's court-appointed guardians, due to the attention Schiavo had received in the fifteen years she was bedridden, she had 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. [15]

A claim that Michael Schiavo stood to inherit the remainder of Schiavo's malpractice settlement upon her death raised the issue of a possible conflict of interest. However, the December 2003 Wolfson GAL report, [16] 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 was 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 [17]. 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 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 Terri and relinquish guardianship because he wanted to ensure her final wishes (to not be kept alive in a PVS) were carried out.

During the final stages of the court battle in March 2005, around 30 individuals made a variety of complaints to the Department of Children and Families alleging various abuses. These included Terri supposedly being in pain from recent dental work, Terri not having had any dental work for years, and even the blinds in her room not being open wide enough. DCF investigators found the claims to be groundless, stating that there were "no indicators" of abuse in any of the cases and concluding that "[t]he preponderance of the evidence shows that Michael Schiavo followed doctors' orders [regarding] Ms. Schiavo's diagnosis of being in a persistent vegetative state and that he provided her with appropriate care." [18]

Schindler family

The Schindlers stated that, even if Schiavo had told them of her intention to have artificial nutrition withdrawn, they would not accede. [19] The issue of conflict of interest raised by guardian ad litem Pearse attached to the Schindlers as well, he reported, since, had they prevailed in the various litigation over guardianship, they as the presumed heirs-at-law would have inherited the remainder of Mrs. Schiavo's estate upon her death. [20]

In an attempt to foster improvement in her condition, they contacted Galaxywave, Inc.[21]—psychic healers who claim to possess a Remote Healing ADAM (Aphysical Dimension Access Manager) Technology. [22] On several occasions, the Schindlers attempted to put these psychics in contact with Schiavo via cell phone during their visits with her. [23]

The Schindlers' legal fight was funded by a variety of sources on the political right. [24]

Life-prolonging procedures

Under Florida law, every person—competent and incompetent—has the right to refuse medical treatment.[25] 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. [26] Florida Statutes, Title XLIV, Chapter 765, §101(10) define life-prolonging procedures to be, in part, "any medical procedure, treatment, or intervention, including artificially provided sustenance and hydration, which sustains, restores, or supplants a spontaneous vital function." [27] Thus, in Florida, a feeding tube is a life-prolonging procedure (also known as life support).

PVS and the law

The diagnosis of a persistent vegetative state (or permanent vegetative state, as it has interchangeably been described by some physicians throughout the process—one is a subset of the other [28]) is central to the case. As cited above, the decision to terminate life prolonging procedures by a proxy or guardian has a principle requirement that the ward be in a persistent vegetative state.

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.

Neurologists note that patients in a persistent vegetative state do not experience pain, hunger or thirst due to the removal of their feeding tube. [29]

The prognosis for recovery of awareness in PVS has been quantified, and, 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. [30] [31]

Application of diagnosis—the DNR

In March 1994, after more than three years of trying both established as well as experimental therapies, Mr. Schiavo, according to guardian ad litem Wolfson (see below), came to terms with his doctors' diagnosis of an irreversible persistent vegetative state and transferred his wife to a Largo nursing home. In consultation with his wife's physician, he halted most therapy for his wife and entered a "do-not-resuscitate" (DNR) order, which he later rescinded after the Schindlers and the nursing home protested. Guardian ad litem Jay Wolfson (appointed after guardians ad litem Pecarek and Pearse below) wrote in his 2003 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.

Legally in a PVS

In May 1998, Mr. Schiavo filed a petition to discontinue life support for Schiavo which her parents opposed. Richard Pearse was appointed by the court as a second guardian ad litem, and on December 29, 1998, reported "Dr. [Jeffrey] Karp's opinion of the ward's condition and prognosis is substantially shared among those physicians who have recently been involved in her treatment." Pearse concluded from Karp's and Dr. Vincent Gambone's diagnosis of PVS [32] that Schiavo was legally in a persistent vegetative state as defined by Florida Statutes, Title XLIV, Chapter 765, §101(12): [33]

(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 but that Mr. Schiavo's decisions may have been influenced by the potential to inherit what remained of Schiavo's estate. Due to a lack of a living will and questions regarding Mr. Schiavo's credibility, Pearse recommended denying his petition to remove her feeding tube.

End-of-life wishes - Schiavo I

Schiavo did not have a living will; therefore a trial was held during the week of 24 January 2000 to determine what Schiavo's wishes would have been regarding life prolonging procedures. Arguments from both sides of the issue were heard, with testimony from eighteen witnesses regarding her medical condition and her end of life wishes. Her parents claimed that Schiavo was a devout Roman Catholic who did not wish to violate the Church's teachings on euthanasia by refusing nutrition and hydration. 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 was upheld by Florida's 2nd District Court of Appeal [35] and came to be known by the court as Schiavo I in its later rulings.)

The Schindler family issued a statement on June 16, 2005 concerning the medical examiner's report of Theresa's autopsy. In it, the Schindlers repeated their case, saying, "our family would encourage the media to remember that this case was allegedly about 'Terri’s choice.' There is absolutely no evidence that Terri wanted to die of dehydration, or that she believed that that the level of one’s disability gives anyone the moral and legal right to end another’s life." [36]

Oral feeding

Oral feeding is not considered a life prolonging procedure, and on or about 2 March 2000, the Schindlers filed a motion to permit oral feeding of Schiavo. Since clinical records indicate that Schiavo was not responsive to swallowing tests and required a feeding tube, [37] Judge Greer ruled that insufficient nutrition and hydration could be ingested orally to sustain Schiavo and denied the request. [38] The Medical Examiner in his report was more definitive and concluded that Schiavo could not have swallowed and thus could not have received sufficient nutrition or hydration by mouth to sustain life. [39]

Three appeals - Schiavo II

In April, 2001, the Schindlers filed a motion for relief from judgement citing new evidence of Terri's wishes. Judge Greer denied the motion as untimely under Rule 1.540(b)(5) of "Florida Rules of Civil Procedure" [40] (p. 65). The 2nd DCA upheld Greer's decision but remanded the issue in order to give the Schindlers an opportunity to file a new motion.

At about the same time, the Schindlers filed an action against Michael which was assigned to another court and whose judge, Frank Quesada, issued an injunction against removal of feeding tube. On appeal by Schiavo, the 2nd DCA reversed Judge Quesada's order.

Also in the same time frame, Michael filed a motion to enforce mandate of the guardianship court (that the feeding tube be removed). The 2nd DCA denied the motion. (These decisions, all published in a single order by Florida's 2nd District Court of Appeal [41], came to be known by the court as Schiavo II in its later rulings.)

Hearing ordered - Schiavo III

On 10 August 2001, on remand from the 2nd DCA, Judge Greer heard a motion from the Schindlers claiming that new medical treatment could restore sufficient cognitive ability that Terri herself would decide to continue life-prolonging measures. The court also heard motions from the Schindlers to remove the guardian (Michael) and to require Judge Greer to recuse himself. Judge Greer denied the motions and the Schindlers appealed to the 2nd DCA.

On 17 October the Court of Appeal affirmed the denials of the motions to remove and recuse, but found that although their previous opinion had misled the guardianship court, they would remand the question of Terri's wishes and require an evidentiary hearing be held. The court specified that five board certified neurologists were to testify, and said, "...the Schindlers may choose two doctors to participate in discovery and present their opinions at evidentiary hearing. In addition, to control the scope of this hearing and to prevent the proverbial "war of experts," Mr. Schiavo may introduce in rebuttal the testimony of two doctors of his choosing. ...we further conclude that the trial court should appoint a new independent physician to examine and evaluate Mrs. Schiavo's current condition. ...In the event that counsel are unable to stipulate to the selection of a new physician for the purposes of this independent examination, the trial court shall make the selection." (These decisions, all published in a single order by Florida's 2nd District Court of Appeal [42], came to be known by the court as Schiavo III in its later rulings.)

PVS diagnosis ruling - Schiavo IV

In October 2002, on remand by the 2nd District Court of Appeal, an evidentiary hearing was held in Judge Greer's court to determine whether new therapy treatments could help Schiavo restore any cognitive function. In preparation for the trial, a new computed axial tomography scan (CAT scan) was performed, which showed severe cerebral atrophy. An EEG showed no measurable brain activity. The court viewed a six-hour tape of Schiavo and concluded that her vegetative condition was factual and not subject to legal dispute.

In accordance with the 2nd DCA's instructions, five doctors were selected to provide their expert testimony to the trial: two by Schiavo's parents, two by Mr. Schiavo, and one to have been selected by mutual agreement of the parties:

• The Schindler family selected Dr. William Maxfield (the Schindlers' family doctor, who was a radiologist) and Dr. William Hammesfahr (a neurologist).
• Michael Schiavo selected Dr. Ronald Cranford and Dr. Melvin Greer (no relation, and both neurologists).
• The parties having failed to agree, the court selected Dr. Peter Bambakidis (also a neurologist).

These five doctors examined Schiavo's medical records, brain scans, the videos, and Schiavo herself. Drs. Cranford, Greer, and Bambakidis testified to their conclusion that Schiavo was in a persistent vegetative state. Drs. Maxfield and Hammesfahr testified to their conclusion that she was in a minimally conscious state.

Judge Greer ruled that Schiavo was in a PVS, and was beyond hope of significant improvement. The trial court order was particularly critical of Hammesfahr's testimony which claimed positive results in similar cases by use of vasodilation therapy, the success of which is unsupported in the medical literature. [43]

Little detail of testimony from the individual physicians in the hearing is extant beyond that cited in the Judge Greer's order, although salient points by Dr. Cranford can be read in an article in "Florida Today" (the article cites the wrong date for the exam). He was quoted in that article 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." [44])

Florida's 2nd District Court of Appeal, in its order affirming Judge Greer, said, "this court has closely examined all of the evidence in the record," and "we have...carefully observ[ed] the video tapes in their entirety." The court concluded that "...if we were called upon to review the guardianship court's decision de novo we would still affirm it." (this decision by the 2nd DCA [45] came to be known as Schiavo IV in later rulings.)

Bone scan

A bone scan [46] 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 [47], though in a later interview [48], 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. On November 22, 2002, Judge Greer denied the motion, stating that the issue of trauma 12 years earlier was irrelevant to the current case. [49]

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." [50]

The autopsy carried out after Schiavo's death found only one fracture, the minor compression fracture in the L1 vertebra, which Thogmartin, the medical examiner who led the autopsy, said was probably caused by osteoporosis. [51] Thogmartin also concluded that misleading information on the bone scan request form was the likely genesis of questions of trauma raised earlier (a well documented and thorough rebuttal of the claim of trauma suffered by Schiavo is found on pages 32-34 of the report but is beyond the scope of this article). [52]

2003 petition

On September 11, 2003, the Schindlers petitioned the court to forestall removal of the feeding tube to provide for "eight weeks' therapy." Accompanying the petition were four affidavits from members of the Schindler family and one from Dr. Alexander T. Gimon. At the hearing the Schindlers' counsel read into the record additional affidavits from three speech professionals and two nurses.

One of the nurses, Carla Sauer Iyer claimed in her affidavit 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 stated 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 stated that standing orders were not to contact the Schindler family, but that she "would call them anyway." Iyer stated that she eventually called the police and was fired the next day.

On September 17, Judge Greer denied the petition, and 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." [53] To date there have been no records presented to the courts of any police reports filed in Iyer's name.

Oral feeding II

On February 23, 2005, the Schindlers filed a motion for "Relief from Judgement Pending Contemporary Medical-Psychiatric-Rehabilitative Evaluation." [54] 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 25, 2005, Judge Greer denied the motion and issued an order which excluded both feeding by tube and orally, and set a time and date for the removal of the feeding tube. [55]

On February 28, the Schindlers filed a 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. [56]

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 requested that Schiavo be given VitalStim swallowing therapy. 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. [57] This was the second time that oral feeding had been denied. [58]

On March 9, Judge Greer denied the Schindlers' first motion for the experimental testing and swallowing therapy, citing that 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 [59], and because VitalStim had only been performed on patients who were not in a 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." [60]

No stay was granted by the appellate courts, and on 18 March 2005, Michael Schiavo complied with the 25 February order. Thirteen days after her feeding tube was removed the third and final time, Schiavo died on March 31 2005.

Diagnosis dispute

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

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 disagreed, saying that her level of brain damage made responsiveness impossible and that her behavior represented reflex or instinctive actions.

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.) [61]

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 aphasic (unable to speak) since her cardiac arrest 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. [62]

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.

Three Florida neurologists viewed 12 of Schiavo's CT scans on March 22, 2005. [63] 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." [64]

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, filed an affidavit. [65] Cheshire graduated from, and is an adjunct professor at Trinity University, a Christian institution, and has written opinion articles on stem-cell research and other scientific debates from a conservative Christian viewpoint. [66] In his affidavit, Cheshire explains that he had been asked by the Florida Dept. of Children and Families [67] to investigate allegations of abuse of Schiavo five days after her feeding tube had been removed. Cheshire reported no abuse was found. His visit lasted 90 minutes and consisted only of visual observation, not a medical exam. During his visit, he observed what he interpreted to be purposeful behavior, as when he stated that Schiavo appeared to be watching him for "about half a minute."[68] (Schiavo's autopsy[69], performed two weeks after Cheshire's visit, concluded she was cortically blind.) Cheshire's affidavit said he believed he had found reason to doubt the PVS diagnosis and to prefer a diagnosis of "minimally conscious state" or MCS. Based on Cheshire's affidavit, Governor Jeb Bush filed a petition to have Schiavo's feeding tube restored. [70]

Public opinion and activism

Main article: Public opinion and activism in the Terri Schiavo case

The Terri Schiavo case held the attention of the American public, as well as an international audience, and had major political ramifications. A number of polls of public opinion were carried out, particularly on the question of federal involvement in the Terri Schiavo case, with conflicting results.

The case drew in notable figures on both sides of the debate, as well as many pressure groups and public protesters. Two of the more extreme acts of protest included death threats aimed towards Michael Schiavo, although the vast majority of protests were non-violent.

Government involvement

Main article: Government involvement in the Terri Schiavo case

Terri's Law

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," [71]giving Governor Jeb Bush the authority to intervene in the case. Bush immediately ordered the feeding tube reinserted, but Judge Baird [72] and the Florida Supreme Court [73] both overturned the law as unconstitutional.

Congressional subpoenas

On March 18, 2005, after the order to remove the feeding tube was given by Judge Greer, Republicans in Congress subpoenaed both Michael and Terri Schiavo to testify at a congressional hearing [74] (it is contempt of Congress to prevent or discourage congressional witnesses from testifying [75]). Greer opted to ignore the subpoenas, telling congressional attorneys over a conference call that, "I have had no cogent reason why the (congressional) committee should intervene." He also stated that last-minute action by Congress does not invalidate years of court rulings. [76] [77] 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"

Main article: Palm Sunday Compromise

Governor Bush and Congressional Republicans anticipated Greer's adverse ruling well before it was delivered and worked on a virtually daily basis to find an alternative means of overturning the legal process by utilizing the authority of the United States Congress. [78] On March 20, 2005, the Senate (with only three members present) passed their version of the resolution, followed by the House of Representatives, which came to be called the "Palm Sunday Compromise" (S-686), transferring jurisdiction of the Schiavo case to the federal courts. The bill passed the House on March 21 at 12:41 a.m. EST. President Bush flew to Washington from his vacation in Texas in order to sign the bill into law at 1:11 a.m. EST. As in the state courts, all of the Schindlers' federal appeals were denied, and the U.S. Supreme Court declined to grant certiorari, effectively ending the Schindlers' legal options.

Potential constitutional crisis

On March 24, 2005, Judge Greer denied a petition for intervention by the Department of Children & Families and signed an order forbidding the department from "taking possession of Theresa Marie Schiavo or removing her" from the hospice and directed "each and every and singular sheriff of the state of Florida" to enforce his order. The order was appealed to the 2nd District Court of Appeals the following day, which resulted in an automatic stay under state law. While the stay was in effect, Florida Department of Law Enforcement personnel prepared to take custody of Terri and transfer her to a local hospital for reinsertion of the feeding tube. Once Greer was made aware of the stay, he ordered it lifted and all parties stood down. Governor Bush decided to obey the court order despite enormous pressure from the political right. If 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 FDLE agents could have ensued. It has been speculated that this could have led to a standoff or a constitutional crisis. In jest, one official said local police discussed, "...whether we had enough officers to hold off the National Guard." [79]

Final stages

On March 26, 2005, Bob and Mary Schindler announced that their legal options had been exhausted. Brother Paul O'Donnell, a Franciscan monk and the spiritual advisor 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 as her tongue was too dry. 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 2005. 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 in order for Schiavo to 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. [80] [81] [82] [83]

Autopsy

Official autopsy report of Terri Schiavo

After her death, Schiavo's body was taken to the office of the medical examiner for Pinellas and Pasco counties. The autopsy was led on April 1 2005 by Dr. Jon Thogmartin, the medical examiner for District 6; Dr. Stephen J. Nelson, the medical examiner for District 10, provided neuropathologic consultation. Dr. Thogmartin also arranged for specialized cardiac and genetic examinations to be made. Their report was released to intense public attention on June 15, 2005.

Examination of Schiavo’s nervous system had revealed extensive injury. The brain itself weighed 615 grams, only half the weight expected for a female of her age, height, and weight. There was a large volume of cerebrospinal fluid, weighing 678 grams — greater than the weight of her brain. Microscopic examination revealed extensive damage to numerous brain regions, including the cortex, the thalami, the basal nuclei, the hippocampus, the cerebellum, and the midbrain.

The neuropathologic changes in Schiavo’s brain were precisely of the type seen in patients who enter a PVS following cardiac arrest. Throughout the cerebral cortex, the large pyramidal neurons that comprise some 70% of cortical cells — fundamentally critical to the functioning of the cortex — were completely lost. The pattern of gradient damage to the cortex, with injury tending to worsen from the front of the cortex to the back, is also a typical finding. There was marked damage to important relay circuits deep in the brain (the thalami) — this too a common pathologic hallmark of the PVS. The damage was, in the words of Dr. Thogmartin, "irreversible, and no amount of therapy or treatment would have regenerated the massive loss of neurons."[84]

The intensely controversial nature of Terri Schiavo's final years was likely not lost on the medical examiners, as seen by the care with which they worded their report. Dr. Nelson cautioned that a pathologic examination of the brain, alone, may not prove a diagnosis of a vegetative state.[85] The vegetative state is a behaviorally-defined syndrome of complete unawareness, to self and to environment, that occurs in a person who nevertheless experiences wakefulness. As the condition is defined in clinical terms, it can therefore only be diagnosed in persons who, at some point, are shown to meet those clinical terms. Ancillary investigations, such as CT scans, MRI, EEGs, and lately fMRI and PET scanning, may only provide support for the clinical impression - as might the pathologic findings, after death. In the case of Terri Schiavo, 7 of the 8 neurologists who examined her in her last years stated that she met the clinical criteria for PVS; the serial CT scans, EEGs, the one MRI, and finally, the pathologic findings, were all consistent with that diagnosis.

The cause of the cardiac arrest which felled Schiavo 15 years before she died has never been determined. Aside from a localized, healed inflammation, the cardiac pathologist who studied Schiavo's heart found it and the coronary vessels to be healthy. Although it was widely speculated that Schiavo suffered from an eating disorder that caused a serious electrolyte disturbance, stopping her heart, there is little evidence to support this claim. The examiners also found no evidence that Schiavo had been the victim of trauma or foul play.

To the question of the cause and manner of Schiavo’s death, Dr. Thogmartin wrote, "Mrs. Schiavo suffered severe anoxic brain injury. The cause of which [sic] cannot be determined with reasonable medical certainty. The manner of death will therefore be certified as undetermined."

Memorial

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, [86] delivered the main sermon. [87]

On May 7, 2005 the parents of Terri Schiavo made public a complaint that they had not been informed of when and where the ashes of their daughter were (or are to be) buried by Michael Schiavo. He was under court order to provide this information to them. The Schindlers' attorney stated that the family was notified by fax only after the memorial service; by then, the Schindler family had already started getting calls from reporters. [88]

On June 20, 2005, the cremated remains of Terri Schiavo were interred under an oak tree near a pond and fountain at Sylvan Abbey Memorial Park in Clearwater, Florida. Behind the grave marker sits a polished stone bench inscribed with the name, "Schiavo". [89] On the flat bronze marker, Michael Schiavo inscribed the words, "Departed this Earth February 25, 1990" and "At peace March 31, 2005". Below this, an engraving of a dove with an olive branch appears with the words, "I kept my promise".

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
• Parodies
  • South Park's "Best Friends Forever" (season 9, episode 4)
  • Terri Schiavo blog

Sources

Compilations
(legal documents relating to the Schiavo case)

• Findlaw's compilation
• Tampa Bay Online's compilation
• Abstract Appeal's compilation
• The University of Miami Ethics Programs' compilation

Information sites

• Amicus National, Inc. (2005). Legaldocs Living Wills. Site providing free living will forms on a state-by-state basis. Retrieved April 16, 2005
• Zorn, Eric (2005). For your reference - the Schiavo case. Eric Zorn's Notebook, Chicago Tribune. Retrieved March 31, 2005

Articles

• "Before fight over death, Terri Schiavo had a life." CNN. October 25, 2003. ^[90]
• Fackelmann, Kathleen. "Schiavo not likely to experience a painful death, neurologists say." USA Today. March 23, 2005. ^[91]
• Kumar, Anita. "The Terri Schiavo case: Before the circus." St. Petersburg Times. April 3, 2005. ^[92]
• Quill, Timothy E., MD. "Terri Schiavo—A Tragedy Compounded." New England Journal of Medicine. 21 April 2005. ^[93]
• Rufty, Bill. "Doctors lament misuse of proper terminology in Schiavo debate." The Ledger. March 23, 2005. ^[94]
• Wilson, Jamie. "Schiavo autopsy vindicates husband." The Guardian, June 16, 2005. ^[95]

Legal documents
(PDF files, unless otherwise noted)

• Report of guardian ad litem, Richard Pearse, Jr.. December 28, 1998.
• Court Order authorizing discontinuance of artificial life support. Circuit Court for Pinellas County. February 11, 2000.
• 2nd DCA affirms. (Text file). Florida 2nd District Court of Appeal 24 January 2001. Schiavo I
• Court Order denying petition for evaluation of swallowing. Circuit Court for Pinellas County. March 7, 2000.
• 2nd DCA affirms but remands for new motion on swallowing tests. (Text file). Florida 2nd District Court of Appeal 11 July, 2001. Schiavo II
• 2nd DCA orders hearing on PVS diagnosis. Florida 2nd District Court of Appeal 17 October, 2001. Schiavo III
• Court Order affirming diagnosis of persistent vegetative state, and scheduling withdrawal of life support. (Text file). Circuit Court for Pinellas County. November 22, 2002
• 2nd DCA affirms diagnosis of PVS. Florida 2nd District Court of Appeal 6 June, 2003. Schiavo IV
• Governor Bush's Executive Order Number 02-201 (HTML file). October 21, 2003. (Subsequently ruled as unconstitutional).
• Report of guardian ad litem, Jay Wolfson. December 1, 2003.
• Jeb Bush v. Michael Schiavo, SC-04925. Supreme Court of Florida. September 23, 2004.
• Affidavit of Dr. William Polk Cheshire, Jr.. March 23, 2005.
• Three judge panel rules 2-1 to deny a motion to reverse lower courts and reinsert a feeding tube. United States Court of Appeals for the 11th Circuit. March 23, 2005.
• Court order denying a motion for a rehearing en banc. United States Court of Appeals for the 11th Circuit. March 23, 2005.
• The Schindler's emergency request to the Supreme Court for a stay. Supreme Court of the United States. March 23, 2005.
• Michael Schiavo's detail of opposition to application of injunction. Supreme Court of the United States. March 24, 2005.
• Supreme Court order denying injunction pending whether to grant certiorari (HTML file). Supreme Court of the United States. March 24, 2005.
• Court order denying motion to reinsert feeding tube. U.S. District Court for the Middle District of Florida (Tampa Division). March 25, 2005.
• Court order denying motion for rehearing. United States Court of Appeals for the 11th Circuit. March 30, 2005.
• Theresa Schiavo Autopsy Report. June 15, 2005.

Advocacy and commentary

• Blogs For Terri
• terrisfight.org
• Compassion in Dying, End of Life Choices
• End-of-Life Choices