Schiavo's feeding tube has been removed...

[quickdodge®]

From MSNBC.com:

PINELLAS PARK, Fla. - With a furious legal and political battle raging outside her hospice room, doctors removed Terri Schiavo’s feeding tube Friday after a judge rebuffed an unprecedented attempt by Republican lawmakers in Congress to keep the brain-damaged woman alive.

It is expected that it will take one to two weeks for Schiavo, 41, to die, provided no one intercedes and gets the tube reinserted.

The tube has twice been removed in the past, but was re-inserted within days in both cases.

The latest removal came amid a flurry of maneuvering by Schiavo’s parents, state lawmakers and Congress to keep her alive. Committees in the Republican-controlled Congress issued subpoenas for Schiavo, her husband and her caregivers, demanding that they appear at hearings in the coming weeks. The lawmakers argued that the subpoenas kicked in legal protections that prohibit doing harm to a prospective witness.

But the judge presiding over the case refused a request from House attorneys to delay the removal, which he had previously ordered to take place at 1 p.m. EST, and a private physician was called in to remove the feeding tube keeping Schiavo alive.

Request to high court
Late Friday, the U.S. Supreme Court, without comment, denied an emergency request from the House committee that issued the subpoenas to reinsert Schiavo's feeding tube while the committee files appeals in the lower courts to have its subpoenas recognized.

Meanwhile, Republican congressional leaders said in a statement that they planned to work through the weekend to try to save Terri Schiavo’s life.

"Right now, murder is being committed against a defenseless American citizen in Florida," House Majority Leader Tom DeLay of Texas said in an earlier statement. "Terri Schiavo's feeding tube should be immediately replaced, and Congress will continue working to explore ways to save her.

http://msnbcmedia.msn.com/j/msnbc/Components/Photos/050318/050318_schaivo_hmed_1110p.h2.jpg

http://msnbcmedia.msn.com/j/msnbc/Components/Video/050318/n_viqueria_schiavo_050318.htease.jpg

Later, QD.

[accented]

my dad and i were discussing this, because my grandfather was kept alive by a tube as well.. my uncle was the main caregiver so he had the final decision to keep the tube in.. i looked at my dad and said, "if it were me, pull the tube."

he says, "yeah me too.."

[quickdodge®]

I agree, also. Later, QD.

[Leisa]

I honestly dont know which side to take... on one hand noone should have to live like that , but on another hand they say that she is able to communicate in her own special way... I know she used to be a beautiful young woman,, thats a shame!

[quickdodge®]

I agree with your comment, too, Leisa. For her to be able to communicate, if she is conscious of what's going on around her, putting her down would seem like killing her. Not letting her die. Later, QD.

[RISKYB]

she may be brain dead, but she is still human and she may not be as bad off as they think, i think its cruel that someone should have to lay there fo weeks to starve to death slowly and painfully

[Tracer]

Really, who has the right to say if someone should live or die. If she is breathing and able to communicate in some way....No One has the right to take her life. Its just sad that someone can say enough is enough, pull the cord. To me that's just killing someone. I don't care about the odds against her.....Miracles happen everyday

[Leisa]

I agree

[Red]

I don't really know the background in this story but didn't she tell here husband that she didn't want to be on a tube? I thought I heard that she did that. And last night I heard she's been on it for 15 years.

[Leisa]

Yeah she has been on it for about 15 yrs,... her husband ( or whatever you wanna call that piece of shit he is ) has either a wife or a girlfriend and a couple of kids... UGHHHH!!!

[accented]

the only reason ppl keep other ppl alive on tubes is to keep drawing social security.

[Tracer]

How can you say that? Sorry but someone I love and care about, the last thing on my mind is social security.

[Tracer]

The husband does have a girlfriend and kids by her. He can't marry her because by LAW he's still married to Schiavo and the only way he can marry his girlfriend, Schiavo has to die. I guess he forgot the promise he made when he got married to Schiavo......"till death due us apart"

[A.P. Photography]

What people fail to realize is that her communication might be a plea to let her die. 15 yrs on a feeding tube with no real turn of events is a long time and I know if it was me, pull the tube. I don't want to have that kind of existence nor do I want my family to have to deal with me being like that. I know it would be hard for the family to have to let their daughter die but after 15 yrs, it is time to let her go.

[quickdodge®]

she may not be as bad off as they think,

But she may also not be as well off, either.


i think its cruel that someone should have to lay there fo weeks to starve to death slowly and painfully

I agree, but, we also don't know if she is laying there suffering. We don't know if she's been suffering for the last 15 years. Think about this: If she is aware of her surroundings, she may know that she has a HUGE chance of never having a life. Knowing that you would possibly be in the state you are(like her), for the rest of your life, would you want to keep on? No talking, no walking, no nothing except laying down, sitting up, drinking your food and that's it.

I wonder if she knows what is going on. If she knows that the tube is gone and that she has a couple of weeks left. If she does realize, is she happy? Is she relieved knowing that she will no longer suffer(if she is). Even if not in pain, I don't think I'd like to live as a "vegetable" for the rest of my life.

I'm not agreeing or disagreeing to anything here. Just stating from both sides of the debate. I undertsand both causes. Later, QD.

[accented]

How can you say that? Sorry but someone I love and care about, the last thing on my mind is social security.
if you loved and cared about them you would let them die in peace not 15 years of wishing you would die.

[quickdodge®]

I guess he forgot the promise he made when he got married to Schiavo.....

I don't think so, seeing as how he hasn't left her side in these last 15 years.


."till death due us apart"

And it's "part", not "apart." Lolol. Later, QD.

[accented]

and its do not due

[Leisa]

its one of those situations where, there is not a wrong or right answer

[accented]

this is why everyone needs to put in their will whether or not they would like to be kept alive.. unfortunatly a will isnt rock solid either.

[quickdodge®]

^^ Yeah, nowadays. Later, QD.

[accented]

im gonna put in my will that i do not want to kept alive artificially and if that is challenged to donate all my assets to charity.


which is no big deal right now, a pos hyundai, a couple computers, a couple hundred dollars, and a ps2, lmao..

[Tracer]

Sorry for the typing errors no one is perfect.

[A.P. Photography]

It really comes down to a quality of life. Ask yourself this, would you want to be nothing more than a vegtable for the rest of your life. Unable to express your feelings, talk to anyone, walk outside, feel the grass under your feet, be able to love, laugh, play with loved ones and family members. Would you want to see the hurt and pain in loved ones faces when they come to your hospital bed. Imagine you are this girl, you can see images and the only images you see is your loved ones coming in standing by your bedside talking to you and crying at the same time wishing that you could respond, and no matter how bad you want to all you can do is lay there and look at them. That is not a life I want or wish upon my family.


And who is to say she is not trying to communicate to someone that she wants to die. Does anyone remember Metalallica "One", pretty close to the same thing.

[quickdodge®]

^^To Jason STi-- Just picking fun, dude. All in fun. Later, QD.

[Tracer]

QD, its ok.....

[accented]

It really comes down to a quality of life. Ask yourself this, would you want to be nothing more than a vegtable for the rest of your life. Unable to express your feelings, talk to anyone, walk outside, feel the grass under your feet, be able to love, laugh, play with loved ones and family members. Would you want to see the hurt and pain in loved ones faces when they come to your hospital bed. Imagine you are this girl, you can see images and the only images you see is your loved ones coming in standing by your bedside talking to you and crying at the same time wishing that you could respond, and no matter how bad you want to all you can do is lay there and look at them. That is not a life I want or wish upon my family.


And who is to say she is not trying to communicate to someone that she wants to die. Does anyone remember Metalallica "One", pretty close to the same thing.

i was saying the same thing about my grandfather, knowing him and his attitude towards thing, my dad and i are sure that if he could speak, he would have said, "unplug me and let me die asshole"

[accented]

QD, its ok.....
what about me :(

[Tracer]

Ok...sorry

[accented]

Ok...sorry
lol

[Tracer]

This topic was really worth talking about. Thanks QD, for starting this. Maybe by this we can actually open the eyes to the viewers. Really, there's no right or wrong choice.

[quickdodge®]

Lolol. Funny, I was thinking the same thing. Good discussion. Later, QD.

[accented]

This topic was really worth talking about. Thanks QD, for starting this. Maybe by this we can actually open the eyes to the viewers. Really, there's no right or wrong choice.
i agree, we had some heated debate! no name calling, no drama, just pure debate about a strong subject.

[Tracer]

This is what we need more of. No name calling or drama......We are all friends here. I just wish some of the other members on this forum will remember that.

[Leisa]

I feel you ... when my father was dying of congestive heart failure a few yrs back, he had a living will;...that said he did not want to be on life support or any other type of machine... some stupid fucking dr didnt read it and revived him,,,, pissed me off... then a couple of days later, he died...

[accented]

i think thats malpractice

[RISKYB]

good point QD, it just seems that we dont know what she want',s feels, or needs, that is fact but letting someone starve just seems inhumane whether you know it or not, theremust be a protocal for this situation and if not there should be

[HyPer50]

I feel really bad about that story, I've been following it for quite some time now and I got mixed feelings on it. On one hand, I feel that she wouldn't want to be living like that, I mean, she's not a complete vegetable, but pretty close. And on the other hand, I dont think starving the poor girl is the way to put her out.. I mean, if you have to do it, I'd say do it the way they do animals, quick/painless. But then again, you never know when she could just start making a huge recovery. I was reading something last month about a woman who was in a coma for 10 years or so, she came to, told the nurse not to say anything to her parents, and waited til mothers day to suprise her mom by calling her. You never know. Although Shiavo's chances at that are extremely slim seeing as how she has so much brain damage... sad story.

[HiPSI]

I feel really bad about that story, I've been following it for quite some time now and I got mixed feelings on it. On one hand, I feel that she wouldn't want to be living like that, I mean, she's not a complete vegetable, but pretty close. And on the other hand, I dont think starving the poor girl is the way to put her out.. I mean, if you have to do it, I'd say do it the way they do animals, quick/painless. But then again, you never know when she could just start making a huge recovery. I was reading something last month about a woman who was in a coma for 10 years or so, she came to, told the nurse not to say anything to her parents, and waited til mothers day to suprise her mom by calling her. You never know. Although Shiavo's chances at that are extremely slim seeing as how she has so much brain damage... sad story.


after this long, it's pretty suffice to say that she's not going to recover to a point where she can function without the need for medical equipment. i think in that type of case that the family should have a say in how the matter is handled. this isn't a coma, unfortunately it's severe brain damage.

[uncle_el]

this case is very sad, on both parts. the parents seem to be out of touch with reality, and the doctor(s) there seem not to be able to get across the truth to the parents.

if you've never seen someone with a significant brain injury, it all just sounds like words. you believe what people tell you, because you have nothing to compare it to.




here's a paper i wrote on diagnosing brain death about a year and a half ago...



Mr. JF is a 57 year old man with a past medical history of hypertension who was found unresponsive by a family member. Emergency Medical Services found the patient to be unresponsive and hypertensive. Upon arrival to the Emergency Room at Grady Memorial Hospital, the patient was in respiratory distress. He was a very difficult intubation, and a tracheal tube for breathing was eventually placed. On Computed Tomography (CT) of the head, he was found to have bilateral posterior cerebellar artery (PCA) infarcts and uncal herniation.


Whether as a physician in the emergency room, in the trauma bay, in the medical intensive care unit, or on the neurology service, we already have or will encounter a situation such as this at some point during our careers. Many difficult decisions need to be made immediately, and others will need to be made over the next few hours and days. As with many patients, these decisions will be critical to the patient’s prognosis for survival, the family’s perception of the patient’s prognosis, as well as their perception of the care given to the patient. The comatose state, vegetative state, and brain death are issues that are discussed by those outside of medicine. These topics have quite a bit of confusion among the general public, and it is quite apparent in the with the Terri Schindler-Schiavo case.




According to www.terrisfight.org, Ms. Schindler-Schiavo “is in a locked-in state”. Furthermore “though she is responsive to stimuli, interacts with her environment and her loved ones and is capable of communicating in limited ways, she is a disabled and vulnerable adult - requiring protection, therapy and the route to recovery.”1

Her case has spawned debate on television, on Internet forums, and even a new “Terri’s Law”- the term given to the decision of Florida governor Jeb Bush to restore tube feedings to Ms. Schindler-Schiavo. It is important for us as physicians to dispel any misconceptions our patients’ families may have. It is also important for us to respect and honor the decisions of our patients’ families.




Brain Death, a definition:

The levels of consciousness can be thought of as a continuum: from alert, oriented, and active in a meaningful way with other individuals to absolute absence of alertness, orientation, or activity.

Coma, from the Greek word “koma”, literally means deep sleep 1. The comatose state is one of pathologic unconsciousness. The comatose patient is unaware of his/her surroundings, and is unable to be aroused. There are many anatomical and metabolic reasons for a person to be in a coma, which are outside the scope of this paper. However, all of the different reasons for coma affect the cerebral cortex and/or the reticular activating system. The cerebral cortex, which is composed of the right and left hemispheres, controls voluntary movement and sensation. It is also responsible for thought, reasoning, and memory. The reticular activating system is not located in a particular area of the brain, but rather it is a collection of different portions of the brain, including the thalamus, brainstem, and medulla. Together, the cerebral cortex and the reticular activating system are responsible for consciousness.2, 3

A comatose patient may or may not make a meaningful recovery. One comatose patient may regain consciousness, as well as regain all abilities present prior to the coma, whereas another comatose patient may regain consciousness, but with impairment of some or all abilities. Yet another comatose patient may remain in a coma. This third scenario is termed a persistent vegetative state. A persistent vegetative state is also characterized by unawareness, but patients have normal sleep-wake cycles and are arousable. A fourth comatose patient may progress to brain death.

Brain death can be defined as “an unresponsiveness and lack of receptivity, the absence of movement, and breathing, the absence of brain-stem reflexes, and coma whose cause has been identified”4. In the brain dead state, a patient is completely relying upon medical interventions to keep the heart beating and the lungs respiring.




Mimickers of brain death: hypothermia, drug intoxication, “locked in” syndrome.

There is an old saying that a dead body must be a warm body. Hypothermia is a condition that occurs when body temperature falls below 35 degrees Celsius. It may occur when a person is subjected to extremely cold temperatures, or if there is a pathological condition affecting the temperature regulating portion of the brain, found in the hypothalamus. As the core temperature of the body drops below 35 degrees Celsius, coordination will begin to be lost. The skin may become pale, muscles may become rigid, and shivering may occur in an attempt to maintain and perhaps raise core temperature. Heart rate, respiratory rate, and blood pressure may begin to rise in this early stage of hypothermia. As the core temperature continues to drop, speech may become slurred and confusion may begin to set in. As the core temperature of the body drops below 32 degrees Celsius, the response to light is lost (i.e. no pupillary response). Although they rose in the early stage of hypothermia, heart rate, respiratory rate, and blood pressure will begin to plummet once core temperature falls below 32 degrees Celsius. As the core temperature drops below 28 degrees Celsius, brain-stem reflexes are lost. It is imperative to remember that people can survive the extreme cold, and all of these deficits are potentially reversible.5

http://www.rendlake.com/images/hypothermia-chart.gif


A chart used by EMS.

Somewhere between twenty-five to forty percent of hospital admissions are related to substance abuse and its sequelae, and ten to sixteen percent of outpatients seen in primary care practice are suffering from addiction related problems. Roughly ten percent of Americans, report misuse of sedatives in their lifetime. Approximately five to ten of primary care patients meet clinical criteria for major depression. Approximately ten percent meet criteria for minor depression. Antidepressant has increased dramatically within the last ten years with the advent of selective serotonin reuptake inhibitors (SSRIs), the television commercials and advertisements of pharmaceutical companies, leading to the increased awareness and recognition of depression by the general public. Sixty-two percent of Americans age eighteen and over have had alcohol in the past year. Thirty-two percent of those had five or more drinks on the same occasion at least once in the past year. Needless to say, sedatives, antidepressants, and alcohol are commonly used, misused, and abused in today’s American society. When used in combination, the effects can be deleterious, even fatal. Barbiturates, other sedatives, antidepressants, even alcohol can mimic brain death when present at extreme or toxic levels. However, certain portions of brain-stem function remain intact, such as the pupillary response to light.6, 7, 8, 9, 10, 11, 12, 13


Guillain-Barré syndrome (GBS) is an acute inflammatory demyelinating polyneuropathy of unknown origin, characterized by progressive muscle weakness and areflexia. It appears that GBS, also known as ascending paralysis, was first described by James Wardrop in 1834. It was more fully described by Jean Baptiste Octave Landry de Thézillat in 1859, and for a time was known as Landry’s ascending paralysis. In 1916, the landmark study was undertaken by Guillain, Barré, and Strohl. The name "Guillain-Barré Syndrome" was first used in 1927 and persists to this day. GBS occurs in both men and women, affecting people of all ages. It has an annual incidence of 0.6 to 2.4 cases per 100,000; and is now the most common cause of acute flaccid paralysis in healthy people. 14, 15, 16, 17



Though spontaneous remission is the typical outcome, GBS can progress to involve cranial and peripheral nerves, resulting in a “Locked-In Syndrome” (LIS). The term LIS was introduced by Plum and Posner in 1966 and is used to define a clinical picture characterized by a total paralysis of voluntary motor functions with preservation of vertical eye movements combined with synergetic elevation of the upper eyelids when looking upwards. This syndrome is usually associated with a bilateral ventral pontine lesion.18, 19, 20

Brain death is a completely irreversible condition, whereas hypothermia, drug intoxication, and locked-in syndrome are potentially reversible.







Determination of brain death:

One must use his/her clinical neurological skills to find and document coma, the complete absence of brain-stem reflexes, and apnea. The clinical criteria consist of: coma, absence of motor responses to pain, absence of pupillary responses to light, absence of corneal reflexes, absence of caloric responses, absence of gag reflex, absence of coughing in response to tracheal suctioning, absence of sucking and rooting reflexes, and absence of respiratory drive at a PaCO2 that is 60 mm Hg or 20 mm Hg above normal base-line values (i.e. failed apnea test). 21

http://content.nejm.org/content/vol344/issue16/images/large/06t1.jpeg

A physician should refer to the rules, regulations, and criteria of the particular hospital in order to establish brain death in a patient. It is of note, “that it is not the physician’s role to diagnosis death, but rather to diagnose life.”22


What to do if uncertainty remains about brain death?

If uncertainy remains, so-called confirmatory tests can be ordered: electroencephalography (EEG), transcranial Doppler ultrasonography, cerebral angiography, and/or cerebral scintigraphy. None of these technological modalities should be used alone in determining brain death, but rather their interpretation should be combined with the objective findings of the physical exam.

An EEG is a non-invasive procedure in which electrodes are placed on the head of the patient. The electrical output and activity of the brain is recorded and read on a monitor. In brain death, a lack of reactivity to stimuli needs to be demonstrated on EEG.23

Transcranial Doppler ultrasonography is another non-invasive procedure. However, this modality uses sound waves to detect direction, velocity, and direction of blood flow.

A cerebral angiography test is an invasive procedure where a radiopaque substance is injected into the arteries so that the blood vessels will be prominent on X-ray. In brain death, no filling of the cerebrum should be detected in the carotid or vertebral arteries on cerebral angiography.24

Cerebral scintigraphy uses a radionucleotide, generally technetium bound to another molecule, to determine perfusion of the cerebral perfusion. There should be absence of cerebral and brain stem activity on cerebral scintigraphy in order for brain death to be determined.


Conclusion:

The subject of brain death is a hot button issue in today’s society. Care should be taken by the physicians, and the rest of the health care team in establishing brain death. The cause of the patient’s coma must first be determined. Mimickers of brain death need to be ruled out. A careful physical and neurological exam will lead the physician to diagnose life, or determine a state of brain death. If the objective physical exam does not fit all clinical criteria of brain death, there are a number of confirmatory tests which can be done. The results of any test performed should be used in conjunction with the physical exam. In the end, it is important for the physicians: 1. to answer any questions of the patient’s family, 2. to dispel any misconceptions about the patient’s condition, and 3. to honor the decisions of the family, even if it goes against what the physicians would choose to do.



Upon neurological exam, Mr. JF was found to have absence of all brain stem reflexes. He failed the apnea test. However, he did have a reproducible triple reflex with plantar stimulation. An EEG was obtained, which was found to be severely abnormal, but not isoelectric. The medical ICU team was informed of the findings. The family, taking everything into account, decided to withdraw care.







in my mind, this is one of the most important pieces:
http://content.nejm.org/content/vol344/issue16/images/large/06t1.jpeg


beyond that, as i said above, there are other tests that can be done:
eeg to show if there's any brainwaves...
mri to see if there's any metabolism
ultrasound
cerebral scintigraphy to see if there's any blood flow...

i just wonder in terri schiavo's case whether or not any of this has been done. i imagine that it has, but we never hear about it.

also, as i said earlier, if you've never seen someone with a significant head injury; never seen someone comatose... never seen someone brain dead, you have no idea what the experience is like.

for instance, you can pinprick the bottom of someone's foot. if you or i had our foot pricked by a pin, we would move our foot away from it (and maybe even hit the person, lol). someone who's brain dead may not move, or the foot may move towards the stimulus... the movement doesn't mean the person is aware of it.

also, reflexes may be intact, but that doesn't mean anything, as we do not control our reflexes- it's simply an electrical relay between the neurons of the foot and the spinal cord... the brain isn't involved. but if a layperson came in during that exam, he or she might think the person moves on his/her own.







just one medical student's opinion...

[HiPSI]

after reading all that i now know how it feels to be braindead ;). excellent info though, i can see what you mean about the misconceptions of certain reactions being taken as someone's "will" rather than merely an automated response to a stimulus. there's a lot of psychological crap tied up in all this conventional medicine too.

[Jaimecbr900]

Very good discussion.

I feel that she died years ago technically. I personally wouldn't want to be kept alive if there were no signs of me coming back. This poor lady will never be the same. As many have mentioned, she may have been suffering for a long time and not been able to communicate that. 15 yrs is really a long time. If it was a month, then I would see it differently. 15 yrs is a long time.

Personally, she needs to be let to rest. She's had enough suffering in one lifetime.

[SniperJoe]

I agree that she should be allowed to pass, but I just wish that there would be a more humane way to do it. No, she won't feel it, but I still wish that there would be a way to end it quickly. This is what is so difficult about a PVS (Persistant Vegitative State), the subject will react to certain stimuli, but there is no conciousness whatsoever. This isn't like a coma, where people have come out of it, there has been no one in recorded medical history who has recovered from being in a PVS. It is just really hard for the family to accept, because the person is responding to certain things, but there is just nothing there.

[HiPSI]

I agree that she should be allowed to pass, but I just wish that there would be a more humane way to do it. No, she won't feel it, but I still wish that there would be a way to end it quickly. This is what is so difficult about a PVS (Persistant Vegitative State), the subject will react to certain stimuli, but there is no conciousness whatsoever. This isn't like a coma, where people have come out of it, there has been no one in recorded medical history who has recovered from being in a PVS. It is just really hard for the family to accept, because the person is responding to certain things, but there is just nothing there.


i have to agree with you on that as well... but that also gets into the topic of assisted suicide which has always been a hot topic. honestly in this case it's been deemed that she will die, but they might as well give her an injection and end it quickly instead of causing her to starve to death, whether she feels it or not.

[SL65AMG]

yeah i heard today that theyre definitely putting it back in till they can make some sort of decision.

[quickdodge®]

No. They(Congress) are meeting today to decide whether or not to re0insert it. It is still out and staying out as of this moment. Later, QD.

[Leisa]

thats what going on 3 days with no food ... i wonder if she has given any type of sign to anyone taking care of her that she is hungry?

[Chris Mazda]

if you go back about 14 or so years ago you will know that Michael Schiavo (The husband) received 600,000 in a malpractice lawsuit and Terri received 250,000 and 1.4 million. Ever since he received the money he has continiously denied advanced research and therapy for Terri. All he seems to have wanted was the money.

[SL65AMG]

if you go back about 14 or so years ago you will know that Michael Schiavo (The husband) received 600,000 in a malpractice lawsuit and Terri received 250,000 and 1.4 million. Ever since he received the money he has continiously denied advanced research and therapy for Terri. All he seems to have wanted was the money.

well what else is he gonna get? his wife is a vegetable and is not going to recover so he really doesnt have anything else. i just dont see why u would wanna keep someone alive that is in that bad shape.... laying there in a bed for 15 years not being able to do anything. im sure shed pull the plug herself if she could. hell....i would