There is just no pleasing some people

In a change of original plans, Michael Schiavo decided to inter his late wife's ashes in a Clearwater, Florida cemetery instead of a family plot in suburban Philadelphia near where he and Terri Schiavo grew up. Terri Schiavo's (the Schindlers) family had orginally requested that she be buried in Florida, instead of Pennsylvania, because they had moved there to be closer to her. Despite this change in plan, one that should please the Schindler family, the Schindler's are complaining via their attorney that they were not notified of the service beforehand and their distate for the grave marker which indicates the date of her collapse and decopmpensation into an irrreversible vegetative state February 25, 1990 as the day she "departed this Earth" and the date she was declared dead as the date she was "at peace."

Considering all the rancor that surrounded the case, the unsubstantiated claims of: spousal abuse (including a Fristian diagnosis of Michael Schiavo as a "wife-abuser" at the Robert Schindler's request) and/or attempted murder by Michael Schiavo, the threats of violence against Michael Schiavo's family,and the recent pronouncements indicating that Jeb Bush, along with the support of the Schindler family and their supporters, will proceed to waste even more taxpayer money for an investigation in an attempt to try find evidence to bring criminal charges against Michael Schiavo, it is perfectly understandable that Schiavo would have preferred to conduct his memorial service to his late wife without the glare of the media spotlight or the continued attacks by her family and the so called "pro-life" movement.

The only thing good to come from this debacle is a heightened awareness of the need for a "Living Will"/Advanced Directive prior to having to face theses sorts of decisions. The AMA is finally considering the best way to address the issues posed by cases like these to head off well-intentioned but completely irrational plans for legistlation that would automatically presume a desire for artificial hydration and nutrittion in perpetuity in the absence of dcoument legal instructions otherwise.

Current AMA policy states that it "is not unethical to discontinue all means of life-sustaining medical treatment in accordance with a proper substituted judgment or best interests analysis" and further states that courts should "determine who is to make treatment decisions, including appointing a guardian, rather than making treatment decisions."

The AMA is also considering a proposal from the American Association of Public Health Physicians that would require health insurers, including Medicare and Medicaid, to obtain written advance directives from all new patients at time of enrollment in health plans.

Moreover, the Public Health Physicians are asking the AMA to amend the group's Principles of Medical Ethics to "explicitly recognize the rights of the patients and legally responsible family members when patients are unable to speak for themselves in determining the care provided."

In an abstract presented last month's American Thoracic Society meeting, the reported results of a survey conducted of Intensivists at San Francisco General confirmed what anyone with ICU experience already knows: many of the decisions to withdraw life support from patients who lack surrogate decision makers are made without legal intervention. In cases in which there is no Advanced Directive, but family members are available to act as surrogate decision makers, most states list a succession of relatives as legal decision makers (in general, the succession order is spouse, adult child, parent then sibling). In general, when there is dissent among family members, hospital staff end up playing peace-makers in order to try to achieve some degree of family consensus and comfort on a decision regarding continued intervention. This usually does bring about resolution, but when it does not, hospital staff will follow the directive of the family member with legal standing to make such decisions.

Unfortunately, while the Schiavo affair provided much needed attention to living wills, many people started considering extreme measures to refuse intervention because they feared the possiblity of mandated intervention in perpetuity should initiation of life support occur (especially in light of Congress' ill thought out legislative interference). Ultimately, the best practice would be to educate the public on the various types of intervention and provide general guidance regarding reversible/treatable conditions vs palliative care vs continued intervention in cases of medical futility, and encourage legal documentation of wishes (including delegation of a legally authorized respresentative to make further decisions as necessary) as well as encouraging frequent review and update as life circumstances change. In the absence of such documentation, any legislation presuming perpetual care regardless of reversibility and/or availabilty of next of kin to make decisions by proxy is irresponsible and inhumane.

Tags: terri schiavo; disability; medical futility;living will; Autonomy; Healthcare

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