Inside Terri's brain
She's probably not in pain. Still, doctors can't read her mind
Smooth passage? Doctors who have sat at bedsides after feeding tubes have been removed can offer a studied guess at what a dying person feels. Most believe that when food and drink stop, the body's own chemical reactions smooth the way toward death. "All mammals eventually stop eating and drinking," says Ira Byock, director of palliative medicine at Dartmouth Hitchcock Medical Center. "Nature has provided us with a very gentle way for life to end." When someone is in a persistent vegetative state, with no conscious awareness, there is no pain, no hunger and no thirst. "In [Schiavo's] case, there's no reason to believe she'd feel anything," says Joanne Lynn, geriatrician and researcher with Rand Health. "It's as if she were anesthetized."
Even when a person is extremely sick but aware, feelings of hunger dissipate after about 24 hours. "The dying process creates an involution of normal hunger and thirst," says Bernat. Movement of the gut slows, as does plasma volume, decreasing the sensations of hunger and thirst. Normal palliative care in such cases includes moistening the lips, mouth, and throat for comfort. And if there is a concern about pain, physicians can treat with drugs.
Persistent vegetative state has been argued in court cases going back 29 years. The first was in 1976 when the parents of Karen Ann Quinlan asked that their daughter be taken off a respirator. In 1990, the U.S. Supreme Court ruled that Nancy Cruzan's parents could have her feeding tube removed. In all such cases, the courts have asked for evidence that the actions are what the patient would have wanted.
In the Schiavo case, that standard has been met, according to the many court rulings, with testimony from her husband and others that she would not wish to continue living as she is. Americans have come to expect the right to accept or reject medical treatment, regardless of their condition. "You can exempt yourself from medical care, except for the rare circumstance that you have a dangerous disease that is contagious, or a mental illness where you might hurt someone," says Lynn.
In an article from the April 21 New England Journal of Medicine, released last week (early because of the Schiavo case), Timothy Quill, director of the Center for Palliative Care and Clinical Ethics at the University of Rochester Medical Center, wrote that the New Jersey Supreme Court asked the right question in 1976. In the case of Quinlan, the court asked, "If the patient could wake up for 15 minutes and understand his or her condition fully, and then had to return to it, what would he or she tell you to do?" It is a question every American would do well to discuss with loved ones--and have the answer in writing.
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