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The tragic case of the 39 year old Florida woman, Terri Schiavo, who had been in a coma for years, brought the dispute between her husband and her parents regarding Terri’s right to die into the limelight.  It was a painful and very public airing of the rare, but not unheard of situation where a patient can remain in a vegetative state for months or years.  The patient is no longer able to make decisions about treatment and it falls to others – usually family and physicians.  It is not unusual that one family member will not agree with another on courses of action – this happens often in the care of people.  However, the question of whether to stop the life-preserving treatment of a comatose patient is a very difficult one for anyone who has to make it, including the physician who has been taught that we must do everything we can to preserve life.  And, with a comatose or in other cases with severely demented patients, we cannot ask the patient what they really want us to do – this puts an unwanted burden of responsibility on those who must decide.   

How did we get to this place?
In the past medical technology was limited.  We were not able to sustain life in people who could not breathe, or who could not eat, or had a host of other illnesses that caused death.  Steadily over the past century we developed remarkable medicines and artificial techniques to sustain life despite the patient’s ability to do so alone.  For this reason we have saved many lives and have extended lives many years – importantly, we have been able to bring patients back to a normal life who would have in a previous time expired.  One most ironic twist to this series of life-saving therapies is heart transplant.  There is no doubt that this procedure transforms those who receive it from nearly dead and facing certain death to vastly improved quality of an extended life.  But, the heart transplant cannot be done if someone else is not declared dead and taken from life-support that preserves the undamaged heart in a patient who has suffered brain damage so severe that the patient is legally dead.  Life support is then removed from that patient so that another can survive.  Terri Schiavo survived in a vegetative support environment where she was given nutrition by tubes, but she was able to breathe without a respirator.  Physicians agreed that she was in a coma and would not emerge from it.  This put everyone in the very unenviable position of trying to answer the question: if Terri could speak to us, what would she want?  There are obviously, other religious and ethical questions here as well, but I will not probe them for they differ and begin a different debate.  They should not be ignored, however.

Options and Differences
Every case is unique and should be treated as such.  No patient or family is exactly the same.  This means that every case has to be dealt with individually.  For example, if a patient has a terminal disease like disseminated cancer and the patient gets pneumonia and falls into a coma – does one aggressively teat the pneumonia?  Some would argue as it used to be said that “pneumonia is the old person’s friend.”  Others would want every thing done in hopes that the pneumonia can be treated and the patient regains consciousness.  Many of us have seen examples where the question of death and prolonged life are raised and the patient is not able to discuss it. 

Advanced Directives and Power of Attorney
This column has devoted a lot of newsprint to ways that we can practice preventive care.  That term usually means – by our actions we can promote healthy aging.  We know what to eat, all about exercise and lots of other things that we should be doing to keep us healthy.  This column has some advice on a different kind of preventive care – this time it is to be certain that one has a “living will” or advanced directive.  This might prevent the giving of unwanted care.  The living will that one can make with forms from the internet (Livingwill.com or agingwithdignity.org) or with an attorney or when checking into hospital will make it clear what you – while fully conscious want done in case you suffer an unexpected serious illness or injury that makes you unconscious and dependent on “life-support.”  It is also advised that you assign a durable power of attorney for healthcare to someone else who fully understands your wishes and desires on this very difficult subject.  It is crucial that the person(s) you designate as your proxy understand exactly how you feel about being perpetuated in a vegetative state similar to Terri Schiavo.  As uncomfortable as it is to have these discussions, it is the type of preventive care that will insure that people do what you want them to do when you are unable to tell them. 

Other Online Resources:
Task Force Working Group Encourages Patient-Provider Partnership in Making Decisions about Preventive Care  (Agency for Healthcare Research and Quality)
National Healthcare Quality Report: Summary  (Agency for Healthcare Research and Quality)

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