Judges and Life-Ending Decisions

On January 23, 2009, an article entitled "Judge May Make Life or Death Decision on Infant" posted by MSNBC, reported that a Texas court "may decide Tuesday whether to end life support for a 6-month-old Dallas baby who has suffered severe brain damage, dozens of bone fractures and numerous scars."

Such decisions regarding elderly persons are less publicized, but more frequent.

In the current Texas case, child abuse is alleged by authorities as the source of the infant patient's dire physical condition:

A court-appointed guardian for the boy has filed a motion in Dallas County juvenile court asking that doctors at Children's Medical Center of Dallas be permitted to remove the boy from life support.

The motion says the parents have not consented to withdrawing the support, but it argues that the move is in his best interests.

His parents * * * were arrested Dec. 23 on charges of injury to a child. Bail was set at $500,000 each and they remain in jail.

"Both parents are responsible for long-term, extensive physical abuse to their only infant son," a Child Protective Services report alleged. * * *

Landmark cases involved previously healthy, younger adults, who suffered an incident that resulted in an irreversible coma, such as Karen Ann Quinlan (1975), Nancy Cruzan (1983), and Terry Schiavo (1990).

Their cases, applicable principles, and legislative developments are carefully considered on the website Court and the End of Life.

Traditionally, death was defined as the total cessation of circulatory and respiratory functions.

In 1968 the Ad Hoc Committee of the Harvard Medical School defined irreversible coma, or brain death, as a new criterion for death.

As medical technology has become increasingly able to maintain patients who would otherwise die from severe injuries or illnesses, the debate about defining death, and about whether patients have the right to choose to die, has intensified.

See also: Advance Directives - A Brief History Of Advance Directives, Living Wills, Importance Of Communication, Additional Instructions In Advance Directives.

The far more frequent and common setting for end-of-life decision making involves terminally-ill or comatose patients who are elderly. In counties with large medical centers, the local courts may, by a review of a surrogate's proposed end-of-life decision, become the decision-maker of last resort for some elderly folks.

On January 26, 2009, The Morning Call (Allentown, PA) published an article by Veronica Torrejón, entitled "Lehigh County judge's panel wrestles with end-of-life decisions" which examined end-of-life decision reviews presented to an Orphan's Court Judge sitting in Lehigh County, Pennsylvania.

Everyone dies, but how and under what circumstances are matters Lehigh County Judge Edward Reibman often finds himself pondering.

Not because he's a particularly morbid man. He has the awesome responsibility of making decisions when a person is incapacitated and there's a dispute over who makes end-of-life choices.

In the absence of a living will, Reibman can decide whether someone lives on a respirator in a hospital room or dies at home with friends.

He wrestles with his decisions, wondering if his rulings reflect his own end-of-life preferences or the little he knows about the wishes of the person he's charged with deciding for.

''I'm sitting there on the bench, I'm supposed to make this decision based on the law, a sound rational decision,'' he said. ''How do I make sure that my own biases don't dictate that decision?'' * * *

To receive general input on end-of-life issues, but not specific cases, the Judge sought out experts and divergent viewpoints.

His search for answers led him to convene a panel earlier this month, a talk that those who attended said probably will be the first of many.

Reibman called together doctors, lawyers, religious leaders and court-appointed guardians, all charged with helping make decisions for others.

They all agreed on one thing -- the right choices are seldom clear.

''The reasonable person standard sounds great, until the rubber hits the road,'' Reibman told more than two dozen assembled at Lehigh Valley Hospital-Cedar Crest to discuss what has become an increasingly complex issue. * * *

The article points out that the number of guardianship cases in Lehigh County is increasing, and that "advancing medical technology and shifting social realities" make end-of-life situations more complex. The conjunction of these two factors in a surrogate decision making setting often places a court in the role of reviewer in individual cases.

Medical prognoses remain crucial evidence in such cases:

Medical advances in just one lifetime have been tremendous, said Dr. Lou Lukas, who heads a program at Lehigh Valley Health Network for managing serious illness. What used to be impossible medically has become the norm and patients are now faced with making decisions about how they will die.

''At almost any time there is something we can do,'' she said. ''Death now results from conscious decisions.'' * * *

Although medical diagnoses are important, so are the personal beliefs once expressed by the patient.

''There are many sources of inspiration that we all turn to,'' Reibman told the panel. For some it is the Torah, others the Bible, the Quran, medical texts or a ''combination of science and scripture.''

The panel's conversation often veered into the personal, with guardians sharing times they wrestled with their conscience on issues such as whether to force a feeding tube on someone who is mentally retarded. * * *

Pennsylvania law, in Chapter 54 of Title 20 ("Health Care") of the Probate, Estates & Fiduciaries Code, effective January, 2007, provides a means whereby any individual can express their wishes as to medical care in advance of a disability, and how decisions should be made by a designated or appointed representative when a patient's capability to make a decision becomes impaired.

For guidance, see: PA HealthCare DecisionMaking website. See also: Decide for Yourself—A Guide to Advance Health Care Directives (PDF), a 12-page brochure posted by the Pennsylvania Medical Society that answers patients' frequently asked questions about end-of-life and other health care planning.

End of life decisions are never easy. But the process can embody respect and the outcome reflect individual preferences if a patient's wishes have been previously-expressed, deliberately.

It is best to do so, while deliberate expression remains a possibility.

“In the long run, we shape our lives, and we shape ourselves.
The process never ends until we die.
And the choices we make are ultimately our own responsibility.”

-- Eleanor Roosevelt, quoted on ThinkExist