Terri Schiavo case

From Wikipedia, the free encyclopedia

Schiavo in PVS and under hospital care.

Left: CT scan of normal brain; Right: Schiavo's 2002 CT scan provided by Ronald Cranford, showing loss of brain tissue. The black area is liquid, indicating hydrocephalus ex vacuo.^[1] The glowing piece in the right image is the Thalamic stimulator implanted in her brain.

The Terri Schiavo case was a seven-year long successful effort by Michael Schiavo to have his wife, Terri Schiavo — already diagnosed as being in a persistent vegetative state (PVS) for several years — disconnected from life support, thus soon ending her biological life. While as early as 1993, Michael as Terri's guardian, had entered a Do not resuscitate order for her which he was soon convinced to have rescinded, in 1998 he petitioned under Florida law Section 765.401(3) the Pinellas County Circuit Court to remove her feeding tube.^[2] The parents of Terri Schiavo, Robert and Mary Schindler, opposed this, arguing Terri was conscious. Michael later ceded authority over the matter to the court, which determined that Terri would not wish to continue life-prolonging measures.^[3]

After the initial 5-year struggle by the family members where the feeding tube had been removed for a few days, the governments of Florida and later the United States passed laws that sought, unsuccessfully, to reverse subsequent removals of Schiavo's feeding tube; the periods leading up to these lawmaking efforts received publicity included involvement by politicians and advocacy groups, particularly those involved in pro-life or disability rights causes.^[4] The Federal government's significant involvement during March 2005 in a last-ditch effort to keep Schiavo alive, with President Bush travelling from vacation back to Washington D.C. specifically to sign the legislation, made it a major national news story throughout that month. By March 2005, the legal history around the Schiavo case included fourteen appeals and numerous motions, petitions, and hearings in the Florida courts; five suits in Federal District Court; Florida legislation struck down by the Supreme Court of Florida; a subpoena by a congressional committee to qualify Schiavo for witness protection; federal legislation (Palm Sunday Compromise); and four denials of certiorari from the Supreme Court of the United States.^[5]

The local court's decision to disconnect Schiavo from life support was carried out, on March 18, 2005 and Schiavo died of effects of dehydration at a Pinellas Park hospice on March 31, 2005.

[edit] Background

Schiavo had collapsed in her home on February 25, 1990, and experienced respiratory and cardiac arrest, resulting in extensive brain damage, a diagnosis of persistent vegetative state (PVS) and 15 years of institutionalization. Terri Schiavo was normal, healthy, active, and employed until her cardiac arrest event.

[edit] Initial medical crisis

On the morning of February 25, 1990, at approximately 4:30 a.m. EST, Terri collapsed in a hallway of their St. Petersburg apartment. Firefighters and paramedics arriving in response to Michael's 9-1-1 call found her face-down and unconscious. She was not breathing and had no pulse. They attempted to resuscitate her, she was defibrillated several times, and she was transported to the Humana Northside Hospital. There she was intubated, ventilated, and eventually given a tracheotomy. The long period without oxygen led to profound brain injury ("anoxic-ischemic encephalopathy" noted at autopsy), severely damaging the parts of the brain^[6] concerned with cognition, perception, and awareness.

The cause of her cardiac arrest has never been determined but her lack of balanced nourishment has always been suspected. The possibility of strangulation or domestic violence were investigated at the scene but no evidence was found. For a time, it was believed that her cardiac arrest had been caused by an imbalance of electrolytes in her blood. On admission to hospital, her serum potassium level was noted to be very low, at 2.0 mEq/L; the normal range for adults is 3.5–5.0 mEq/L. Her sodium and calcium levels were normal.^[7] Electrolyte imbalance can be caused by losing fluids. Her medical chart contained a note that "she apparently has been trying to keep her weight down with dieting by herself, drinking liquids most of the time during the day and drinking about 10–15 glasses of iced tea." Iced tea is a mild diuretic; that is, it is a food that causes fluid loss. However, the low potassium could have been a spurious result caused by the intravascular administration of fluids during the attempt to resuscitate her. It is unclear whether she had bulimia.

Schiavo's husband later filed and won a malpractice suit against her obstetrician, Dr. Stephen Igel, on the basis that the physician failed to recognize and diagnose bulimia in her. In November 1992, the jury awarded $1 million. By February 1993, Schiavo had the money from the lawsuit.^[8]

Schiavo remained comatose for two and a half months. When she emerged from the coma, Schiavo regained a sleep-wake cycle, but did not exhibit repeatable and consistent awareness of herself or environment. While initially fed by means of a nasogastric feeding tube, she eventually received a percutaneous endoscopic gastrostomy (PEG) feeding tube—inserted through the abdominal wall.

Dr. Garcia J. DeSousa, a board-certified neurologist in St. Petersburg, Florida, cared for Schiavo during her initial admission to Humana; both he and Dr. Victor Gambone, an internist and Schiavo family physician, independently made the diagnosis of persistent vegetative state (PVS) within approximately one year after Schiavo's cardiac arrest. Other neurologists—Drs. Jeffery M. Karp, James H. Barnhill, and Thomas H. Harrison—also examined Schiavo over the years and made the same diagnosis; they also shared an opinion about her very poor chances for recovery. Dr. Ronald Cranford, a neurologist and expert on coma and unconsciousness, testified in 2005 that nothing in the medical records suggested disagreement among Terri’s physicians about the underlying diagnosis.^[9][10]

[edit] Rehabilitation efforts

Schiavo came home to her family in September; however, after becoming overwhelmed with her needs, the family sent her back to the College Park facility. In November, Michael took her to the University of California, San Francisco for an experimental procedure involving the placement of a thalamic stimulator implant in her brain. The experimental treatment took several months but was unsuccessful. Michael returned to Florida with her in January 1991 and admitted her as an inpatient to the Mediplex Rehabilitation Center in Bradenton, Florida. While there, he later said that he often took "her to parks and public places in hopes of sparking some recovery". On July 19, 1991, Schiavo was transferred to the Sabal Palms Skilled Care Facility,^[11] where she received neurological testing and regular speech and occupational therapy until 1994.

Schiavo's husband trained and became a respiratory therapist and emergency room nurse. In 2004, he was hired as a nursing supervisor at the Pinellas County Jail in Florida.

In mid-1993, just months after Michael and Terri received the money for her rehabilitation (in February, 1993^[8] from the lawsuit), she contracted a urinary tract infection and Michael halted most therapy for his wife and entered a "Do Not Resuscitate" (DNR) order. Jay Wolfson^[12] (though it would be five more years until he filed a petition in court to remove the feeding tube) later wrote a report stating that Michael's decision had been based on consultation with his wife's physician and was "predicated on his reasoned belief that there was no longer any hope for Terri's recovery."^[13]

[edit] Initial family conflict

From 1998 to the end of 2002, the Schindlers were locked in a struggle in the courts, first to decide if Schiavo should be removed from life support and then the appeals by her parents to block this determination. This legal struggle received no notable publicity. This phase started with her husband's initial petition to have the feeding tube removed and involved four legal decisions of note. Michael did not directly make the ultimate decision about whether Terri should live or die: he petitioned the court, asking it to act as Terri's surrogate and determine what she would decide to do if she were able. The court determined that Terri would not wish to continue life-prolonging measures. While Michael remained interested and visible in the proceedings, he had conceded control to the court and the Schindlers now faced the decision of the court. In many ways, the legal status at the end of these five years was the same as immediately after these initial court decisions, but up until the end of this time, the story had received little coverage in the media, and thus it was still a family affair.

Schiavo's husband insisted that she had expressed her wishes not to be kept on life support with no hope for improvement. During a trial in 2000, testimony was heard from witnesses on both sides to establish Schiavo's wishes regarding life support. The court determined that she had made "credible and reliable" statements that she would not want to be "kept alive on a machine," based on expert testimony, finding that Americans do not want to live "with no hope of improvement," and that her condition in a persistent vegetative state had "long since satisfied" the requirement that there be no hope of improvement.^[14]

One objection the parents had was to Schiavo dying by dehydration. Terri Schiavo was never diagnosed as terminally ill. However, numerous studies have shown that for terminally ill patients who choose to die, deaths by dehydration are generally peaceful, and not associated with suffering, when supplemented with adequate pain medication.^{[15][16][17][18][19][20]}

[edit] Petition to remove feeding tube

In May 1998, Terri's husband, Michael, filed a petition to remove Schiavo's feeding tube,^[21] which her parents opposed. Richard Pearse was appointed by the court as a second guardian ad litem (GAL), and on December 29, 1998, reported "Dr. Jeffrey Karp's opinion of the ward's condition and prognosis is substantially shared among those physicians who have recently been involved in her treatment". Pearse concluded from Karp's and Dr. Vincent Gambone's diagnosis of PVS^[21] that Schiavo was legally in a persistent vegetative state as defined by Florida Statutes,^[22] Title XLIV, Chapter 765, §101(12). This includes the "absence of voluntary action" and an "inability to communicate or interact purposefully."^[23]

Pearse found that there was no possibility of improvement but that Michael's decisions might have been influenced by the potential to inherit what remained of Terri Schiavo's estate. Due to a lack of a living will and questions regarding Michael's credibility, Pearse recommended denying his petition to remove her feeding tube. The issue of conflict of interest raised by guardian ad litem Pearse attached to the Schindlers as well, he reported, since, had they prevailed in the various litigation over guardianship, they as the presumed heirs-at-law would have inherited the remainder of Mrs. Schiavo's estate upon her death.^[21]

[edit] Schiavo's end-of-life wishes – Schiavo I

Given the lack of a living will, a trial was held during the week of January 24, 2000, to determine what Schiavo's wishes would have been regarding life-prolonging procedures. Testimony from eighteen witnesses regarding her medical condition and her end-of-life wishes were heard. Michael claimed that Schiavo would not want to be kept on a machine with no hope for recovery. Her parents claimed that Schiavo was a devout Roman Catholic who would not wish to violate the Church's teachings on euthanasia by refusing nutrition and hydration. Judge George Greer issued his order granting Michael's petition for authorization to discontinue artificial life support for his wife in February 2000. In this decision, the court found that Schiavo was in a persistent vegetative state and that she had made reliable oral declarations that she would have wanted the feeding tube removed.^[14] This decision was upheld by the Florida Second District Court of Appeal^[24] (2nd DCA) and came to be known by the court as Schiavo I in its later rulings.

[edit] Oral feeding and the Second Guardianship Challenge

In March 2000, the Schindlers filed a motion to permit oral feeding of Schiavo, which is not considered a life-prolonging procedure under Florida law. Since clinical records indicated that Schiavo was not responsive to swallowing tests and required a feeding tube,^[13] Judge Greer ruled that Schiavo was not capable of orally ingesting sufficient nutrition and hydration to sustain life, and denied the request.^[25] The Medical Examiner in his postmortem report was more definitive and reaffirmed that Schiavo could not have swallowed.^[26]

In 2000, the Schindlers again challenged Michael's guardianship. Their new evidence cited that he had relationships with other women and that he had failed to provide appropriate palliative^[27] care and treatment for Terri. The Schindlers further suggested that he was wasting the assets within the guardianship account by transferring Schiavo to Pinellas Park, Florida hospice "after it was clear that she was not 'terminal' within Medicare guidelines" for hospices. By this time, while still legally married to Terri Schiavo, Michael was in a relationship with Jodi Centonze, and had fathered their first child. Michael denied wrongdoing, stating that the Schindlers had actively encouraged him to "get on with his life" and date since 1991. Michael said he chose not to divorce his wife and relinquish guardianship because he wanted to ensure her final wishes (not to be kept alive in a PVS) were carried out. The court denied the motion to remove the guardian, allowing that the evidence was not sufficient and in some instances, not relevant. It set April 24, 2001 as the date on which the tube was to be removed.

[edit] Three appeals – Schiavo II and first feeding tube removal

In April 2001, the Schindlers filed a motion for relief from judgment citing new evidence of Schiavo's wishes. Judge Greer denied the motion as untimely under Rule 1.540(b)(5) of the Florida Rules of Civil Procedure.^[28] The Second District Court of Appeal upheld Greer's decision but remanded the issue in order to give the Schindlers an opportunity to file a new motion. On April 24, Schiavo's feeding tube was removed for the first time. The Schindlers filed a civil suit against Michael alleging perjury, which was assigned to another court. The judge, Frank Quesada, issued an injunction against removal of feeding tube until this was settled. The feeding tube was reinserted on April 26. On appeal by Michael, the Second District Court of Appeal reversed Judge Quesada's order. In the same time frame, Michael filed a motion to enforce mandate of the guardianship court (that the feeding tube be removed). The Second District Court of Appeal denied the motion. (These three decisions, all published in a single order by Florida's Second District Court of Appeal,^[29] came to be known by the court as Schiavo II in its later rulings.)

[edit] Challenging the PVS diagnosis – Schiavo III

After the failure of challenges to Michael's guardianship and to the ruling on Schiavo's end-of-life wishes, the Schindlers adopted the position that Schiavo was not in a PVS and began to challenge that diagnosis in court. Schiavo's parents claim that their daughter did not meet the definition of a persistent vegetative state, and was in a "minimally conscious state" instead. Her parents argued that at times her actions indicated responses to external stimuli, not instinctive or reflex behavior. For example, the Schindlers claimed that their daughter smiled, laughed, cried, moved, made childlike attempts at speech, and attempted to say "Mom" or "Dad"; or "yeah" when they asked her a question. They claimed that when they kissed her, she looked at them and sometimes puckered her lips.

On August 10, 2001, on remand from the Second District Court of Appeals, Judge Greer heard a motion from the Schindlers claiming that new medical treatment could restore sufficient cognitive ability such that Schiavo herself would be able to decide to continue life-prolonging measures. The court also heard motions from the Schindlers to remove the guardian (Michael) and to require Judge Greer to recuse himself. Judge Greer denied the motions and the Schindlers appealed to the Second District Court of Appeals.

On October 17, the Court of Appeal affirmed the denials of the motions to remove and recuse. The Court of Appeals acknowledged that their opinion misled the trial court, and they remanded the question of Schiavo's wishes back to the trial court and required an evidentiary hearing to be held. The court specified that five board certified neurologists were to testify. The Schindlers were allowed to choose two doctors to present findings at an evidentiary hearing while Michael could introduce two rebuttal experts. Finally, the trial court itself would appoint a new independent physician to examine and evaluate Schiavo's condition. (These decisions, all published in a single order by the Florida Second District Court of Appeal,^[30] came to be known by the court as Schiavo III in its later rulings.)

[edit] PVS diagnosis ruling – Schiavo IV

In October 2002, on remand by the Second District Court of Appeal, an evidentiary hearing was held in Judge Greer's court to determine whether new therapy treatments could help Schiavo restore any cognitive function. In preparation for the trial, a new computed axial tomography scan (CAT scan) was performed, which showed severe cerebral atrophy. An EEG showed no measurable brain activity. The court viewed a six-hour tape of Schiavo and concluded that her vegetative condition was factual and not subject to legal dispute.

In accordance with the Second District Court of Appeal's instructions, five doctors were selected to provide their expert testimony to the trial: two by Schiavo's parents, two by Michael, and one to have been selected by mutual agreement of the parties:

• The Schindler family selected Dr. William Maxfield (a radiologist) and Dr. William Hammesfahr (a neurologist).
• Michael Schiavo selected Dr. Ronald Cranford and Dr. Melvin Greer (both neurologists).
• Because the parties failed to agree, the court selected Dr. Peter Bambakidis (a neurologist).

These five doctors examined Schiavo's medical records, brain scans, the videos, and Schiavo herself. Drs. Cranford, Greer, and Bambakidis testified that Schiavo was in a persistent vegetative state. Drs. Maxfield and Hammesfahr testified that she was in a minimally conscious state.

As part of the court-ordered medical exam, six hours of video of Schiavo were taped and filed at the Pinellas County courthouse. The tape included Schiavo with her mother and neurologist William Hammesfahr. The entire tape was viewed by Judge Greer, who wrote, Schiavo "clearly does not consistently respond to her mother". From that six hours of video, the Schindlers and their supporters produced six clips totaling almost six minutes and released those clips to public websites.^[31]

Judge Greer ruled that Schiavo was in a PVS, and was beyond hope of significant improvement. The trial court order was particularly critical of Hammesfahr's testimony, which claimed positive results in similar cases by use of vasodilation therapy, the success of which is unsupported in the medical literature.^[32] This ruling was later affirmed by Florida's Second District Court of Appeal, which stated that "this court has closely examined all of the evidence in the record," and "we have... carefully observed the video tapes in their entirety." The court concluded that "...if we were called upon to review the guardianship court's decision de novo, we would still affirm it." (This decision by the Second District Court of Appeals^[33] came to be known as Schiavo IV in later rulings.)

[edit] Second feeding tube removal and state involvement: Terri's Law

Main article: Government involvement in the Terri Schiavo case

Around the start of 2003, the Schindlers began to create more publicity by lobbying for their case to keep their daughter alive. They selected pro-life activist Randall Terry as their spokesman but continued to pursue their available legal options. On September 11, 2003, the Schindlers petitioned the court to forestall removal of the feeding tube to provide for "eight weeks' therapy". Accompanying the petition were four affidavits from members of the Schindler family and one from Dr. Alexander T. Gimon. At the hearing, the Schindlers' counsel read into the record additional affidavits from three speech professionals and two nurses. On September 17, Judge George Greer denied the petition, and wrote that "the Petition is an attempt by Mr. and Mrs. Schindler to re-litigate the entire case. It is not even a veiled or disguised attempt. The exhibits relied upon by them clearly demonstrate this to be true." Regarding (Nurse) Iyer's^[34] statements,^[35] Greer wrote that they were "incredible to say the least" and that "Ms. Iyer details what amounts to a 15-month cover-up April 1995 through July 1996 which include the staff of Palm Garden of Largo Convalescent Center, the Guardian of the Person, the guardian ad litem, the medical professionals, the police and, believe it or not, Mr. and Mrs. Schindler... It is impossible to believe that Mr. and Mrs. Schindler would not have subpoenaed Ms. Iyer for the January 2000 evidentiary hearing had Iyer contacted them in 1996 as her affidavit alleges",^[36] September 17, 2003.^[37]

On October 15, 2003, Schiavo's feeding tube was removed. Within a week, when the Schindlers' final appeal was exhausted, the Florida Legislature hastily passed "Terri's Law,"^[38] giving Governor Jeb Bush the authority to intervene in the case. Bush immediately ordered the feeding tube reinserted. Bush sent the Florida Department of Law Enforcement to remove Schiavo from the hospice. She was taken to Morton Plant Rehabilitation Hospital in Clearwater, where her feeding tube was surgically reinserted.^[39] She was then returned to the hospice. Part of the legislation required the appointment of a guardian ad litem (GAL), Dr. Jay Wolfson, to "deduce and represent the best wishes and best interests" of Schiavo, and report them to Governor Bush. Wolfson's report did not change Michael's role as her legal guardian and did not otherwise obstruct him legally.^[13]

Michael Schiavo opposed the Governor's intervention in Schiavo's case, and was represented, in part, by the American Civil Liberties Union (ACLU). At the same time, Robert and Mary Schindler, her parents, attempted to intervene and participate in the "Terri's Law" case but were denied by Judge W. Douglas Baird, a Circuit Judge in the Florida 6th Circuit, the same circuit as for Judge George W. Greer. They appealed, and, on February 13, the Florida Second District Court of Appeal (Second District Court of Appeals) reversed Baird's ruling, allowing them to participate. On March 17, Baird denied the Schindlers the right to intervene a 2nd time,^[40] and the Schindlers, represented by the conservative American Center for Law and Justice (ACLJ), appealed the right to participate in the "Terri's Law" case, with the court scheduling an oral argument date for June 14.^[41] The Schindlers' other attorney, Pat Anderson, was concurrently challenging Michael Schiavo's right to be her guardian, and, on June 16, she made a petition for writ of Quo Warranto, a pleading that asks "by what right" someone acts in an official capacity.

On May 5, 2004, Baird found "Terri's Law" unconstitutional, and struck it down.^[42] Bush appealed this order to the Second District Court of Appeals, but, on May 12, they issued an "Order Relinquishing Case for Entry of Final Judgment and Order to Show Cause Why this Proceeding Should Not be Certified to the Supreme Court As Requiring Immediate Resolution."^[43] The Second District Court of Appeals, in sending it directly to the Florida's Supreme Court, invoked "pass through" jurisdiction.^[44]

The Florida Supreme Court then overturned the law as unconstitutional.^[45]

[edit] Final feeding tube removal and federal involvement

[edit] Early 2005 motions

From about the start of 2005, publicity for this case again began to grow and climaxed in the last half of March with Schiavo's last days, dominating the national news through most of that month. Jesse Jackson went to Florida to support and argue on behalf of the Schindler family. The Schindlers filed two motions in an effort to forestall the removal of Schiavo's feeding tube. No stay was granted by the appellate courts.

On February 23, 2005, the Schindlers filed a motion for relief from judgment pending medical evaluations.^[46] The Schindlers wanted Schiavo to be tested with an fMRI and given a swallowing therapy called VitalStim. The motion was accompanied by thirty-three affidavits from doctors in several specialties, speech-language pathologists and therapists, and a few neuropsychologists, all urging that new tests be undertaken.^{[47] [48]} Patricia Fields Anderson, the Schindler family attorney, still held out hope "that Terri might be able to take nourishment orally, despite past findings that she is incapable."^[49] Judge Greer formally denied the motion and ordered the "removal of nutrition and hydration from the ward". Anderson argued that Greer did not specify "artificial nutrition and hydration" versus "oral nutrition and hydration" and stated that "the withholding of food and water...was not ordered by the Court but by Michael Schiavo."^[50] In his order, Greer also set a time and date for the removal of the feeding tube: "1:00 p.m. on Friday, March 18, 2005."^[51]

On February 28, the Schindlers filed a motion, asking for permission to attempt to provide Schiavo with "Food and Water by Natural Means." This second motion asked for permission to "attempt to feed" Schiavo by mouth.^[52] Judge Greer denied the second motion on March 8, saying "it has become clear that the second motion is part and parcel of the previous motion on medical evaluations. The same declarations are being used for both motions and the motion appears to be an alternative pleading to the previous motion. Both are asking for an experimental procedure."^[53] The following day, Greer denied the first motion as well, citing that an affiant doctor for Michael cautioned that fMRI was an experimental procedure that should be conducted in an academic setting, because Schiavo had already undergone swallowing tests and failed, and because VitalStim had only been performed on patients who were not in a PVS. Greer noted that "[m]ost of the doctor affidavits submitted are based on their understanding of Schiavo's condition from news reports or video clips they have seen. Many are obviously not aware of the medical exams undertaken for the 2002 trial..."^[47]

[edit] Final removal and federal involvement

Main article: Government involvement in the Terri Schiavo case

Following Greer's order on March 18, 2005 to remove the feeding tube, Republicans in the United States Congress subpoenaed both Michael and Terri Schiavo to testify at a congressional hearing.^[54] It is contempt of Congress to prevent or discourage congressional witnesses from testifying.^[55] The purpose of the subpoenas was thus to postpone the feeding tube removal.

Greer told congressional attorneys, "I have had no cogent reason why the (congressional) committee should intervene." He also stated that last-minute action by Congress does not invalidate years of court rulings.^[56][57] Although Senate Majority Leader Bill Frist, Senator Rick Santorum, and House Majority Leader Tom DeLay brought the possibility of sanctioning Greer on charges of contempt of Congress, Congress did not attempt to enforce the subpoenas or take any action against Greer.

[edit] Palm Sunday Compromise

Main article: Palm Sunday Compromise

Governor Bush and Congressional Republicans anticipated Greer's adverse ruling well before it was delivered and worked on a daily basis to find an alternative means of overturning the legal process by utilizing the authority of the United States Congress. On March 20, 2005, the Senate, by unanimous consent, passed their version of a relief bill; since the vote was taken by voice vote, there was no official tally of those voting in favor and those opposed. Soon after Senate approval, the House of Representatives passed an identical version of the bill S.686, which came to be called the "Palm Sunday Compromise" and transferred jurisdiction of the Schiavo case to the federal courts. The bill passed the House on March 21 at 12:41 a.m. EST. President Bush flew to Washington D.C. from his vacation in Texas in order to sign the bill into law at 1:11 a.m. EST. As in the state courts, all of the Schindlers' federal petitions and appeals were denied, and the U.S. Supreme Court declined to grant certiorari, effectively ending the Schindlers' legal options.

At the same time, the so-called Schiavo memo surfaced, causing a political firestorm. The memo was written by Brian Darling, the legal counsel to Florida Republican senator Mel Martinez. It suggested the Schiavo case offered "a great political issue" that would appeal to the party's base (core supporters) and could be used against Senator Bill Nelson, a Democrat from Florida, because he had refused to co-sponsor the bill.^[58] Nelson won re-election in 2006.

[edit] Final local motions, death and autopsy

On March 24, 2005, Greer denied a petition for intervention by the Department of Children & Families (DCF) and signed an order forbidding the department from "taking possession of Theresa Marie Schiavo or removing her" from the hospice and directed "each and every and singular sheriff of the state of Florida" to enforce his order. The order was appealed to the Second District Court of Appeals the following day, which resulted in an automatic stay under state law. While the stay was in effect, Florida Department of Law Enforcement personnel prepared to take custody of Terri and transfer her to a local hospital for reinsertion of the feeding tube. Once Greer was made aware of the stay, he ordered it lifted and all parties stood down. Governor Bush decided to obey the court order despite enormous pressure from the political right. If Bush (or the Florida Legislature) had ignored Greer's order by attempting to remove her from the hospice, a confrontation between the Pinellas Park Police Department and the FDLE agents could have ensued. In jest, one official said local police discussed "...whether we had enough officers to hold off the National Guard."^[59]

Schiavo died at a Pinellas Park hospice on March 31, 2005.

After her death, Schiavo's body was taken to the Office of the District 6 Medical Examiner for Pinellas and Pasco counties, based in Largo, Fla. The autopsy occurred on April 1, 2005. It revealed extensive brain damage. The manner of death was certified as "undetermined". The autopsy was led by Chief Medical Examiner Jon R. Thogmartin, M.D. In addition to consultation with a neuropathologist (Stephen J. Nelson, M.D.), Dr. Thogmartin also arranged for specialized cardiac and genetic examinations to be made. The official autopsy report^[26] was released on June 15, 2005. In addition to studying Mrs. Schiavo's remains, Thogmartin scoured court, medical and other records and interviewed her family members, doctors and other relevant parties.

Examination of Schiavo’s nervous system by neuropathologist Stephen J. Nelson, M.D., revealed extensive injury. The brain itself weighed only 615 g, only half the weight expected for a female of her age, height, and weight, an effect caused by the loss of a massive amount of neurons. Microscopic examination revealed extensive damage to nearly all brain regions, including the cerebral cortex, the thalami, the basal ganglia, the hippocampus, the cerebellum, and the midbrain. The neuropathologic changes in her brain were precisely of the type seen in patients who enter a PVS following cardiac arrest. Throughout the cerebral cortex, the large pyramidal neurons that comprise some 70% of cortical cells – critical to the functioning of the cortex – were completely lost. The pattern of damage to the cortex, with injury tending to worsen from the front of the cortex to the back, is also typical. There was marked damage to important relay circuits deep in the brain (the thalami) – another common pathologic finding in cases of PVS. The damage was, in the words of Thogmartin, "irreversible, and no amount of therapy or treatment would have regenerated the massive loss of neurons."^[60]

Stephen J. Nelson, M.D., the Board-certified neuropathologist who examined her nervous system at autopsy, cautioned that "neuropathologic examination alone of the decedent's brain – or any brain for that matter – cannot prove or disprove a diagnosis of persistent vegetative state or minimally conscious state."^[26] The vegetative state is a behaviorally defined syndrome of complete unawareness, to self and to environment, that occurs in a person who nevertheless experiences wakefulness. As the condition is defined in clinical terms, it can therefore only be diagnosed in persons who, at some point, are shown to meet those clinical terms. Ancillary investigations, such as CT scans, MRI, EEGs, and lately fMRI and PET scanning, may only provide support for the clinical impression—as might the pathologic findings, after death. In the case of Terri Schiavo, seven of the eight neurologists who examined her in her final years stated that she met the clinical criteria for PVS; the serial CT scans, EEGs, the one MRI, and finally, the pathologic findings, were consistent with that diagnosis.

The cardiac pathologist who studied Schiavo's heart found it and the coronary vessels to be healthy (which excludes the possibility that her initial collapse was the result of myocardial infarction, although there was a localized area of healed inflammation (opening to the possibility of myocarditis)).

Although the basis of Michael Schiavo's $1 million medical malpractice settlement was his claim that Terri Schiavo suffered from an eating disorder (bulimia) that caused a serious electrolyte disturbance, stopping her heart, Thogmartin found that "there was no proof that Terri Schiavo ever had an eating disorder such as bulimia." The main piece of evidence cited for an eating disorder — the low levels of potassium in her blood in 1990 — could have been caused by the emergency treatment she received at the time, Thogmartin said. While she had lost more than 100 pounds since high school, Schiavo never confessed to an eating disorder, she did not take diet pills and no one had ever witnessed her purging food.^{[citation needed]}

Regarding the possibility of strangulation or domestic violence as a cause of Schiavo's initial collapse, the report states: "No trauma was noted on any of the numerous physical exams or radiographs performed on Mrs. Schiavo on the day of, in the days after, or in the months after her initial collapse. Indeed, within an hour of her initial hospital admission, radiographic examination of her cervical spine was negative. Specifically, external signs of strangulation including cutaneous or deep neck injury, facial/conjunctival petechiae, and other blunt trauma were not observed or recorded during her initial hospital admission. Autopsy examination of her neck structures 15 years after her initial collapse did not detect any signs of remote trauma, but, with such a delay, the exam was unlikely to show any residual neck findings."^{[citation needed]}

Regarding the cause and manner of Schiavo’s death, Thogmartin wrote, "Mrs. Schiavo suffered severe anoxic brain injury. The cause of which [sic] cannot be determined with reasonable medical certainty. The manner of death will therefore be certified as undetermined."^[26]

"We weren't surprised the medical examiner said Terri's brain was damaged," said Bobby Schindler, Jr., her brother, in an interview hours after the autopsy report was released. "The fact that the medical examiner ruled out bulimia and ruled out a heart attack, without a doubt, adds more questions."^[61]

[edit] Public opinion and activism

Main article: Public opinion and activism in the Terri Schiavo case

The Terri Schiavo case held the attention of both American and international audiences and had major political ramifications. A number of opinion polls were carried out, particularly on the question of federal involvement in the Terri Schiavo case, with conflicting results. The case drew notable figures on both sides of the debate, as well as many pressure groups and public protesters. Although the vast majority of protests were nonviolent, two of the more extreme acts included death threats aimed towards Michael Schiavo.

Terri's parents alleged that her husband was abusive and that this had led indirectly to her condition. The Florida Department of Children and Families rejected these allegations.^[62] Some have since maintained that her death constituted judicial murder.^{[63][64][65][66][67]} In 2004, Pope John Paul II stated that health care providers are morally bound to provide food and water to patients in persistent vegetative states. This led to a challenge in 2005 by Schiavo's parents, who requested a new trial about whether their daughter, as a devout Catholic, would wish to go against the Church's teaching. David Gibbs III, the lead lawyer for Terri Schiavo’s parents, supported Vatican statements which condemned her treatment as euthanasia. Judge Greer rejected their request.^[68]

On March 11, 2005, media tycoon Robert Herring (who believes that stem cell research could have cured Schiavo's condition) offered $1 million to Michael Schiavo if he agreed to cede his guardianship to his wife's parents.^[69] The offer was rejected; George Felos, attorney for Michael Schiavo, described it as offensive, adding that Michael had rejected other monetary offers, including one of $10 million.

During the final stages of the court battle in March 2005, around 30 individuals made a variety of complaints to the DCF, alleging various abuses.^[70] These included Terri Schiavo being in pain from recent dental work, although she had not had any dental work for years prior to that, and sensory deprivation. DCF investigators found the claims to be groundless, stating that there were "no indicators" of abuse in any of the cases and concluding that "the preponderance of the evidence shows that Michael Schiavo followed doctors' orders regarding Ms. Schiavo's diagnosis of being in a persistent vegetative state and that he provided her with appropriate care."^[71]

[edit] Notes

[edit] Further reading

• Terri's Story: The Court-Ordered Death of an American Woman by Diana Lynne (2005) ISBN 1-58182-488-2
• Silent Witness: The Untold Story of Terri Schiavo's Death by Mark Fuhrman (2005) ISBN 0-06-085337-9
• A Life That Matters: The Legacy of Terri Schiavo — A Lesson For Us All by Mary and Robert Schindler (2005) ISBN 0-446-57987-4
• Remembering Terri Schiavo: Reflections of a Health Care Warrior by Audrey Ignatoff (2005) ISBN 1-4116-3220-6
• Terri: The Truth by Michael Schiavo, Michael Hirsh (2006) ISBN 0-525-94946-1
• "Terri Schiavo: When Does Personhood End?" The Elements of Bioethics, Gregory Pence, ISBN 978-0-07-313277-8
• The Case of Terri Schiavo: Ethics at the End of Life edited by Arthur L. Caplan, James J. McCartney, and Dominic A. Sisti, ISBN 159102398X

[edit] External links

[edit] Compilations

(legal documents relating to the Schiavo case)

• Findlaw's compilation
• Tampa Bay Online's compilation
• The University of Miami Ethics Programs' compilation

[edit] Information sites

• Michael Schiavo.org Website on Michael Schiavo.
• ProCon.org's legal papers, timeline, and examination
• American Center for Law and Justice. ACLJ National "Civil Rights" law firm. Retrieved August 30, 2005
• Liberty to the Captives. Compilation of testimonies, interviews and information on the case: Bone Scan this link. Retrieved January 9, 2007
• Conigliaro, Matt, Esq., Editor of "Abstract Appeal" Legal Blog. (2005). THE TERRI SCHIAVO INFORMATION PAGE Retrieved August 31, 2005
• End-of-Life Choices (2005). Advance Health Care Directives: End-of-Life Choices — Make Your Wishes Known!^{[dead link]} Retrieved August 30, 2005
• Hospice Patients Alliance Retrieved August 30, 2005. Includes the initial 1999 Police Report

[edit] Articles, advocacy, and commentary

This information is available on the Public opinion and activism in the Terri Schiavo case article.