DECEMBER 16, 1996 VOLUME 4, NUMBER 24
“W.L.”, an 85-year-old Tucson woman, lives in her daughter’s home. She has been unable to speak coherently, or to communicate her wishes, since a massive stroke over two years ago.
Less than a year before her stroke, W.L. signed a Living Will (and a Health Care Proxy) in another state. Her Living Will provides that:
If the situation should arise in which I should have an incurable or irreversible condition that is likely to cause my death within a relatively short time, or if I should be permanently unconscious or in a permanent vegetative state, I direct that I be allowed to die and not be subjected to or continue to be kept alive by medication, medial procedures interventions or artificial means of any kind, including artificial nutrition and hydration.
Since shortly after her stroke, W.L. has received both nutrition and hydration through a gastrointestinal tube, which is permanently inserted directly into her stomach. She is mobile and in excellent health; the care she receives in her daughter’s home is exceptional and her health care professionals agree that she can be maintained in her current circumstance for a considerable time.
Last year, in connection with unrelated court proceedings, an attorney was appointed to represent W.L.’s interests. Her attorney questioned whether W.L. should be receiving artificial feedings, given the language of her Living Will. He brought a new court proceeding, asking the judge to authorize the removal of the tube.
W.L.’s medical providers objected, indicating that because of her excellent care, the quality of her life and the slight inconvenience associated with her gastrointestinal tube, it would be wrong to remove the tube at this point. Her family concurred, arguing forcefully that they felt that her quality of life is excellent and that she knows and is interested in family members. Family members also noted that W.L. had suffered another stroke seven years earlier, and had accepted tube feedings and substantially recovered from the first stroke; they argued that administration of tube feedings was consistent with W.L.’s previous practice.
After legal arguments, Pima County Superior Court Judge William Sherrill ruled that W.L.’s feeding tube should not be removed. He noted that there is some ambiguity in W.L.’s Living Will (it indicates that her agent under the Health Care Proxy may have the final decision as to withholding life-sustaining treatment), that there are questions about her understanding of the terms of the Living Will when she signed it, and that her present condition may not be one which would “cause her death.” Finally, according to Judge Sherrill, no decision to remove a feeding tube (particularly over the objections of both family and treatment team) should be made unless the evidence of the patient’s wishes is “clear and convincing.”
Assuming that a patient wishes to avoid W.L.’s current situation, what might she do? Two items would help ensure that strongly-held opinions are honored:
- Clear expressions of the patient’s wishes. W.L. relied on pre-printed forms (although they were filled out by her attorney and executed in his office). Unfortunately, they did not speak in her own voice, and did not tell the reader which issues were more important to her.
- Full discussion with family. At least some of W.L.’s family was surprised to learn of her Living Will, and first saw it after the decision to place the feeding tube had been made. If they had been aware of her wishes earlier, they might have acted differently.
Of course, Judge Sherrill’s decision might well have been exactly what W.L. wanted. Unfortunately, her ambiguous Living Will prevents us from ever knowing for certain.