The role of the courts in terminating life-sustaining medical treatment.

In this article I address the issues generated by a mother's decision to withdraw further life-sustaining medical treatment from her daughter, who languished for nine years in a nursing home in a persistent vegetative state. In 1983 the daughter, Martha Sue DeGrella (Sue), then age thirty-five, was severely beaten, sustaining an acute subdural hematoma causing severe brain damage, for which medical treatment was of no benefit. She was transferred to a nursing home, where she sustained life through a surgically implanted tube that supplied artificial nutrition and hydration. The doctors agreed that further medical treatment was of no possible therapeutic value, but the nursing home advised the family that it would require court authorization before permitting or participating in the withdrawal of treatment. The case involved is DeGrella v. Elston.(1) The trial court authorized the mother to direct medical personnel to discontinue life-sustaining medical treatment. This order was affirmed in a divided opinion (5/2). I authored the majority opinion. Many of the issues are interdependent, and I do not imply otherwise by covering them separately in this article. Some are simply sub-issues, and all lead to the ultimate questions, which are (1) is it appropriate for a court to entertain a case of this nature and (2) if so, what is the appropriate role for the court in the ultimate decision? Sue's mother applied to be, and was appointed, her legal guardian in October 1991, and in February 1992 she filed a petition seeking a declaratory judgment (1) acknowledging Sue's persistent vegetative state and (2) asking the court to declare that she, as Sue's mother, "is permitted by Kentucky law to substitute her judgment for that of her daughter" and direct discontinuation of further treatment. The immediate cause of the suit was the nursing home's refusal to permit Sue's mother, as legal guardian, to direct the termination of treatment. The trial court appointed a guardian ad litem (GAL) to advocate Sue's interest, and the GAL denied anyone had a legal right to an order of this nature. A trial took place over a two-day period in July 1992. Sue's mother presented extensive evidence, which was appropriately tested by cross-examination from the GAL. The court heard testimony from three doctors and the nursing home administrator, three of Sue's siblings and her mother, her ex-husband, and two theologians. The uncontradicted medical testimony established that Sue reacted only at a reflexive level, meaning she would withdraw from a painful stimulus, but she did not experience pain by cognitive thought. Ceasing nutrition and hydration would cause no pain, although, of course, neither would continuing the treatment. With continued nutrition and hydration she might live many years, and with withdrawal all signs of life would expire in a few days. While competent, Sue had expressed explicitly and frequently her desire that her life not be maintained by extraordinary means. One of Sue's brothers testified that he and Sue frequently had discussions about incurable disease and imminent death or suffering. in one specific conversation after they had seen the movie Brian's Song, Sue said she would not want to go through treatment as the character in the movie did and expressed her belief that, when no recovery was possible and the end inevitable, a continuation of treatment would be senseless and would cause pain for herself and her family. She said it would be humiliating to become a vegetable, and she could not understand why anyone would desire to be treated or accept treatment under such circumstances. She also said she would never choose to have that indignity forced upon her. Another brother testified that, in conversations precipitated by their niece's dying of a brain tumor at age eight, he and Sue discussed how neither of them wanted to be kept alive by extraordinary means--either mechanical or other artificial means. …