Opinion ID: 2525487
Heading Depth: 3
Heading Rank: 1

Heading: The primary standard: a decision in accordance with the conservatee's wishes

Text: The conservator asserts she offered sufficient evidence at trial to satisfy the primary statutory standard, which contemplates a decision in accordance with the conservatee's . . . wishes . . . . (§ 2355, subd. (a).) The trial court, however, determined the evidence on this point was insufficient. The conservator did not [meet] her duty and burden, the court expressly found, to show by clear and convincing evidence that [the] conservatee . . ., who is not in a persistent vegetative state nor suffering from a terminal illness would, under the circumstances, want to die. To be sure, the court made this finding under former section 2355 rather than the current versionand not because the former statute expressly called for such a finding but under the belief that case law required it. (See ante, 110 Cal.Rptr.2d at p. 418, 28 P.3d at p. 156.) But the finding's relevance under the new statute cannot easily be dismissed: The new statute expressly requires the conservator to follow the conservatee's wishes, if known. (§ 2355, subd. (a).) The conservator argues the Legislature understood and intended that the low preponderance of the evidence standard would apply. Certainly this was the Law Revision Commission's understanding. On this subject, the commission wrote: [Section 2355] does not specify any special evidentiary standard for the determination of the conservatee's wishes or best interest. Consequently, the general rule applies: the standard is by preponderance of the evidence. Proof is not required by clear and convincing evidence. (30 Cal. Law Revision Com. Rep., supra, p. 264.) We have said that [explanatory comments by a law revision commission are persuasive evidence of the intent of the Legislature in subsequently enacting its recommendations into law. ( Brian W. v. Superior Court (1978) 20 Cal.3d 618, 623, 143 Cal.Rptr. 717, 574 P.2d 788.) Nevertheless, one may legitimately question whether the Legislature can fairly be assumed to have read and endorsed every statement in the commission's 280-page report on the Health Care Decisions Law. (Cf. Van Arsdale v. Hollinger (1968) 68 Cal.2d 245, 250, 66 Cal.Rptr. 20, 437 P.2d 508 [describing the inference of legislative approval as strongest when the commission's comment is brief].) The objectors, in opposition, argue that section 2355 would be unconstitutional if construed to permit a conservator to end the life of a conscious conservatee based on a finding by the low preponderance of the evidence standard that the latter would not want to live. We see no basis for holding the statute unconstitutional on its face. We do, however, find merit in the objectors' argument. We therefore construe the statute to minimize the possibility of its unconstitutional application by requiring clear and convincing evidence of a conscious conservatee's wish to refuse life-sustaining treatment when the conservator relies on that asserted wish to justify withholding life-sustaining treatment. This construction does not entail a deviation from the language of the statute and constitutes only a partial rejection of the Law Revision Commission's understanding that the preponderance of the evidence standard would apply; we see no constitutional reason to apply the higher evidentiary standard to the majority of health care decisions made by conservators not contemplating a conscious conservatee's death. Our reasons are as follows: At the time the Legislature was considering the present version of section 2355, no court had interpreted any prior version of the statute as permitting a conservator deliberately to end the life of a conscious conservatee. Even today, only the decision on review so holds. The court in Drabick, supra, 200 Cal.App.3d 185, 245 Cal.Rptr. 840, as we have seen, found sufficient authority in the statute to confirm a conservator's decision that artificial hydration and nutrition was not in the best interest of a permanently unconscious, persistently vegetative conservatee. The Drabick court, however, expressly limited its decision to cases involving conservatees in the same medical condition and stated that its reasoning was, in some unexplained way, predicated on such facts. (Id. at p. 217, fn. 36, 245 Cal.Rptr. 840.) While the conservator embraces Drabick in other respects, the authoring court, she writes, was flat-out wrong to limit the applicability of [section] 2355, of its statutory analysis, and of its constitutional insights to permanently unconscious conservatees as these limitations ignore the plain language of the statute as well as logic. To the contrary, by limiting its decision in this way the Drabick court thereby avoided the constitutional problem we confront here, namely, the propriety of a decision to withhold artificial nutrition and hydration from a conscious conservatee who, while incompetent, may nevertheless subjectively perceive the effects of dehydration and starvation. (See ante, 110 Cal.Rptr.2d at p. 426, 28 P.3d at p. 163) In amending section 2355 in 1999, neither the Legislature, nor the Law Revision Commission in its official report to the Legislature, alluded to the possibility that the statute might be invoked to justify withholding artificial nutrition and hydration from a conscious patient. The conservator sees evidence of specific legislative authority for such a decision in the findings that accompanied the Health Care Decisions Law, but we do not. These findings, which first entered California law as part of the former Natural Death Act (Health & Saf.Code, former § 7185.5; see ante, 110 Cal.Rptr.2d at p. 423, 28 P.3d at p. 160), were revised and recodified in the new legislation as Probate Code section 4650. [11] The Law Revision Commission in its report accurately explained the proposed change in the findings as follows: The earlier legislative findings were limited to persons with a terminal condition or permanent unconscious condition. This restriction is not continued here in recognition of the broader scope of this division and the development of case law since enactment of the original Natural Death Act in 1976. (30 Cal. Law Revision Com. Rep., supra, p. 61.) From this history, the conservator deduces that the commission, and by inference the Legislature, intended to give conservators the power she has sought in this case to end a conscious conservatee's life. Considering, however, the subject's importance and potentially controversial nature, it seems extremely unlikely that the Legislature intended to regulate the subject through the deletion of a few limiting words from a legislative finding. In any event, the commission's reference to the broader scope (ibid.) of the new law more plausibly refers simply to the fact that the new law, unlike the former Natural Death Act, permits a competent person to provide by advance directive for virtually all aspects of his or her future health care rather than, as previously, simply the withdrawal of life support under narrowly circumscribed facts. (See ante, 110 Cal.Rptr.2d at p. 423, 28 P.3d at p. 160.) Certainly the commission's reference to the development of case law since 1976 cannot be understood as suggesting that conservators may end the life of conscious patients. At the time the commission wrote, no California case had addressed the subject. Moreover, of the four cases the commission cites, two involved competent patients ( Bouvia v. Superior Court, supra, 179 Cal.App.3d 1127, 225 Cal.Rptr. 297; Bartling v. Superior Court, supra, 163 Cal.App.3d 186, 209 Cal. Rptr. 220), and two concerned patients in persistent vegetative states ( Drabick, supra, 200 Cal.App.3d 185, 245 Cal.Rptr. 840; Barber, supra, 147 Cal.App.3d 1006, 195 Cal.Rptr. 484); none involved withdrawal of life support from a conscious but incompetent patient. One also finds in the commission's lengthy report, albeit in a different comment, the cryptic statement that the amended version of section 2355 is consistent with . . . Drabick. (30 Cal. Law Revision Com. Rep., supra, com. to § 2355, p. 263.) But Drabick was expressly limited to patients in persistent vegetative states. ( Drabick, supra, 200 Cal. App.3d 185, 217, fn. 36, 245 Cal.Rptr. 840.) Consistency with Drabick on this point does not support the conservator's position. For all these reasons, we are not convinced the Legislature gave any consideration to the particular problem before us in this case. The prefatory note and comments to the Uniform Health-Care Decisions Act are also silent on the point. Notwithstanding the foregoing, one must acknowledge that the primary standard for decisionmaking set out in section 2355 does articulate what will in some cases form a constitutional basis for a conservator's decision to end the life of a conscious patient: deference to the patient's own wishes. This standard also appears in the new provisions governing decisions by agents and surrogates designated by competent adults. (§§ 4684, 4714.) As applied in that context, the requirement that decisions be made in accordance with the principal's individual health care instructions . . . and other wishes (§ 4684) merely respects the principal-agent relationship and gives effect to the properly expressed wishes of a competent adult. Because a competent adult may refuse life-sustaining treatment (see ante, 110 Cal.Rptr.2d at p. 420, 28 P.3d at p. 158 et seq.), it follows that an agent properly and voluntarily designated by the principal may refuse treatment on the principal's behalf unless, of course, such authority is revoked. (See, e.g., §§ 4682, 4689, 4695 [providing various ways in which the authority of an agent for health care decisions may be revoked or the agent's instructions countermanded].) The only apparent purpose of requiring conservators to make decisions in accordance with the conservatee's wishes, when those wishes are known, is to enforce the fundamental principle of personal autonomy. The same requirement, as applied to agents and surrogates freely designated by competent persons, enforces the principles of agency. A reasonable person presumably will designate for such purposes only a person in whom the former reposes the highest degree of confidence. A conservator, in contrast, is not an agent of the conservatee, and unlike a freely designated agent cannot be presumed to have special knowledge of the conservatee's health care wishes. A person with sufficient capacity . . . to form an intelligent preference may nominate his or her own conservator (§ 1810), but the nomination is not binding because the appointment remains solely in the discretion of the court (§ 1812, subd. (a)). Furthermore, while statutory law gives preference to spouses and other persons related to the conservatee (id., subd. (b)), who might know something of the conservatee's health care preferences, the law also permits the court in its sole discretion to appoint unrelated persons and even public conservators (ibid.). While it may be constitutionally permissible to assume that an agent freely designated by a formerly competent person to make all health care decisions, including life-ending ones, will resolve such questions in accordance with the principal's . . . wishes (§ 4684), one cannot apply the same assumption to conservators and conservatees (cf. § 2355, subd. (a)). For this reason, when the legal premise of a conservator's decision to end a conservatee's life by withholding medical care is that the conservatee would refuse such care, to apply a high standard of proof will help to ensure the reliability of the decision. The function of a standard of proof is to instruct the fact finder concerning the degree of confidence our society deems necessary in the correctness of factual conclusions for a particular type of adjudication, to allocate the risk of error between the litigants, and to indicate the relative importance attached to the ultimate decision. ( Weiner v. Fleischman (1991) 54 Cal.3d 476, 487, 286 Cal.Rptr. 40, 816 P.2d 892; accord, Addington v. Texas (1979) 441 U.S. 418, 423, 99 S.Ct. 1804, 60 L.Ed.2d 323.) Thus, the standard of proof may depend upon the `gravity of the consequences that would result from an erroneous determination of the issue involved.' ( Weiner v. Fleischman, supra, at p. 487, 286 Cal.Rptr. 40, 816 P.2d 892, quoting People v. Jimenez (1978) 21 Cal.3d 595, 604, 147 Cal.Rptr. 172, 580 P.2d 672.) The default standard of proof in civil cases is the preponderance of the evidence. (Evid.Code, § 115.) [12] Nevertheless, courts have applied the clear and convincing evidence standard when necessary to protect important rights. We applied the clear and convincing evidence standard, for example, in Conservatorship of Valerie N., supra, 40 Cal.3d 143, 168, 219 Cal.Rptr. 387, 707 P.2d 760, to ensure that a conservator's decision to authorize sterilization of a developmentally disabled conservatee was truly in the latter's best interests. We have also applied the clear and convincing evidence standard to findings necessary to terminate parental rights ( In re Angelia P. (1981) 28 Cal.3d 908, 922, 171 Cal.Rptr. 637, 623 P.2d 198) and to findings supporting the discipline of judges ( Broadman v. Commission on Judicial Performance (1998) 18 Cal.4th 1079, 1090, 77 Cal.Rptr.2d 408, 959 P.2d 715; Geiler v. Commission on Judicial Qualifications (1973) 10 Cal.3d 270, 275, 110 Cal. Rptr. 201, 515 P.2d 1). The Courts of Appeal have required clear and convincing evidence of a person's inability to provide for his or her personal needs as a prerequisite to the appointment of a conservator ( Conservatorship of Sanderson (1980) 106 Cal.App.3d 611, 615-621, 165 Cal.Rptr. 217), and of a conservatee's incompetence to accept or reject treatment as a prerequisite to permitting involuntary electroconvulsive therapy ( Conservatorship of Waltz (1986) 180 Cal.App.3d 722, 733, 227 Cal. Rptr. 436; Lillian F. v. Superior Court, supra, 160 Cal.App.3d 314, 324, 206 Cal. Rptr. 603). Similarly, the United States Supreme Court has applied the clear and convincing evidence standard in cases implicating fundamental liberty interests protected by the Fourteenth Amendment, such as proceedings to terminate parental rights ( Santosky v. Kramer (1982) 455 U.S. 745, 753, 769-770, 102 S.Ct. 1388, 71 L.Ed.2d 599), to commit to a mental hospital ( Addington v. Texas, supra, 441 U.S. 418, 425, 432-433, 99 S.Ct. 1804, 60 L.Ed.2d 323), and to deport ( Woodby v. Immigration Service (1966) 385 U.S. 276, 285, 87 S.Ct. 483,17 L.Ed.2d 362). In this case, the importance of the ultimate decision and the risk of error are manifest. So too should be the degree of confidence required in the necessary findings of fact. The ultimate decision is whether a conservatee lives or dies, and the risk is that a conservator, claiming statutory authority to end a conscious conservatee's life in accordance with the conservatee's . . . wishes (§ 2355, subd. (a)) by withdrawing artificial nutrition and hydration, will make a decision with which the conservatee subjectively disagrees and which subjects the conservatee to starvation, dehydration and death. This would represent the gravest possible affront to a conservatee's state constitutional right to privacy, in the sense of freedom from unwanted bodily intrusions, and to life. While the practical ability to make autonomous health care decisions does not survive incompetence, [13] the ability to perceive unwanted intrusions may. Certainly it is possible, as the conservator here urges, that an incompetent and uncommunicative but conscious conservatee might perceive the efforts to keep him alive as unwanted intrusion and the withdrawal of those efforts as welcome release. But the decision to treat is reversible. The decision to withdraw treatment is not. The role of a high evidentiary standard in such a case is to adjust the risk of error to favor the less perilous result. The high court has aptly explained the benefits of a high evidentiary standard in a similar context: An erroneous decision not to terminate results in a maintenance of the status quo; the possibility of subsequent developments such as advancements in medical science, the discovery of new evidence regarding the patient's intent, changes in the law, or simply the unexpected death of the patient despite the administration of life-sustaining treatment at least create the potential that a wrong decision will eventually be corrected or its impact mitigated. An erroneous decision to withdraw life-sustaining treatment, however, is not susceptible of correction. [14] ( Cruzan, supra, 497 U.S. 261, 283, 110 S.Ct. 2841, 111 L.Ed.2d 224; see also In re Martin (1995) 450 Mich. 204, 538 N.W.2d 399, 409-411 [requiring, under Michigan law, clear and convincing evidence of a conscious but incompetent conservatee's desire to refuse artificial nutrition and hydration].) In conclusion, to interpret section 2355 to permit a conservator to withdraw artificial nutrition and hydration from a conscious conservatee based on a finding, by a mere preponderance of the evidence, that the conservatee would refuse treatment creates a serious risk that the law will be unconstitutionally applied in some cases, with grave injury to fundamental rights. Under these circumstances, we may properly ask whether the statute may be construed in a way that mitigates the risk. If a statute is susceptible of two constructions, one of which will render it constitutional and the other unconstitutional in whole or in part, or raise serious and doubtful constitutional questions, the court will adopt the construction which, without doing violence to the reasonable meaning of the language used, will render it valid in its entirety, or free from doubt as to its constitutionality, even though the other construction is equally reasonable. [Citations.] The basis of this rule is the presumption that the Legislature intended, not to violate the Constitution, but to enact a valid statute within the scope of its constitutional powers. ( Miller v. Municipal Court (1943) 22 Cal.2d 818, 828, 142 P.2d 297; accord, People v. Superior Court ( Romero ) (1996) 13 Cal.4th 497, 509, 53 Cal.Rptr.2d 789, 917 P.2d 628; see also San Francisco Taxpayers Assn. v. Board of Supervisors (1992) 2 Cal.4th 571, 581, 7 Cal.Rptr.2d 245, 828 P.2d 147.) Here, where the risk to conservatees' rights is grave and the proposed construction is consistent with the language of the statute, to construe the statute to avoid the constitutional risk is an appropriate exercise of judicial power. We base our decision on California law. It is nevertheless worth mentioning that no decision of which we are aware has approved a conservator's or guardian's proposal to withdraw artificial nutrition and hydration from a conscious conservatee or ward. The highest courts of three other states have spoken to the matter. Of these decisions, In re Martin, supra, 450 Mich. 204, 538 N.W.2d 399, is most like the case before us. Conservatee Michael Martin, like the conservatee here, suffered a head injury in an automobile accident that left him minimally conscious, unable to walk or talk, and dependent on artificial nutrition and hydration. At his highest level of functioning, Michael could move his leg or arm in response to a therapist's request and move his head in response to questions seeking a yes or no answer. On one occasion he indicated no in response to the question whether there were ever times when he felt he did not want to go on living; the witnesses, however, disagreed about the consistency and significance of Michael's responses to questions. (Id. at pp. 402-403.) The Supreme Court of Michigan, applying that state's common law, did not permit the conservator, Michael's wife, to withdraw artificial nutrition and hydration because clear and convincing evidence did not show he had expressed a desire to refuse such treatment under his present circumstances. The court adopted the clear and convincing standard for essentially the same reasons we do so here, namely, to ensure that a decision to refuse treatment drawing its legal justification from the conservatee's right to make autonomous medical decisions actually enjoys the conservatee's approval (id at pp. 406-409), and to impose the risk of an erroneous decision on those seeking to withdraw treatment in view of the decision's grave consequences (id. at pp. 409-410). Only when the patient's prior statements, the court held, clearly illustrate a serious, well thought out, consistent decision to refuse treatment under these exact circumstances, or circumstances highly similar to the current situation, should treatment be refused or withdrawn. (Id. at p. 411.) Michael's wife testified that he had demanded she promise not to let him live like a vegetable or on machines in reaction to movies depicting persons who were vegetative, had terminal illnesses, or could not care for themselves because of serious disabilities. (Id. at p. 412.) Michael's coworkers also testified that he had expressed disdain for living in a vegetative state, but they did not understand him as having referred to his present, minimally conscious condition. Considering all this evidence, the court did not find clear and convincing evidence of a decision to refuse life-sustaining medical treatment under the present circumstances. (Id at p. 413.) The Supreme Courts of Wisconsin and New Jersey have also refused permission, under their own states' common law, to withhold artificial nutrition and hydration from incompetent but conscious patients. The Wisconsin court required a clear statement of the conservatee's desires, proved by a preponderance of the evidence. ( Matter of Edna M.F. (1997) 210 Wis.2d 557, 563 N.W.2d 485, 490.) The court described the necessary clear statement as an exceptional requirement, not applicable to other, less permanent, decisions, and justified by the interest of the state in preserving human life and the irreversible nature of the decision to withdraw nutrition from a person. (Ibid., fn. omitted.) Ruling in the case of a woman with Alzheimer's dementia, the court did not find a sufficiently clear statement of the desire to refuse treatment in her predementia comment that she `would rather die of cancer than lose [her] mind'; she had not, the court noted, said anything specifically about withdrawing life-sustaining medical treatment. (Id. at p. 487.) The court also specifically refused to extend to conscious patients its earlier decision giving conservators, as a matter of law, the power to withhold life-sustaining treatment from persistently vegetative patients. (Id at pp. 488-490; see Matter of Guardianship of L.W. (1992) 167 Wis.2d 53, 482 N.W.2d 60.) The Supreme Court of New Jersey, articulating that state's common law, adopted a fairly complex three-part test. ( Matter of Conroy (1985) 98 N.J. 321, 486 A.2d 1209.) Under a pure-objective test (id. at p. 1232), essentially a best interests test, the court would not require any evidence of the patient's wishes when the patient was in such recurring, unavoidable and severe pain . . . that the effect of administering life-sustaining treatment would be inhumane. (Ibid.) Under a limited-objective test (id at p. 1232), the court would permit treatment to be withdrawn for those in unavoidable pain of less severity when there is some trustworthy evidence the patient would have refused treatment and it is clear that the burdens of the patient's continued life with the treatment outweigh the benefits of that life for him. (Ibid.) In other circumstances, however, the court would permit treatment to be withdrawn only when it is clear that the particular patient would have refused the treatment under the circumstances involved. (Id. at p. 1229.) That standard, the court explained, is a subjective one, consistent with the notion that the right that we are seeking to effectuate is a very personal right to control one's own life. The question is not what a reasonable or average person would have chosen to do under the circumstances but what the particular patient would have done if able to choose for himself. (Ibid.) Under this subjective test, the court did not find a sufficiently `clear' showing of intent to refuse treatment in a bedridden, severely demented and unresponsive woman's history of scorning medicine and refusing hospitalization. (Id. at pp. 1218,1242-1243.) About these three decisions one point deserves emphasis: In each case, the court required a clear statement by the patient of the intent to refuse life-sustaining treatment when a conservator or guardian proposed to withdraw treatment from a conscious conservatee or ward in order to effectuate the latter's own right to refuse treatment. ( In re Martin, supra, 450 Mich. 204, 538 N.W.2d 399, 406-411; Matter of Edna M.F., supra, 210 Wis.2d 557, 563 N.W.2d 485, 488-491; Matter of Conroy, supra, 98 N.J. 321, 486 A.2d 1209, 1229.) As we have explained, the only apparent purpose of California's statutory language requiring a decision in accordance with the conservatee's . . . wishes (§ 2355, subd. (a)) is to enforce the fundamental principle of personal autonomy, in the same way that the identical language in other provisions (§§ 4684, 4714) governing agents and surrogates freely designated by competent persons enforces the principles of agency. While we place no great emphasis on the out-of-state cases, they nevertheless support the fundamental principles that underlie our conclusions, including the imposition of a high standard of proof. One amicus curiae argues that [i]mposing so high an evidentiary burden [i.e., clear and convincing evidence] would . . . frustrate many genuine treatment desiresparticularly the choices of young people, who are less likely than older people to envision the need for advanced directives, or poor people, who are less likely than affluent people to have the resources to obtain formal legal documents. But the Legislature has already accommodated this concern in large part by permitting patients to nominate surrogate decision makers by orally informing a supervising physician (§ 4711) and by giving effect to specific oral health care instructions (§ 4670). To go still farther, by giving conclusive effect to wishes inferred from informal, oral statements proved only by a preponderance of the evidence, may serve the interests of incompetent persons whose wishes are correctly determined, but to do so also poses an unacceptable risk of violating other incompetent patients' rights to privacy and life, as already explained. To the argument that applying a high standard of proof in such cases impermissibly burdens the right to determine one's own medical treatment, one need only repeat the United States Supreme Court's response to the same assertion: The differences between the choice made by a competent person to refuse medical treatment, and the choice made for an incompetent person by someone else to refuse medical treatment, are so obviously different that the State is warranted in establishing rigorous procedures for the latter class of cases which do not apply to the former class. ( Cruzan, supra, 497 U.S. 261, 287, fn. 12, 110 S.Ct. 2841, 111 L.Ed.2d 224; see ante, 110 Cal.Rptr.2d p. 425, fn. 9, 28 P.3d p. 162, fn. 9.) On the same general subject, a group of amici curiae contends as follows: If this court decides that physicians may not follow a surrogate's instruction to withdraw life-sustaining treatment unless the evidence of the patient's wishes satisfies a `clear and convincing' standard of proof, many physicians will refuse to do so without judicial approval. But this will not be a valid concern, as we have already explained, in the case of patients who have personally appointed agents or surrogates for health care decisions or left formal instructions for health care, nor in the vast majority of health care decisions, i.e., those less weighty than the decision to withdraw life-sustaining treatment from a conscious patient. The constitutional considerations on which we rely justify applying the clear and convincing evidence standard only when a conservator seeks to withdraw life-sustaining treatment from a conscious, incompetent patient who has not left legally cognizable instructions for health care or appointed an agent or surrogate for health care decisions. In the case before us, the trial court found that the conservator failed to show by clear and convincing evidence that conservatee Robert Wendland, who is not in a persistent vegetative state nor suffering from a terminal illness would, under the circumstances, want to die. The conservator does not appear to challenge the trial court's finding on this point; her challenge, rather, is to the trial court's understanding of the law. For these reasons, we need not review the sufficiency, of the evidence to support the finding. Nevertheless, given the exceptional circumstances of this case, we note that the finding appears to be correct. The clear and convincing evidence test requires a finding of high probability, based on evidence `so clear as to leave no substantial doubt [and] sufficiently strong to command the unhesitating assent of every reasonable mind.' ( In re Angelia P., supra, 28 Cal.3d 908, 919, 171 Cal.Rptr. 637, 623 P.2d 198; accord, Sheehan v. Sullivan (1899) 126 Cal. 189, 193, 58 P. 543.) Applying that standard here, we ask whether the evidence the conservatee would have refused treatment under the circumstances of this case has that degree of clarity, bearing in mind that what we are asking, in essence, is whether the conservatee would actually have wished to die. On this point the trial court wrote: [T]he testimony adduced focuses upon two pre-accident conversations during which the conservatee allegedly expressed a desire not to live like a Vegetable.' These two conversations do not establish by clear and convincing evidence that the conservatee would desire to have his life-sustaining medical treatment terminated under the circumstances in which he now finds himself. One of these conversations allegedly occurred when the conservatee was apparently recovering from a night's bout of drinking. The other alleged conversation occurred following the loss of conservatee's father-in-law, with whom he was very close. The court finds that neither of these conversations reflect an exact `on all-fours' description of conservatee's present medical condition. More explicit direction than just `I don't want to live like a vegetable' is required in order to justify a surrogate decision-maker terminating the life of . . . someone who is not in a PVS [persistent vegetative state]. We agree with the trial court's assessment of the evidence. That assessment is essentially in accord with the only case directly on point, in which the Michigan Supreme Court found no clear and convincing evidence of a desire to refuse treatment under very similar facts. (See In re Martin, supra, 450 Mich. 204, 538 N.W.2d 399, discussed ante, 110 Cal.Rptr.2d at p. 435, 28 P.3d at p. 170 et seq.) We add to the trial court's assessment only that Rose acknowledged Robert did not describe the precise condition in which he later found himself (see ante, 110 Cal.Rptr.2d at p. 419, 28 P.3d at p. 157) and that, while experts dispute the consistency and accuracy of Robert's responses to questions, it is difficult to ignore the fact that he declined to answer the question Do you want to die? while giving facially plausible yes or no answers to a variety of other questions about his wishes. (See ante, 110 Cal.Rptr.2d at p. 419, 28 P.3d at p. 157 et seq.) On this record, we see no reason to hold that the evidence does not support the trial court's finding.