Opinion ID: 2276022
Heading Depth: 1
Heading Rank: 6

Heading: degrella.

Text: Martha Sue DeGrella's brain was damaged by an acute subdural hematoma caused by a savage beating. She languished in a persistent vegetative state with her biological life maintained only by artificially supplied ventilation, nutrition, and hydration. Unlike Matthew Woods, she was able to react on a reflexive level to painful stimuli and apparently did not suffer from myoclonus. Also unlike Woods, she had expressed, when competent, her wishes against the use of artificial life-sustaining treatment, specifically expressing abhorrence at the plight of Karen Ann Quinlan ( Quinlan, supra ). On another occasion after being injured in an automobile accident, she protested being put on a respirator even though there was no question that she would recover. Employing the substituted judgment inquiry, we upheld the trial court's decision to permit DeGrella's guardian to authorize withdrawal of her artificial life-support systems. We recognize that previous oral statements cannot be considered conclusive in nature. The oral directives the patient gives to a family member, friend or health care provider are of significant value as a relevant evidentiary consideration, but there are other evidentiary matters which may outweigh such statements, such as written directives to the contrary, reactions the patient voiced regarding particular types of medical treatment, religious beliefs and the tenets of that religion, or the patient's consistent pattern of conduct with respect to prior decisions about his own medical care. ... [The patient's] statements of choice made before she became incompetent, while not dispositive of the question at hand, are competent evidence upon which a surrogate decision-maker could exercise judgment in the circumstances presented. DeGrella, 858 S.W.2d at 708-09. We grounded our decision in DeGrella primarily in the common law right of self-determination and informed consent, id. at 709, and on the substituted judgment principle enunciated in Strunk v. Strunk, Ky., 445 S.W.2d 145 (1969), wherein the mother/guardian of an incompetent adult was permitted to authorize transplantation of the ward's kidney into the body of his competent brother. The right to act for the incompetent in all cases has become recognized in this country as the doctrine of substituted judgment and is broad enough not only to cover property but also to cover all matters touching on the well-being of the ward. DeGrella , at 704 (quoting Strunk, 445 S.W.2d at 148). DeGrella also pointed to the reasoning in Strunk that the ward was so dependent upon his brother that losing him would have jeopardized the ward's well-being (best interest?) more than the loss of a kidney. Id. (quoting Strunk, supra, at 146). We then cited with approval the following passage from Rasmussen: Under the substituted judgment standard, the guardian `attempt[s] to reach the decision that the incapacitated person would make if he or she were able to choose.' ... This standard best guides a guardian's decisionmaking when a patient has manifested his or her intent while competent. DeGrella , at 705 (quoting Rasmussen, 741 P.2d at 688 (internal citations omitted)). The guardian ad litem naturally attaches great significance to the sentence immediately following the Rasmussen quote, viz : We do not go the next step, as the Arizona court did in the Rasmussen case, to decide that best interest can extend to terminating life-sustaining medical treatment where the wishes of the ward are unknown. Id. However, we said that [w]e do not go to the next step, not that we would not go. Our statement was an expression of restraint because the facts in DeGrella did not require us to reach the best interest analysis, as the case could be decided on the basis of substituted judgment. The guardian ad litem also emphasizes the following statement of policy expressed as obiter dictum in the opinion: As long as the case is confined to substitute decision-making by a surrogate in conformity with the patient's previously expressed wishes, the case involves only the right of self-determination and not the quality of life. However, as evidence regarding the patient's wishes weakens, the case moves from self-determination towards a quality-of-life test. At the point where the withdrawal of life-prolonging medical treatment becomes solely another person's decision about the patient's quality of life, the individual's inalienable right to life, as so declared in the United States Declaration of Independence and protected by Section One (1) of our Kentucky Constitution, outweighs any consideration of the quality of life, or the value of the life, at stake. Nothing in this Opinion should be construed as sanctioning or supporting euthanasia, or mercy killing. We do not approve permitting anyone to decide when another should die on any basis other than clear and convincing evidence that the patient would choose to do so. Id. at 702 (emphasis added). Although the statement referred to the individual's inalienable right to life, it did not mention the individual's inalienable right to liberty. Cf. Cruzan, 497 U.S. at 281, 110 S.Ct. at 2853 (It cannot be disputed that the Due Process Clause protects an interest in life as well as an interest in refusing life-sustaining medical treatment.). That may have been because, unlike the case sub judice, the guardian seeking to authorize withdrawal of DeGrella's artificial life support was her mother, not a state agency; thus, arguably the Fourteenth Amendment analysis in Cruzan did not apply. See United States v. Morrison, 529 U.S. 598, 621, 120 S.Ct. 1740, 1756, 146 L.Ed.2d 658 (2000) (Fourteenth Amendment applies only to state action); but see L.W., 482 N.W.2d at 71 ([A] guardian is a state actor. A guardian's authority derives from the state's parens patriae power and is purely statutory.). Finally, we note that had DeGrella's mother been her health care surrogate under the Health Care Surrogate Act, rather than a judicially-appointed guardian, she would have been required by KRS 311.978(1), supra, to consider the recommendation of the attending physician, the decision the grantor would have made if the grantor then had decisional capacity, if known, and the decision that would be in the best interest of the grantor. (Emphasis added.)