Court Opinion

ID: 9702259
Source: CourtListenerOpinion
Date Created: 2023-08-25 23:04:01.603451+00
Date Added: 2024-06-11T18:21:35.896735
License: Public Domain

The opinion of the Court was delivered by
GARIBALDI, J.
Today, in In re Peter, 108 N.J. 365 (1987), we set forth the guidelines and procedures under which life-sustaining medical treatment could be withdrawn from an elderly nursing home patient in a persistent vegetative state who, prior to her incompetency, had clearly expressed her desire not to be sustained in that condition. This appeal requires us to develop the guidelines and procedures under which life-sustaining medical treatment may be withdrawn from a non-elderly nursing home patient in a persistent vegetative state who, prior to her incompetency, failed to express adequately her attitude toward such treatment. Specifically, we must determine who decides for the incompetent patient, the standard that the surrogate decisonmaker must use, and who must be consulted and concur in the decision.
Embarking on this task, we are mindful that the patient’s right to self-determination is the guiding principle in determining whether to continue or withdraw life-sustaining medical treatment; that therefore the goal of a surrogate decision-maker for an incompetent patient must be to determine and effectuate what that patient, if competent, would want; and that the court does not decide whether to withdraw life-supporting treatment. Rather, our role is to establish for those who make that decision criteria that respect the right to self-determination and yet protect incompetent patients.
*400I
Since July 1980, Nancy Jobes has been a resident patient at the Lincoln Park Nursing Home (hereinafter nursing home). In May 1985 her husband John and her parents requested that the nursing home withdraw the jejunostomy tube (hereinafter j-tube), which provides her with nutrition and hydration. The nursing home refused on moral grounds.
Thereafter Mr. Jobes asked the Chancery Division to “authorize and order” the withdrawal of the j-tube.1 He contended that his wife was in a persistent vegetative state, and that therefore he and her family had concluded that she would choose to terminate artificial feeding and that it was in her best interests to do so.
The trial court appointed Richard Kahn, Esq., as guardian ad litem for Mrs. Jobes. After reviewing the medical evidence and interviewing her family, close friends and clergyman, Mr. Kahn filed a report in favor of Mr. Jobes’ decision. The nursing home then moved for the appointment of a “life advocate.” The trial court denied that motion. In re Jobes, 210 N.J.Super. 543 (Ch. Div. 1986). The nursing home unsuccessfully appealed that decision.
The Public Advocate intervened, with the consent of Mr. Jobes and Mr. Kahn, as a party in opposition to them.
Prior to trial, the judge visited Mrs. Jobes at the nursing home and filed an observation report. After a seven-day trial, the court found that Mr. Jobes had proved by clear and convincing evidence that his wife is in a persistent vegetative state with no prospect of improvement, and that, if competent, she would not want to be sustained by the j-tube under her present circumstances. The court therefore authorized Mr. Jobes to implement removal of the j-tube under the supervision of a licensed physician. However, the court held that the nursing *401home was entitled to refuse to participate in the withdrawal of the j-tube and could keep Mrs. Jobes connected to it until she was transferred out of that facility. Judgment was entered on April 28, 1986, but relief was stayed pending final determination of this appeal. Both Mr. Jobes and the nursing home petitioned this court for direct certification, which we granted. 105 N.J. 532 (1986).2
II
Nancy Ellen Jobes is thirty-one years old. She is the daughter of Robert and Eleanor Laird, both of whom are living. She has three living siblings. She married John H. Jobes, III, on July 31, 1976. Prior to March of 1980, Mrs. Jobes had no significant mental or physical handicap. She was employed as a certified laboratory technologist, and was four and one-half months pregnant with her first child.
On March 11, 1980, Mrs. Jobes was admitted to Riverside Hospital for treatment of injuries sustained in an automobile accident. Doctors soon determined that her fetus had been killed. During the course of an operation to remove the dead fetus, she sustained a severe loss of oxygen and blood flow to her brain. She suffered massive and irreversible damage to the part of her brain that controls thought and movement.3 She has never regained consciousness.
*402On July 28, 1980, Mrs. Jobes was transferred to the nursing home.4 Her condition has not changed since she was admitted. She is unable to speak or make any kind of noise. A towel is kept under her chin to catch the secretions that drip from her mouth. She has a tracheostomy, which is covered with a plastic shield to which a flexible tube is attached. An air compressor must humidify the air moving into her throat through this tube to prevent it from becoming clogged with mucous.
She is incontinent and requires a catheter to continuously irrigate her bladder. She receives routine enemas for bowel evacuation. She has chronic urinary tract infections. She is given antibiotics when necessary, as well as medication intended to prevent seizures.
Her muscles have atrophied and her limbs are rigidly contracted. Her extremities cannot be moved. Her closely clenched fingers are padded to prevent the skin between them from deteriorating.
She cannot swallow. Originally she was fed and hydrated intravenously, then through a nasogastric tube, then a gastrotomy tube. In June 1985, complications with the gastrotomy tube necessitated an even more direct approach. Since then, Mrs. Jobes has been fed through a j-tube inserted — through a hole cut into her abdominal cavity — into the jejunum of her small intestine. Water and a synthetic, pre-digested formula of various amino acids are pumped through the j-tube continuously. She has been removed to Morristown Memorial Hospital at least three times because of complications with the j-tube.
After Mr. Jobes instituted this suit, Mrs. Jobes was admitted to Cornell Medical Center-New York Hospital (Cornell) for four days of observation and testing. All of the resulting medical evidence supports Mr. Jobes’ characterization of her condition. *403Dr. Fred Plum, Professor and Chairman of the Department of Neurology at Cornell, examined Mrs. Jobes every day while she was there. As a witness for Mr. Jobes, he testified that she is in a persistent, i.e., irreversible, vegetative state. Dr. Plum is a world renowned- expert on the “persistent vegetative state.” He originally created that term, and is the author of several treatises and numerous articles explaining it. At trial he explained:
Vegetative state describes a body which is functioning entirely in terms of its internal controls. It maintains temperature. It maintains heart beat and pulmonary ventilation. It maintains digestive activity. It maintains reflex activity of muscles and nerves for low level conditioned responses. But there is no behavioral evidence of either self-awareness or awareness of the surroundings in a learned manner.
See also Quinlan, supra, 70 N.J. at 24-25 (Dr. Plum’s similar explanation of the vegetative state); President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Deciding to Forego Life-Sustaining Treatment 174-75 (1983) (hereinafter President’s Commission Report) (“Personality, memory, purposive action, social interaction, sentience, thought, and even emotional states are gone. Only vegetative functions and reflexes persist. If food is supplied, the digestive system functions, and uncontrolled evacuation occurs; the kidneys produce urine; the heart, lungs, and blood vessels continue to move air and blood; and nutrients are distributed in the body.”) (footnote omitted).
Dr. David E. Levy, an associate professor of neurology at Cornell and an associate of Dr. Plum, was retained as an expert by both the Public Advocate and the guardian ad litem, but testified only for the guardian ad litem. Dr. Levy is the author of numerous publications on brain damage resulting from a reduction in bloodflow and oxygen, and the persistent vegetative state. He has studied over six hundred comatose patients.
Dr. Levy observed and tested Mrs. Jobes far more extensively than any of the other neurological experts. He observed her first at the nursing home and then every day that she was at *404Cornell. He spent several hours with her during each of the days that a positron-emission tomograph scan and a nuclear magnetic resonance scan were conducted. On the basis of his clinical observations, Dr. Levy concluded that Mrs. Jobes is in a persistent vegetative state without any chance of recovery.
All the laboratory tests performed on Mrs. Jobes at Cornell were consistent with that diagnosis. A CAT scan and the nuclear magnetic resonance scan both indicated atrophy of the cerebral brain tissue.5 The position emission tomograph scan indicated that blood flow and metabolism in Mrs. Jobes’ cerebral cortex are only thirty to forty percent of that of a normal cognitive brain. This level of brain activity is found in persons under very deep anesthesia and those who have suffered a massive loss in brain function.
Several other doctors examined Mrs. Jobes at the Nursing Home, and testified about their observations. Dr. Henry Liss, a neurosurgeon and Professor of Neurological Surgery at the College of Physicians and Surgeons of Columbia University, and an associate professor of surgery at Rutgers Medical School, and Dr. Daniel Carlin, a neurologist and an associate professor of neurology at Rutgers Medical School, testified for Mr. Jobes. Each reviewed Mrs. Jobes’ medical reports, and examined her in June and again in the Autumn of 1985. Each of them concluded that she is in a persistent vegetative state with no chance of recovery.
Dr. Allan H. Ropper, an associate professor of medicine at Harvard Medical School and Director of the Neurosurgery-Neurology Intensive Care Unit at Massachusetts General Hospital, and Dr. Maurice Victor, Professor of Neurosurgery at Case Western Reserve University School of Medicine, testified for the nursing home. Neither performed any laboratory tests. *405Dr. Victor examined Mrs. Jobes once at the nursing home for about one and one-half hours. He testified that although Mrs. Jobes had suffered severe and irreversible cerebral damage, he did not believe that she is in a vegetative state. Dr. Victor had no written record of Mrs. Jobes’ responses during his examination of her. He based his opinion on his recollection of her reactions to stimuli. He recalled that on four or five occasions he had said, “Nancy, pick up your head” and that, with only one exception, after one or two seconds, she obeyed. He testified that she had responded to commands to wiggle her toes on eight out of twelve occasions; to move her leg once; to stick out her tongue in response to four or five requests. These responses indicated to Dr. Victor that Mrs. Jobes could hear and understand him and that her brain could connect the cerebral cortex, where hearing and understanding take place, to the muscles that she moved.
Dr. Victor testified that he interpreted Mrs. Jobes’ reaction to ammonia under her nose — a “violent grimace” and a retraction of her head — as not purely reflexive. He admitted that this was a “pure interpretation” and that he was less sure about this than he was about her responses to commands.
Dr. Victor testified that he had observed emotions in Mrs. Jobes’ facial gestures. He characterized them as “anticipatory” when he entered her room; “intent” when she received commands; “satisfied” when she was congratulated on having responded.
Dr. Ropper, like Dr. Victor, examined Mrs. Jobes at the nursing home for approximately ninety minutes. He observed that she had a wide range of random or spontaneous movements:
Approximately every thirty seconds to a minute she would lift her right shoulder up off the recliner. She would lift her head from the left armrest off the armrest to sort of a neutral position and move it to the right, taking about three to four seconds to do that, and that she did spontaneously every three to five minutes.
*406She would move her foot downward and her toes slowly about every ten to forty seconds. She would lift her leg, right leg stiffly off the chair about a half inch to an inch every five to ten minutes.
He testified:
Generally vegetative patients ... have a very narrow range of stereotyped movements that are repeated. [I]n general, moving a limb away from the body is not one of them. Certainly lifting an arm off a recliner or a bed wouldn’t be one of them. So higher level movements of that sort or more complicated movements, lifting the head up, moving it to one side and then putting it back, to me, are against the vegetative state.
Like Dr. Victor, Dr. Ropper testified that he had elicited command-responses from Mrs. Jobes.
As a result of his observations, Dr. Ropper concluded that Mrs. Jobes fell “slightly outside of [his] operational definition of the persistent vegetative state.” Dr. Ropper defines that state as one in which the patient “is in or has sleep/wake cycles, is totally incapable of responding and is totally unaware of environment or self.” His definition is subtly but significantly different from that which was offered by Dr. Plum, and accepted by this court in Quinlan, supra, 70 N.J. at 25. Primitive reflex responses to external stimuli would exclude a patient from the persistent vegetative state under Dr. Ropper’s definition but not under Dr. Plum’s.
All of the medical experts retained by the plaintiff, the guardian, and the Public Advocate were unsuccessful in eliciting volitional responses from Mrs. Jobes. They observed the kind of movements reported by Drs. Victor and Ropper, but concluded that they were startle reflexes and random movements rather than evidence of any cognitive awareness.
Some of the nurses and nurses’ aides who work at the nursing home testified that they had observed examples of what they interpreted as cognitive awareness on the part of Mrs. Jobes. They claimed that she moved her head to aid them in washing her hair; smiled at appropriate times; followed people with her eyes; and relaxed when spoken to or touched in a soothing manner.
*407In addition, several nurses and aides testified that they saw tears in Mrs. Jobes’ eyes when her family visited. Nurses pointed out the phenomenon they described as “tears” to Dr. Carlin when he examined her at the nursing home. He characterized it as an unemotional collection of secretions in the corner of Mrs. Jobes’ eyes. Dr. Liss also observed these secretions. He explained that they are merely accumulations of liquid that keep the conjunctiva moist and that they are created by rapid, reflexive eye-blinking, rather than emotions.
Other nurses and nurses’ aides testified that they had not observed any cognitive awareness in Mrs. Jobes, and that she gave no response to their verbal commands.
Ill
In the two other cases that we have decided today, In re Farrell, 108 N.J. 335 (1987), and In re Peter, 108 N.J. 365 (1987), as well as Quinlan and Conroy, there was no disagreement among the medical experts about the patient’s medical condition or prognosis. Moreover, we have not found a dispute among medical experts over a patient’s condition in any other case concerning the withdrawal of life-sustaining treatment. In this case all the medical experts agree that Mrs. Jobes is severely brain damaged. But while the experts for Mr. Jobes, the guardian ad litem, and the Public Advocate contend that she is in a persistent vegetative state, the two nursing home experts contend that she falls slightly outside of their definition of the persistent vegetative state.
In Conroy, we required that all medical determinations made in the course of a decision to withhold treatment from an incompetent patient be based upon clear and convincing medical evidence. See 98 N.J. at 368, 381-82. Evidence is “clear and convincing” when it
produce[s] in the mind of the trier of fact a firm belief or conviction as to the truth of the allegations sought to be established, evidence so clear, direct and weighty and convincing as to enable [the factfinder] to come to a clear conviction, without hesitancy, of the truth of the precise facts in issue.
*408[State v. Hodge, 95 N.J. 369, 376 (1984) (citations omitted).]
Evidence may be uncontroverted, and yet not be “clear and convincing.” See In re Colyer, 99 Wash.2d 114, 143-45, 660 P.2d 738, 754-55 (Wash.1983) (Dore, J., dissenting) (criticizing the Washington Supreme Court’s willingness to accept the uncontroverted prognosis that a patient who had been comatose for only twenty-five days was in a persistent vegetative state in light of the fact that “some physicians have testified in reported cases that a four-to six-month comatose period is used to determine whether there is any improvement in the incompetent, to reach their opinion in testifying as to whether the incompetent would recover to a cognitive or sapient existence”), cited with approval in Conroy, supra, 98 N.J. at 365.6 Conversely, evidence may be “clear and convincing” despite the fact that it has been contradicted. In this case, the reports and testimony of the Nursing Home’s experts are inconsistent with the trial court’s conclusion that Mrs. Jobes is in a persistent vegetative state. Nevertheless, we believe that conclusion was supported by clear and convincing evidence.
Doctors Plum and Levy, each of whom concluded that Mrs. Jobes is in a persistent vegetative state, have devoted their medical careers to the diagnosis, treatment, and prognosis of patients in the persistent vegetative state. Doctors Victor and Ropper, who testified that Mrs. Jobes has some cognitive ability, are unquestionably accomplished neurologists, but their experience and training in this particular area is comparatively limited. Moreover, Doctors Victor and Ropper each based his opinion of Mrs. Jobes’ condition on a single, ninety-minute observation. In contrast, Doctors Plum, Levy, Carlin and Liss — all of whom agree that Mrs. Jobes is in a persistent vegetative state — each spent more time with her. Doctors Plum and Levy in particular based their opinions on extensive clinical and laboratory examinations and observations.
*409We take special note of the testimony of Dr. Levy because, in addition to his having spent the most amount of time with Mrs. Jobes, he was retained by the two most disinterested participants in this case, the Public Advocate and the Guardian ad litem. We cannot ignore the possibility that experts retained in order to litigate an extremely emotional issue like the withdrawal of a life-sustaining feeding tube might be partisan.
Accordingly, we conclude that the neurological experts who testified for Mr. Jobes, the guardian ad litem and the Public Advocate offered sufficiently clear and convincing evidence to support the trial court’s finding that Mrs. Jobes is in an irreversible vegetative state. The trial court heard the testimony, observed the witnesses, and even visited Mrs. Jobes at the nursing home. It was uniquely equipped to decide which experts were more credible. We have always given great deference to trial court evaluations of conflicting medical evidence. See generally Baxter v. Fairmont Food Co., 74 N.J. 588, 597-98 (1977) (Hughes, C.J.) (explaining the “very considerable respect” accorded to trial court evaluations of medical evidence). While we recognize the gravity of the responsibility to evaluate medical evidence in withdrawal-of-treatment cases, we believe that our traditional confidence in the factual determinations made by our trial courts is as appropriate in this as in other contexts.
IV
Mrs. Jobes’ closest friends, her cousin, her clergyman, and her husband offered testimony that was intended to prove that if she were competent, Mrs. Jobes would refuse to be sustained by the j-tube. Deborah Holdsworth, a registered nurse and life-long friend of Mrs. Jobes, recalled a conversation in 1971 in which Mrs. Jobes stated that if she were ever crippled like the children with multiple sclerosis and muscular dystrophy that Ms. Holdsworth cared for, she would not want to live. Ms. Holdsworth also recalled telling Mrs. Jobes on numerous occa*410sions that she, Holdsworth, would not want to live like Karen Quinlan did after the removal of her respirator. She recalled that Mrs. Jobes had not disagreed with her, but could not recall Mrs. Jobes’ position any more clearly than that. Finally Holds-worth recalled that in late 1979 Mrs. Jobes specifically stated that she would not want to be kept alive on a respirator like a patient suffering from amyotrophic lateral sclerosis whom Ms. Holdsworth had described to her.
Another friend of Mrs. Jobes’ since childhood, Donna De-Christofaro, testified that in Autumn 1979 Mrs. Jobes had told her that “it was a shame that [Karen Quinlan] hadn’t died when they removed the respirator; that that wasn’t living, it was existing; that she had wished that God had taken her then____”
Mrs. Jobes’ first cousin, Dr. Cleve Laird, recalled a discussion he had with her in the summer of 1975 about a victim of an automobile accident who was being kept alive by a cardiac stimulator:
She said that she wouldn’t want those measures taken in her case and that she certainly wouldn’t want to live that way.
I said, well, they wouldn’t do that to me because I carried and still carry a form of identification that says that I do not wish to have any heroic measures taken in case of massive injury.
Subsequent to that she became interested in where I had gotten that and I told her that it was pretty common both at Baylor where I had taught prior to going up to Massachusetts and also at Harvard. I said that I would send her a card. My wife was there and I turned around to her and told her why didn’t she send one. Then we moved on into discussion of other technical things.
Dr. Laird testified that his wife had sent the card to Mrs. Jobes, and that Mrs. Jobes thanked them for it in a note she sent them at Christmas. The card has not been found.
John Jobes testified that if his wife were competent, she would “definitely” choose to terminate the artificial feeding that sustains her in her present condition. He generally recalled her having stated that she would not want to be kept alive under Karen Quinlan’s circumstances. She did this fre*411quently when the Quinlan case was in the news, mostly during 1976-77.7
The Reverend George A. Vorsheim, minister of the Morris Plains Presbyterian Church, testified that he had married the Jobes, and that he was familiar with them and with Mrs. Jobes’ parents. They are all members of the Presbyterian Church (U.S.A.). The Reverend Mr. Vorsheim testified that Mrs. Jobes was raised in the Presbyterian Faith, and that in the Presbyterian Faith there is no religious requirement to perpetuate life by artificial means nor is there any doctrine prohibiting life-sustaining medical treatment. The Presbyterian Church leaves decisions like the one at issue here to the individual conscience. See generally Advisory Council of the Presbyterian Church (U.S.A.) on Church and Society, An Essay on the Problems Related to the Prolongation of Life by Technological Methods (1974) (adopted by the 186th General Assembly of the United Presbyterian Church (U.S.A.)); Advisory Council of the Presbyterian Church (U.S.A.) on Church and Society, The Covenant of Life and the Caring Community and Covenant (1983) (adopted by the 195th General Assembly of the United Presbyterian Church (U.S.A.)).
V
In Conroy and Peter we have described the type of evidence that can establish a person’s medical preferences *412under the “subjective test.” See Peter, supra, 108 N.J. at 377-379; Conroy, supra, 98 N.J. at 361-63. We have explained that the probative value of prior statements offered to prove a patient’s inclination for or against medical treatment depends on their specificity, see Conroy, supra, 98 N.J. at 363, their “remoteness, consistency and thoughtfulness ... [,] and the maturity of the person at the time of the statements____” Id. at 362. All of the statements about life-support that were attributed to Mrs. Jobes were remote, general, spontaneous, and made in casual circumstances. Indeed, they closely track the examples of evidence that we have explicitly characterized as unreliable. See id. at 362-63 (negating probative value of “an off-hand remark about not wanting to live under certain circumstances made by a person when young and in the peak of health”); id. at 366 (noting that “informally expressed reactions to other people’s medical condition and treatment” do not constitute clear proof of a patient’s intent).
Other than her prior statements, the only evidence of Mrs. Jobes’ intent that the trial court relied on was her membership in the Presbyterian Church. There is no specific evidence of her personal belief in the tenets of that Church; nevertheless, we have consistently recognized that “a person’s religious affiliation and the tenets of that religion may furnish evidence of his or her intent with regard to medical decisions.” Conroy, supra, 98 N.J. at 362; see Quinlan, supra, 70 N.J. at 30-31. In this case, however, Mrs. Jobes’ minister testified that her religion neither requires nor forbids medical treatment like that at issue here. Therefore, Mrs. Jobes’ religious affiliation does not offer much guidance in determining what her preference would be in this situation.
Thus, we conclude that although there is some “trustworthy” evidence that Mrs. Jobes, if competent, would want the j-tube withdrawn8, it is not sufficiently “clear and convincing” to *413satisfy the subjective test. Therefore, we must determine the guidelines and procedures under which life-sustaining medical treatment may be withdrawn from a patient like Mrs. Jobes when there is no clear and convincing proof of her attitude toward such treatment.
VI
Because of the unique problems involved in decisionmaking for any patient in the persistent vegetative state, we necessarily distinguish their cases from cases involving other patients. Accordingly, in Peter we held that neither the life-expectancy test nor the balancing tests set forth in Conroy are appropriate in the case of a persistently vegetative patient. See Peter, supra, 108 N.J. at 374-376. Those holdings are equally relevant in this case. In any case involving a patient in the persistent vegetative state, “we look instead primarily to Quinlan for guidance.” Id. at 376.
Karen Quinlan was twenty-two years old and hospitalized in an irreversible vegetative state when her father sought authorization to withdraw the respirator that was thought to be sustaining her.9 We began our analysis of his request by recognizing that “if Karen were herself miraculously lucid for an interval (not altering the existing prognosis of the condition to which she would soon return) and perceptive of her irreversible condition, she could effectively decide upon discontinuance of the life-support apparatus, even if it meant the prospect of natural death.” Quinlan, supra, 70 N.J. at 39. We realized that the state had potential interests in prolonging any individual’s life. We explained, however, that those interests weaken *414and the individual’s right to privacy becomes stronger “as the degree of bodily invasion [effected by the medical treatment at issue] increases and the prognosis [for recovery to a cognitive, sapient state] dims.” 70 N.J. at 41. We concluded that Karen Quinlan’s right to choose whether to consent to or refuse life-support outweighed any relevant state interests. Our confidence in that conclusion has not been undermined by our subsequent articulation of the four specific state interests which are generally relevant in cases of this type. See Farrell, supra, 108 N.J. at 349-354; Conroy, supra, 98 N.J. at 348-49. We “find it difficult to conceive of a case in which the State could have an interest strong enough to subordinate a patient’s right to choose not to be sustained in a persistent vegetative state.” Peter, supra, 108 N.J. at 380.
In light of Karen Quinlan’s inability to assert her right to decline continued artificial respiration, we determined that “[t]he only practical way to prevent destruction of the right [was] to permit the guardian and family of Karen to render their best judgment, subject to the qualifications [t]hereinafter stated, as to whether she would exercise it in [her] circumstances.” 70 N.J. at 41. The term “substituted judgment” is commonly used to describe our approach in Quinlan. See President’s Commission Report, supra, at 136; N. Cantor, Legal Frontiers of Death and Dying 79 (1987). This approach is intended to ensure that the surrogate decisionmaker effectuates as much as possible the decision that the incompetent patient would make if he or she were competent. Under the substituted judgment doctrine, where an incompetent’s wishes are not clearly expressed, a surrogate decisionmaker considers the patient's personal value system for guidance. The surrogate considers the patient’s prior statements about and reactions to medical issues, and all the facets of the patient’s *415personality that the surrogate is familiar with10 — with, of course, particular reference to his or her relevant philosophical, theological, and ethical values — in order to extrapolate what course of medical treatment the patient would choose. See In re Roe, 383 Mass. 415, 442, 421 N.E.2d 40, 56-59 (1981).
In Quinlan we held that the patient’s family members were the proper parties to make a substituted medical judgment on her behalf. See Quinlan, supra, 70 N.J. at 41. We make the same determination today. Almost invariably the patient’s family has an intimate understanding of the patient’s medical attitudes and general world view and therefore is in the best position to know the motives and considerations that would control the patient’s medical decisions.
[E]ven if no prior specific statements were made, in the context of the individual’s entire prior mental life, including his or her philosophical, religious and moral views, life goals, values about the purpose of life and the way it should be lived, and attitudes toward sickness, medical procedures,, suffering and death, that individual’s likely treatment/nontreatment preferences can be discovered. Family members are most familiar with this entire life context. Articulating such knowledge is a formidable task, requiring a literary skill beyond the capacity of many, perhaps most, families. But the family’s knowledge exists nevertheless, intuitively felt by them and available as an important decisionmaking tool.
*416[Newman, Treatment Refusals for the Critically III: Proposed Rules for the Family, the Physician and the State, III N. Y.L.Sch. Human Rights Annual 45-46 (1985).]
Family members are best qualified to make substituted judgments for incompetent patients not only because of their peculiar grasp of the patient’s approach to life, but also because of their special bonds with him or her. Our common human experience informs us that family members are generally most concerned with the welfare of a patient. It is they who provide for the patient’s comfort, care, and best interests, see id. at 35, 355 A.2d 647; see Farrell, supra, 108 N.J. at 355, and they who treat the patient as a person, rather than a symbol of a cause. Where strong and emotional opinions and proponents exist on an issue involving the treatment of an incompetent, extreme care must be exercised in determining who will act as his or her surrogate decisionmaker. We believe that a family member is generally the best choice.
As we stated in Farrell:
Our common human experience teaches us that family and close friends care most and best for a patient. They offer love and support and concern, and have the best interest of the patient at heart. The importance of the family in medical treatment decisions is axiomatic.
[F]amilies commonly exhibit the greatest degree of concern about the welfare of ailing family members. It is they who come to the hospital and involve themselves in the sick person’s care and comfort. Competent patients usually actively solicit the advice and counsel of family members in decision-making. Family members routinely ask questions of the medical staff about the patient’s condition and prognosis; one study found they frequently asked more questions than patients themselves did. Family members, in fact, commonly act as advocates for patients in the hospital, looking out for their comfort, care, and best interests____
[Newman, Treatment Refusals for the Critically III: Proposed Rules for Family, the Physician and the State, III N. Y.L.Sch. Human Rights Annual 35 (1985).]
See generally Dyck, Self-determination and Moral Responsibility, 9 W.New Eng.L.Rev. 53, 55-60 (1987) (discussing family involvement in medical decisions in the context of the doctrine of self-determination).
The law has traditionally respected the private realm of family life which the state cannot enter____ We believe that this tradition of respect for and confidence in the family should ground our approach to the treatment of the sick.
*417[Farrell, supra, 108 N.J. at 355 (citation edited).]
Other courts have agreed that the family’s substituted judgment is the best guide in cases where the patient’s intention to accept or refuse life-sustaining treatment has not been clearly established. See, e.g., Barber v. Superior Court, 147 Cal.App.3d 1006, 1021, 195 Cal.Rptr. 484, 492 (Cal.Ct.App.1983); Foody v. Manchester Memorial Hosp., 40 Conn.Supp. 127, 482 A.2d 713 (Superior Ct. 1984); John F. Kennedy Memorial Hosp. v. Bludworth, 452 So.2d 921, 926 (Fla.1984); In re Torres, 357 N.W.2d 332 at 341 n. 4 (Minn.1984); Leach v. Akron General Medical Center, 426 N.E.2d 809 (Ohio Com.Pl.1980); In re Colyer, 99 Wash.2d 114, 660 P.2d 738 (1983).
Medical authorities also have recognized that family members are the appropriate surrogate decisionmakers for incompetent patients. The President’s Commission, for example, specifically concluded:
The decisions of patients’ families should determine what sort of medical care permanently unconscious patients [who have not left clear directives] receive. Other than requiring appropriate decisionmaking procedures for these patients, the law does not and should not require any particular therapies to be applied or continued, with the exception of basic nursing care that is needed to ensure dignified and respectful treatment of the patient.
[President’s Commission Report, supra, at 4-5.]
See also New Jersey Chapter of the American College of Physicians Executive Council Policy Statement on Care of Irreversibly III Patients (Oct. 1986) (“Family members are presumed to be the appropriate surrogate decisionmakers for patients diagnosed as being incapable of giving informed consent.”); Statement of the Council on Ethical and Judicial Affairs of the American Medical Association on Withholding or Withdrawing Life Prolonging Medical Treatment (Mar. 15, 1986) (“[T]he choice of the patient, or his family or legal representative if the patient is incompetent to act on his own behalf, should prevail.”); Los Angeles County Medical and Bar Associations, Principles and Guidelines Concerning the Foregoing of Life Sustaining Treatment For Adult Patients 1 *418(July 17, 1985) (“Immediate family members or close friends ... are the surrogate decisionmakers.”)
Our review of these cases and medical authorities confirms our conclusion that we should continue to defer, as we did in Quinlan, to family members’ substituted judgments about medical treatment for irreversibly vegetative patients who did not clearly express their medical preferences while they were competent.11 Those decisions are best made by the family *419because the family is best able to decide what the patient would want.
Normally those family members close enough to make a substituted judgment would be a spouse, parents, adult children, or siblings. Generally in the absence of such a close degree of kinship, we would not countenance health care professionals deferring to the relatives of a patient, and a guardian would have to be appointed. However, if the attending health care professionals determine that another relative, e.g., a cousin, aunt, uncle, niece, or nephew, functions in the role of the patient’s nuclear family, then that relative can and should be treated as a close and caring family member. See In re Farrell, supra, 108 N.J. at 355 (noting the conspicuous presence of family members vis-a-vis health care professionals).
There will, of course, be some unfortunate situations in which family members will not act to protect a patient. We anticipate that such cases will be exceptional. Whenever a health-care professional becomes uncertain about whether family members are properly protecting a patient’s interests, termination of life-sustaining treatment should not occur without the appointment of a guardian.
We realize that there may be rare situations where a healthcare professional’s assessment of a family situation proves to be wrong. In such a case, if the professional has made a good faith determination in this regard, he or she will not be subject to any criminal or civil liability.
Mrs. Jobes is blessed with warm, close, and loving family members. It is entirely proper to assume that they are best qualified to determine the medical decisions she would make. Moreover, there is some trustworthy evidence that supports *420their judgment of Mrs. Jobes’ personal inclinations. Therefore, we will not presume to disturb their decision.
Thus, we hold that the right of a patient in an irreversibly vegetative state to determine whether to refuse life-sustaining medical treatment may be exercised by the patient’s family or close friend. If there are close and caring family members who are willing to make this decision there is no need to have a guardian appointed. We require merely that the responsible relatives comply with the medical confirmation procedures that we henceforth establish. See infra at 420-421. If there are no close family members, and the patient has not left clear and convincing evidence that he or she intended another relative or a nonrelative friend to make surrogate medical decisions in the case of his or her incompetency, see, e.g., Peter, supra, 108 N.J. at 370 (where patient gave her friend durable power of attorney to make medical decisions), then a guardian must be appointed12 and comply with the following procedural requirements. Cf. id. at 384.
VII
In Quinlan, we realized that in the absence of legislation, the responsibility of establishing procedural guidelines for the effectuation of decisions to withdraw life-support is incumbent upon the court. Therefore, we held that when the guardian, the family, and the attending physician concur that life support should be withdrawn from a hospital patient in a persistent vegetative state, they must secure the confirmation of a hospital prognosis committee that there is no reasonable possibility *421that the patient might recover to a cognitive sapient state. See Quinlan, supra, 70 N.J. at 50. Once such a confirmation is secured, the life-supporting treatment may be withdrawn. Id. Quinlan specifically rejected any provision for judicial review of this procedure as unnecessary and “impossibly cumbersome.” See Id.
Amicus New Jersey Hospital Association has informed us that since Quinlan was decided, approximately eighty-five percent of New Jersey’s acute-care hospitals have established prognosis committees that check the attending physician’s prognosis when withdrawal of life support from a vegetative patient is under consideration. Thus it appears that the Quinlan procedure is functioning in the setting for which it was intended.
Mrs. Jobes, of course, is in a nursing home rather than a hospital. We believe, however, that the processes of surrogate decisionmaking should be substantially the same regardless of where the patient is located. Otherwise, the patient’s right to determine his or her medical treatment could be frustrated by an irrelevant factor. Nevertheless, we recognize there are safeguards in a hospital that are usually not present in a nursing home, i.e., the hospital patient normally has his or her own attending physician13 and, as noted above, many hospitals have prognosis committees.14 The lack of these safeguards was among the reasons that we developed the Ombudsman procedures that protect elderly nursing home patients. See *422Conroy, supra, 98 N.J. at 375-76; Peter, supra, 108 N.J. at 383.
Because Mrs. Jobes is not elderly, the Ombudsman does not have jurisdiction over her case. See N.J.S.A. 52:27G-1, 2(i) (Ombudsman has jurisdiction only in cases where the patient is at least sixty years old). Fortunately, Mrs. Jobes is not in the vulnerable predicament that so many elderly nursing home patients are in because she has a caring and responsible family. For non-elderly non-hospitalized patients in a persistent vegetative state who, like Mrs. Jobes, have a caring family or close friend, or a court-appointed guardian in attendance, we hold that the surrogate decisionmaker who declines life-sustaining medical treatment must secure statements from at least two independent physicians knowledgeable in neurology that the patient is in a persistent vegetative state and that there is no reasonable possibility that the patient will ever recover to a cognitive, sapient state. If the patient has an attending physician, then that physician likewise must submit such a statement. These independent neurological confirmations will substitute for the concurrence of the prognosis committee for patients who are not in a hospital setting and thereby prevent inappropriate withdrawal of treatment. In a proper case, however, they should not be difficult to obtain, and this requirement should not subject the patient to undesired treatment.
As long as the guidelines we hereby establish are followed in good faith,15 no criminal or civil liability will attach to *423anyone involved in the implementation of a surrogate decision to decline medical treatment. Accordingly, judicial review of such decisions is not necessary or appropriate.16 As we have explained, patients and their families may suffer when the courts become involved in their sensitive and personal medical decisions:
No matter how expedited, judicial intervention in this complex and sensitive area may take too long. Thus, it could infringe the very rights that we want to protect. The mere prospect of a cumbersome, intrusive and expensive court proceeding, during such an emotional and upsetting period in the lives of a patient and his or her loved ones, would undoubtedly deter many persons from deciding to discontinue treatment. And even if the patient or the family were willing to submit to such a proceeding, it is likely that the patient’s rights would nevertheless be frustrated by judicial deliberation. Too many patients have died before their right to reject treatment was vindicated in court. See, e.g., Conroy, supra, 98 N.J. at 342; Bartling [v. Superior Court for County of Los Angeles,] supra, 163 Cal.App.3d [186] at 190, 209 Cal.Rptr. [220] at 221 (1984); John F. Kennedy Memorial Hosp. v. Bludworth, 452 So.2d 921, 923 (Fla.1984); Satz v. Perlmutter, supra, 379 So.2d 359; Corbett v. D’Alessandro, 487 So.2d 368, 369 (Fla.Dist.Ct.App.) review denied, 492 So.2d 1331 (Fla.1986); In re L.H.R., 253 Ga. 439, 321 S.E.2d 716 (1984); In re Spring, 380 Mass. 629, [631] n. 1, 405 N.E.2d 115, 118 n. 1 (1980); Saikewicz, supra, 373 Mass, at [734], 370 N.E.2d at 422; In re Storar, 52 N.Y.2d 363, [369] n. 1, 420 N.E.2d 64, 66 n. 1, 438 N.Y.S.2d 266, [268] n. 1, cert. denied, 454 U.S. 858 [102 S.Ct. 309] [70] L.Ed.2d [153] (1981); In re Hamlin, supra, 102 Wash.2d at [811], 689 P.2d at 1374. [In re Farrell, supra, 108 N.J. at 357.]
Of course, if there is a dispute among the members of a patient’s family, the guardian and the physicians, any interested party can invoke judicial aid to insure that the guidelines we *424have established are properly followed and that the patient is protected.17
The “substituted judgment” approach to decisionmaking for patients in the persistent vegetative state is our ideal. We realize that in some cases it may be unworkable, e.g., when the patient has always been incompetent, see President’s Commission Report, supra, at 132-33 (“The substituted judgment standard can be used only if a patient was once capable of developing views relevant to the matter at hand.”), or when the patient has no family or close friends in a position to know his or her subjective personality. See Conroy, supra, 98 N.J. at 375 (noting the social isolation of many nursing home patients). We need not and therefore do not decide those cases today. As Justice Schreiber explained in Conroy:
We have not attempted to set forth guidelines for decisionmaking with respect to life-sustaining treatment in a variety of other situations that are not currently before us. Innumerable variations are possible. However, each case — such as that of the severely deformed newborn, of the never-competent adult suffering from a painful and debilitating illness, and of the mentally alert quadriplegic who has given up on life — poses its own unique difficulties. We do not deem it advisable to attempt to resolve all such human dilemmas in the context of this case. It is preferable, in our view, to move slowly and to gain experience in this highly sensitive field. As we noted previously, the Legislature is better equipped than we to develop and frame a comprehensive plan for resolving these problems.
[Id. at 387-88.]
See also Farrell, supra, 108 N.J. at 360-362 (O’Hern, J., concurring).
VIII
The trial court held that the nursing home could refuse to participate in the withdrawal of the j-tube by keeping Mrs. Jobes connected to it until she is transferred out of that facili*425ty.18 Under the circumstances of this case, we disagree, and we reverse that portion of the trial court’s order.
Mrs. Jobes’ family had no reason to believe that they were surrendering the right to choose among medical alternatives when they placed her in the nursing home. See N.J.S.A. 30:13-5(m) (nursing home residents may not be deprived of constitutional, civil, or legal rights solely by reason of their admission to a nursing home). The nursing home apparently did not inform Mrs. Jobes’ family about its policy toward artificial feeding until May of 1985 when they requested that the j-tube be withdrawn. In fact there is no indication that this policy has ever been formalized. Under these circumstances Mrs. Jobes and her family were entitled to rely on the nursing home’s willingness to defer to their choice among courses of medical treatment. See In re Requena, 213 N.J.Super. 443 (App.Div.), aff'g 213 N.J.Super. 475 (Ch.Div.1986) (subverting a hospital’s policy not to participate in the withholding or withdrawal of artificial feeding where long-term patient had no notice of it prior to her decision to forgo such treatment).
We do not decide the case in which a nursing home gave notice of its policy not to participate in the withdrawal or withholding of artificial feeding at the time of a patient’s admission. Thus, we do not hold that such a policy is never enforceable. But we are confident in this case that it would be wrong to allow the nursing home to discharge Mrs. Jobes. The evidence indicates that at this point it would be extremely difficult, perhaps impossible, to find another facility that would accept Mrs. Jobes as a patient. Therefore, to allow the nursing home to discharge Mrs. Jobes if her family does not consent to continued artificial feeding would essentially frustrate Mrs. Jobes’ right of self-determination. See generally Annas, *426“Transferring the Ethical Hot Potato,” 17 Hastings Center Report 20-21 (Feb.1987) (explaining how patients’ rights are threatened by legal decisions that allow medical institutions to discharge “patients who do not accept everything they offer”).
Throughout the six years that Mrs. Jobes has been at the nursing home she has received extraordinary attention and tender care. We are confident that this excellent treatment will continue. “A decision to forego life-sustaining treatment is not a ground to withdraw all care — nor should care givers treat it in this way____” President’s Commission Report, supra, at 90. Health care professionals must provide for the comfort and dignity of “people who choose to forego life-sustaining therapy or for whom no such therapies are available.” Id. at 4. Their specific obligations depend, of course, on the condition and treatment preferences of the individuals they attend. Certainly, however, “hygenic measures and dignified care for the body” are necessary in every case. Id. at 189; see also Farrell, supra, 108 N.J. at 364-365 (O’Hern, J., concurring). Thus, we recognize that our decision will be burdensome for some of the nursing home personnel. Nevertheless, in view of the immense hardship that would fall on Mrs. Jobes and her family if she were forced out of the nursing home, we are compelled to impose on it for her continued care.
IX
In the trilogy of cases that we have decided today, In re Farrell, supra, 108 N.J. 335, In re Peter, supra, 108 N.J. 365, and this case, In re Jobes, we have formulated guidelines and procedures under which life-sustaining medical treatment (including artificial feeding) may be withdrawn from a competent patient at home, and from two nursing home patients, one elderly and one non-elderly, both of whom are in a persistent vegetative state.
In summary, we state again that the fateful decision to withdraw life-supporting treatment is extremely person*427al. Accordingly, a competent patient’s right to make that decision generally will outweigh any countervailing state interests. See Farrell, supra, 108 N.J. at 354. An incompetent patient does not lose his or her right to refuse life-sustaining treatment. Where such a patient has clearly expressed her intentions about medical treatment, they will be respected. Peter, supra, 108 N.J. at 378.
Where an irreversibly vegetative patient like Mrs. Jobes has not clearly expressed her intentions with respect to medical treatment, the Quinlan “substituted judgment” approach best accomplishes the goal of having the patient make her own decision. In most cases in which the “substituted judgment” doctrine is applied, the surrogate decisionmaker will be a family member or close friend of the patient. Generally it is the patient’s family or other loved ones who support and care for the patient, and who best understand the patient’s personal values and beliefs. Hence they- will be best able to make a substituted medical judgment for the patient.
The location of the patient should occasion minimal interference with the patient’^ right, expressed either directly or through a surrogate decisionmaker, to determine his or her treatment. Particularly at the present time — when terminal and vegetative patients are not permitted to remain in hospitals — we prefer not to impose extra restrictions on the withdrawal of treatment because the patient is at home or in a nursing home. Nevertheless, we recognize that generally, because of the presence of attending physicians and prognosis committees, hospitals afford greater protection against the premature termination or undue prolongation of life-support measures. We believe that the procedures of independent medical verification that we establish today adequately protect patients, without unduly burdening their rights to self-determination and privacy.
If a disagreement arises among the patient, family, guardian, or doctors, or if there is evidence of improper motives or *428malpractice, judicial intervention will be required. We expect, however, that disagreements will be rare and that intervention seldom will be necessary. We emphasize that even in those few cases in which the courts may have to intervene, they will not be making the ultimate decision whether to terminate medical treatment. Rather, they will be acting to insure that all the guidelines and procedures that we have set forth are properly followed.
Courts are not the proper place to resolve the agonizing personal problems that underlie these cases. Our legal system cannot replace the more intimate struggle that must be borne by the patient, those caring for the patient, and those who care about the patient.
The challenge for the courts will be to evolve innovative and flexible processes by which affected individuals can participate comfortably and confidently to secure the vindication of the interests we all seek to protect. [Chief Justice Joseph Weintraub Lecture by Justice Alan B. Handler at Rutgers Law School (March 11, 1987), 119 N.J.L.J. 482 (March 19, 1987).]
Ideally, each person should set forth his or her intentions with respect to life-supporting treatment. This insures that the patient’s own resolution of this extraordinarily personal issue will be honored. Failure to express one’s intentions imposes an awesome and painful responsibility on the surrogate decision-maker.
As we have previously explained, the Legislature is better equipped than the judiciary to frame comprehensive guidelines and procedures for the withdrawal of life-sustaining treatment. Accordingly, we urge it to pass legislation in this area.
As modified, we affirm the judgment of the trial court.

Incident to a prior medical malpractice action, John Jobes had already been appointed guardian of his wife when he made the request at issue here.

The Ombudsman for the Institutionalized Elderly, the New Jersey Hospital Association; American College of Physicians, New Jersey Chapter; Society for the Right to Die, Inc.; New Jersey Catholic Conference; New Jersey Right to Life Committee, Inc.; Concern for Dying; National Association of Prolife Nurses; and Board of Directors of the United Handicapped Federation and the Association for Retarded Citizens/ Minnesota have participated as amici curiae on this appeal.

Because the portion of her brain that controls vegetative functions was not destroyed, Mrs. Jobes is not "brain dead.” See In re Conroy, 98 N.J. 321, 356-57 (1985); In re Quinlan, 70 N.J. 10, 24, 27-28, cert. denied sub nom. Garger v. New Jersey, 429 U.S. 922, 97 S.Ct. 319, 50 L.Ed.2d 289 (1976).

Pursuant to an order entered during the prior malpractice action, which Mr. Jobes and Mr. and Mrs. Laird settled for $900,000, all of Mrs. Jobes’ medical bills are paid by the New Jersey Manufacturers Insurance Company.

The cerebrum is the main part of the brain, situated in the upper part of the cranium. It controls thinking, sensory perception, and voluntary and conscious activities. 1 Attorney's Dictionary of Medicine C-110 (Bender 1986).

Premature diagnosis is not at issue here. Mrs. Jobes has been in her present condition for 6 years.

The Public Advocate called two expert witnesses on the subject of the weight to be given to a witness’ testimony regarding a prior statement of intent. Dr. Elizabeth Loftus, a specialist in human perception and memory, testified that the conversations remembered by Holdsworth, DeChristofaro, Laird, and Jobes should be treated with suspicion because of the length of time that had elapsed since the time of the conversations and because post-event information could have affected their memories. Dr. Irving Crespi, an expert in opinion and attitude research, testified that a statement of intent by itself is not very valuable in predicting behavior. The trial court admitted the testimony on a tentative basis and considered it when weighing the evidence as to statements attributed to Mrs. Jobes, but did not make any specific ruling on the general admissibility of these novel areas of expert testimony. Neither do we.

The consistency of Mrs. Jobes' statements does give them some force.

Two medical ethicists who testified in this case disagreed over whether there is a meaningful distinction between withdrawing nasogastric tubes and other life sustaining medical treatment like respirators. For the reasons we stated in In re Conroy, supra, 98 N.J. at 372-73, and affirm today in In re Peter, supra, 108 N.J. at 380-382, we reject such a distinction.

For example, a surrogate decisionmaker might consider the patient’s likely attitude toward the impact of his or her choice of medical treatment on his or her loved ones:
An individual who is part of a closely knit family would doubtless take into account the impact his acceptance or refusal of treatment would likely have on his family. Such a factor is likewise to be considered in determining the probable wishes of one who is incapable of formulating or expressing them himself. In any choice between proposed treatments which entail grossly different expenditures of time or money by the incompetent’s family, it would be appropriate to consider whether a factor in the incompetent’s decision would have been the desire to minimize the burden on his family.
[In re Roe, 383 Mass. 415, 446, 421 N.E.2d 40, 58 (1981).]
However, as the court in Roe noted, the surrogate "must be careful to avoid examination of [this consideration] in any manner other than one designed and intended to effectuate the individual’s right to self-determination.” Id.

Public opinion also appears to support the substituted judgment approach to surrogate decisionmaking. Public opinion is relevant in the withdrawal-of-treatment cases that we decide today because they present society with moral, social, technological, and philosophical problems that transcend legal issues. See Chief Justice Joseph Weintraub Lecture by Justice Alan B. Handler at Rutgers Law School (March 11, 1987), 119 N.J.L.J. 482 (March 19, 1987); see also Peter, supra, 108 N.J. at 385; Farrell, supra, 108 N.J. at 341-343; Conroy, supra, 98 N.J. at 344 (discussing the need for a legislative resolution of these complicated problems); Quinlan, supra, 70 N.J. at 44 (noting the relevance of "the common moral judgment of the community at large” in cases of this type). Every recent survey that we have found indicates that society believes that a patient’s family members should function as his or her surrogate decisionmakers. In a recent Star Ledger/Eagleton Poll, 84% of the 800 New Jersey residents interviewed felt that a family should be allowed to discontinue treatment for someone "in a coma with no chance of recovery” who is "being kept alive by machines" if the patient had said he or she did not want such treatment; and 64% said the family should be allowed to discontinue treatment under these circumstances even if the patient had said nothing, but the family members nevertheless believe he or she would not want to be sustained in his or her medical condition. Newark Star Ledger, Aug. 10, 1986, at 18, col. 4.
In a nationwide poll conducted in May and June of 1986, 73% of the 1510 respondents approved "withdrawing life support systems, including food and water, from a hopelessly ill patient if they or their family request it.” See N.Y. Times, Nov. 29, 1986, at 32, col. 1-6. Even more recently, 70% of the 2000 persons from across the nation who participated via television in a conference on life-sustaining medical treatment at the United States Chamber of Commerce in Washington, D.C., during the fall of 1986 "strongly agreed” that family members should decide whether to use life-sustaining medical treatment for patients who are unable to choose for themselves. See N.Y. Times, Dec. 2, 1986, at CIO, col. 2-6.
These surveys also indicate that our society overwhelmingly endorses the competent patient’s right to refuse life-sustaining treatment which, as we have explained, grounds our holding in this case. See id. (90%); N.Y. Times, Nov. 29, 1986, supra, at 32, col. 1-6 (73%); Newark Star Ledger, supra, Aug. 10, *4191986, at 18, col. 4 (88%); see also Cleveland Plain Dealer, March 4, 1985, at 1A, col. 1-4 (85% of nationwide survey of 1250 adults); N.Y. Times, Sept. 23, 1984, at 56, col. 3-4 (72% of 1600 Americans surveyed); cf. N.Y. Times, March 17,1985, at 38, col. 4-5 (81% of 1500 adults nationwide agreed with Conroy ruling).

In many cases, an application for the appointment of a medical guardian can be integrated into routine fiduciary guardianship proceedings. When a court considers an application for guardianship, it can also consider whether the proposed guardian will be the appropriate person (i.e., close family member or friend) to make future medical decisions for the ward. Thus, in many cases at the difficult juncture when important medical decisions must be made about an incompetent's medical treatment, no further judicial intervention would be necessary.

By "attending physician” we mean the personal, treating physician of the patient. Unlike an institutional staff physician, the attending physician would be familiar with the patient and, presumably, with the patient's family.

Because it would be helpful whenever life-sustaining treatment has been declined on behalf of a patient in the persistent vegetative state, nursing homes should consider affiliating with the prognosis committees of nearby hospitals. "The Department of Health also might consider the feasibility of developing regional prognosis committees for nursing homes.” Peter, supra, 108 N.J. at 383 n. 13.

Physicians and other health-care personnel are under an ethical, moral, and legal duty to act in good faith and not to deviate from approved medical standards. Physicians who do not adhere to these rules and standards open themselves to potential civil and criminal liability. This fear of liability is substantial, see, e.g., In re Barber, 147 Cal.App.3d 1006, 195 Cal.Rptr. 484 (Cal.Ct.App.1983) (Two doctors who acceded to the requests of family of patient in persistent vegetative state by removing his respirator and feeding tube were charged with murder and conspiracy to commit murder.), and should operate to ensure that the procedures we establish today will be followed.

We specifically disapprove any interpretations of R. 4:83-12, which allows "a hospital, nursing home, treating physicians, relative or other appropriate person" to apply for the appointment of a special medical guardian to consent to emergency treatment when a patient is unable to give consent, that would frustrate the tenor of this opinion. By its own terms, R. 4:83-12 is to be invoked only when "the prompt rendering of medical treatment is necessary in order to deal with a substantial threat to the patient’s life or health." When a decision that a certain course of medical treatment is not necessary is made in accordance with the guidelines that we have established, R. 4:83-12 is inapposite with regard to that course of treatment.

Even when judicial intervention is proper, the trial court’s decision need not and should not always be appealed.

Mr. Jobes did not argue against this portion of the trial court order in his brief or at oral argument. Nevertheless, his appeal to this court must be construed as relating to it because the rest of the trial court’s order is in consonance with his position that Mrs. Jobes’ j-tube may be removed.