Court Opinion

ID: 9698037
Source: CourtListenerOpinion
Date Created: 2023-08-25 19:40:10.555568+00
Date Added: 2024-06-11T18:20:37.785364
License: Public Domain

*631WIEAND, Judge,
concurring.
May the family of a patient, who has been in a persistent vegetative state for several years with no chance for recovery and who has not previously recited his wishes regarding the use of life sustaining medical procedures at a time when he was competent, be permitted to withdraw nutrition and hydration supplied by artificial means? I agree with the majority and join its determination that, when possible, such a decision can and should be made by a close family member and two qualified physicians without the necessity for obtaining a court order. In many instances, however, the circumstances will require that a court intervene. This was such a case. I write separately, therefore, to elucidate those considerations which should affect the decision of a trial court and the review to be conducted by an appellate court.
Daniel Joseph Fiori resides at the Mayo Nursing and Convalescent Center in Philadelphia. He became incompetent in 1971 at the age of twenty-one, when he suffered severe brain damage in a motorcycle accident. He was confined to a wheel chair and could only express himself by limited verbal sounds and facial and bodily gestures. At this time, his cognitive abilities, though limited, were functional.
In 1976 Fiori suffered a second injury, which left him in a persistent vegetative state. This condition has continued until the present. Although his heart still beats and some primitive reflexes still respond to applied stimuli, all cognitive brain functions and thought processes are inoperable.1 He feels no pain or pleasure, and he is unable to interact in his environment or to communicate with others. He cannot think; he *632cannot speak; he cannot move and he cannot eat. He receives all nutrition, hydration and medication through a gastrostomy tube inserted into his stomach. There is no hope that he will recover or that his condition will improve.
In 1992, Rosemarie Sherman, Fiori’s mother, after consulting with Fiori’s physicians and family, concluded that further treatment was not beneficial and that all artificial life sustaining measures should be terminated.2 However, Mayo Nursing refused to carry out her wishes without a prior court order. Therefore, Sherman filed a petition requesting judicial authorization to discontinue life sustaining procedures. A hearing was held and, although no direct evidence of Fiori’s own desires was presented, the trial court applied an objective standard and granted Sherman’s petition. The Office of the Attorney General on behalf of the Commonwealth of Pennsylvania filed the instant appeal.
As the majority recognizes, there will be many occasions when a patient’s close family members, along with the patient’s physician, are most capable of deciding, without court intervention, whether life sustaining treatment should be discontinued for a patient in a persistent vegetative state. Although I would not require judicial involvement in such cases, I recognize that, as a practical matter, there will be frequent occasions when the courts will be called upon to decide such intimate family matters. Thus, in the instant action, Sherman initiated contact with the courts, because the convalescent facility which cared for her son had refused to accept her requests for her son’s treatment. Such a case, in my judgment, can properly be brought before a court. Other cases in which judicial intervention will be required or requested come readily to mind.
Debate over a patient’s right to refuse life sustaining medical treatment has been fueled by advances in medical technology which have enabled medical practitioners to prolong life where, in the past, death would have been shortly forthcoming. A semblance of life may now be sustained long after *633conscious existence has ceased. “Hopelessly or terminally ill patients who in the past would have met with a swift end, now find that medical science can sustain them, near the threshold of death, but not yet across it.” In re Estate of Longeway, 133 Ill.2d 33, 39, 139 Ill.Dec. 780, 782, 549 N.E.2d 292, 294 (1989). As the Supreme Court of Arizona said in Rasmussen by Mitchell v. Fleming, 154 Ariz. 207, 741 P.2d 674 (1987):
Not long ago the realms of life and death were delineated by a bright line. Now this line is blurred by wondrous advances in medical technology — advances that until recent years were only ideas conceivable by such science-fiction visionaries as Jules Verne and H.G. Wells. Medical technology has effectively created a twilight zone of suspended animation where death commences while life, in some form, continues. Some patients, however, want no part of a life sustained only by medical technology. Instead, they prefer a plan of medical treatment that allows nature to take its course and permits them to die with dignity.
As more individuals assert their right to refuse medical treatment, more frequently do the disciplines of medicine, law, philosophy, technology, and religion collide. This interdisciplinary interplay raises many questions to which no single person or profession has all the answers.
Rasmussen by Mitchell v. Fleming, supra at 211, 741 P.2d at 678.
Numerous courts have acknowledged that individuals possess the right to refuse life sustaining medical treatment, including artificial nutrition and hydration, and have found as its basis the right to privacy in the United States Constitution, the rights contained in state constitutional provisions, the common law right to be free from unwanted bodily invasions, and various statutory enactments. See, e.g.: Cruzan v. Director, Missouri Dept. of Health, 497 U.S. 261, 110 S.Ct. 2841, 111 L.Ed.2d 224 (1990) (federal constitution); Rasmussen by Mitchell v. Fleming, supra (federal and state constitutions and common law); Foody v. Manchester Memorial Hosp., 40 Conn.Sup. 127, 482 A.2d 713 (1984) (same); In re Severns, 425 A.2d 156 (Del.Ch.1980) (federal constitution); In re L.H.R., *634253 Ga. 439, 321 S.E.2d 716 (1984) (same); In re Estate of Longeway, supra (common law and statutory provisions); Matter of Lawranee, 579 N.E.2d 32 (Ind.1991) (federal and state constitutions and statutory provisions); DeGrella by Parrent v. Elston, 858 S.W.2d 698 (Ky.1993) (common law); In re P.V.W., 424 So.2d 1015 (La.1982) (state statute); Brophy v. New England Sinai Hosp., Inc., 398 Mass. 417, 497 N.E.2d 626 (1986) (federal constitution and common law); Mack v. Mack, 329 Md. 188, 618 A.2d 744 (1993) (common law); In re Guardianship of Crum, 61 Ohio Misc.2d 596, 580 N.E.2d 876 (Ohio Prob.1991) (federal constitution); Matter of Guardianship of L.W., 167 Wis.2d 53, 482 N.W.2d 60 (1992); (federal and state constitutions and common law). “No right is held more sacred, or is more carefully guarded by the common law, than the right of every individual to the possession and control of his own person, free from all restraint or interference by others, unless by clear and unquestionable authority of law.” Matter of Guardianship of L.W., supra at 68, 482 N.W.2d at 65, quoting Union Pacific Railway Co. v. Botsford, 141 U.S. 250, 251, 11 S.Ct. 1000, 1001, 35 L.Ed. 734 (1891). Cf. In re C.A., 236 Ill.App.3d 594, 603-04, 177 Ill.Dec. 797, 803, 603 N.E.2d 1171, 1177 (1992), appeal denied, 148 Illl.2d 642, 183 Ill.Dec. 20, 610 N.E.2d 1264 (1993).
A majority of courts also agree that the right to self determination is not lost merely because an individual has become' incompetent. See, e.g.: Rasmussen by Mitchell v. Fleming, supra, 154 Ariz. at 219, 741 P.2d at 686; Foody v. Manchester Memorial Hosp., supra, 40 Conn.Sup. at 133, 482 A.2d at 718; In re Severns, supra at 159; In re L.H.R., supra, 253 Ga. at 439, 321 S.E.2d at 718; In re P.V.W., supra at 1017; Mack v. Mack, supra, 329 Md. at 211, 618 A.2d at 756; In re Guardianship of Crum, supra, 61 Ohio Misc.2d at 603, 580 N.E.2d at 881-882; Matter of Guardianship of L.W., supra, 167 Wis.2d at 72-74, 482 N.W.2d at 67. “The existence and viability of a long established personal right does not hinge upon its prescient exercise, nor is it extinguished when one is adjudged incompetent.” Matter of Guardianship of L.W., supra at 74, 482 N.W.2d at 67.
*635Where a patient’s wishes regarding the use of life sustaining treatment can be discerned, those wishes should be honored. Frequently, however, an individual will not have prepared explicit instructions regarding treatment in the event that he or she becomes incompetent. See: Id. Although it is more difficult to determine the circumstances under which life sustaining measures should cease where a patient has become incompetent without having expressed his or her desires, it should not be assumed that a failure to express an intent manifests a decision to accept any and all extraordinary life prolonging treatment. Id. at 74-76, 482 N.W.2d at 68.
Whether it would be appropriate to discontinue life sustaining treatment where the intent of an incompetent patient is not known should be judged by applying objective standards. See, e.g.: Rasmussen by Mitchell v. Fleming, supra, 154 Ariz. at 222, 741 P.2d at 689; Foody v. Manchester Memorial Hosp., supra, 40 Conn.Sup. at 139, 482 A.2d at 721; In re Guardianship of Myers, 62 Ohio Misc.2d 763, 773-774, 610 N.E.2d 663, 669-670 (Oh.Com.Pl.1993); In re Guardianship of Crum, supra, 61 Ohio Misc.2d at 605, 580 N.E.2d at 882; Matter of Guardianship of L.W., supra, 167 Wis.2d at 74-76, 482 N.W.2d at 68. “An incompetent is a ward of the state, and [the] state’s parens patriae power requires [a] court to ensure that the ward’s best interests are protected.” Matter of Guardianship of L.W., supra at 76, 482 N.W.2d at 68.
If the exercise of the right [to self determination] is to be maintained where no expression has been made by an incompetent patient as to treatment, it must take place within the context of an analysis which seeks to implement what is in that person’s best interests by reference to objective societally shared criteria. See Commission Report, pp. 134-35. “In assessing whether a procedure or course of treatment would be in a patient’s best interest, the decision maker must take into account such factors as the relief of suffering, the preservation or restoration of functioning and the quality as well as the extent of life sustained.” Commission Report, p. 135.
*636Foody v. Manchester Memorial Hosp., supra, 40 Conn.Sup. at 139, 482 A.2d at 721.
A court which is asked to decide whether medical treatment should be discontinued should consider whether the family’s or guardian’s recommendation would be in the “best interests” of the patient.
Under the best interests standard, the surrogate decision-maker assesses what medical treatment would be in the patient’s best interest as determined by such objective criteria as relief from suffering, preservation or restoration of functioning, and quality and extent of sustained life. Commission Report at 135. ‘An accurate assessment will encompass consideration of the satisfaction of present desires, the opportunities for future satisfactions, and the possibility of developing or regaining the capacity for self determination.’
Rasmussen by Mitchell v. Fleming, supra, 154 Ariz. at 222, 741 P.2d at 689 (footnote omitted). When applying an objective standard it is appropriate for the court to consider any relevant expressions made by the patient while competent, the treatment options which are presently available, the benefits or non-benefits thereof, the likelihood of improvement, the amount of suffering or discomfort associated with either course, the degree of dependence upon the treatment, the intrusiveness of the procedure, the presence of progressive physical deterioration and the opinion, if any, of the hospital bio-ethics committee. See: Foody v. Manchester Memorial Hosp., supra, 40 Conn.Sup. at 134, 482 A.2d at 718-719; Rasmussen by Mitchell v. Fleming, supra, 154 Ariz. at 222, 741 P.2d at 689; In re Myers, supra, 62 Ohio Misc.2d at 774, 610 N.E.2d at 670; Matter of Guardianship of L.W., supra, 167 Wis.2d at 84-86, 482 N.W.2d at 72-73.
Life is generally worth preserving. Therefore, the burden of proof must necessarily rest upon a petitioner who asks the court to order discontinuation of extraordinary life sustaining measures. He or she will be required to show that the continuation of extraordinary life sustaining measures will not serve the best interests of the patient. In such cases, a court *637should be able to find that “[a] dignified and natural death [will] outweigh the interest of maintaining a physiological life as long as medically possible.” Matter of Guardianship of L.W., supra at 76, 482 N.W.2d at 68. “To require someone to remain in [a persistent vegetative state] for perhaps decades cannot be in the best interest of that individual. Indeed it can be argued that to keep an individual in that condition, with no hope for recovery, is not only against the best interest, but is inhumane.” In re Myers, supra, 62 Ohio Misc.2d at 775, 610 N.E.2d at 670. Where the benefits of continued treatment are limited and outweighed by its burdens on the patient, therefore, it may be in the patient’s best interest to discontinue treatment.
The primary basis for medical treatment of patients is the prospect that each individual’s interests (specifically, the interest in well-being) will be promoted. Thus, treatment ordinarily aims to benefit a patient through preserving life, relieving pain and suffering, protecting against disability, and returning maximally effective functioning. If a prognosis of permanent unconsciousness is correct, however, continued treatment cannot confer such benefits.
Matter of Conservatorship of Toms, 357 N.W.2d 332, 338 (Minn.1984). Although death may result from the termination of treatment, it will be certain and relatively quick; if the patient is allowed to languish for several years, death will still be imminent but will occur at an unknown time. Where it is certain that further extraordinary treatment will produce no beneficial result for a vegetative patient, treatment may be discontinued.
The decision in such cases -will involve a choice between life and death. Therefore, a trial court must exercise caution and remain conscious of the profound responsibility which has been vested in it. An appellate court, it seems to me, must also be cognizant of the profound responsibility which has been vested in the trial court and should not substitute its judgment for that of a trial court. It follows that a decision of a trial court should not be disturbed absent an abuse of discretion or an error of law.
*638In granting Mrs. Sherman’s petition, the trial court properly-applied a “best interests” standard. Fiori is completely incapable of participating in or recognizing his environment. He has no cognitive abilities and only the most primitive ability to respond to stimuli. He has persisted in his present condition -without improvement for seventeen years. The medical evidence is uncontroverted that his condition will never improve. Although medical technology may be employed to perpetuate his existence for several more years, he will continue to deteriorate. As Fiori’s family and physicians have already realized, the continued use of life sustaining treatment will not be beneficial to him. The time has come to suspend attempts to prolong his life unnaturally and to allow his life to follow its natural course. The time has come to allow Fiori to rest.
Because I would hold that the trial court considered appropriate criteria in determining whether Mrs. Sherman’s petition should be granted, I would affirm the court’s order which permitted the withdrawal of life sustaining nutrition and hydration. Because the patient is already represented by a guardian and because a guardian ad litem could have added nothing to the trial court’s careful and sensitive consideration of the petition, I would reject the Attorney General’s contention that we should reverse for the appointment of a guardian ad litem. .
ROWLEY, President Judge, joins.

. A patient in a persistent vegetative state is not “brain dead.” Although most brain functions are inoperable, vital functions such as heart beat and breathing persist. See: Lovato v. District Court in and for the Tenth Judicial Dist., 198 Colo. 419, 426 n. 6, 601 P.2d 1072, 1076 n. 6 (1979). A patient who is brain dead, on the other hand, is non-responsive to all stimuli, unable to breathe independently, and displays absolutely no reflexive movements. Id. at 426, 601 P.2d at 1077. See also: Matter of Guardianship of L.W., 167 Wis.2d 53, 62-64 n. 1, 482 N.W.2d 60, 63 n. 1 (1992), citing the Guidelines for State Court Decision Making in Authorizing or Withholding Life-Sustaining Medical Treatment, National Center for State Courts 1991, Appendix B. 438 PA.Super. —22

. Sherman had been appointed legal guardian of her son in 1980 by order of the Bucks County Orphans' Court.