Terri Schiavo- one physician's perspective

As an oncologist I frequently deal with the terminal care of patients and with end of life situations, and these are invariably complicated by the potential availability of medical interventions that can prolong life indefinitely. Such cases need to be individualized.  They are never easy, are invariably wrenching and take their emotional toll on everyone —patients, relatives, loved ones and myself. But in such difficult situations with enough thought and concern and empathetic communication between the patient, their relatives and the hospital or hospice staff, a course of action that is decent, humane and compassionate usually can be reached for each individual patient. 

Although I have not examined Terri Schiavo and do not have access to her medical records,  there are a number of pertinent medical facts that are clear from the videos I have seen of her and from the results of diagnostic studies that  have made their way into the news media.  A number of years ago she apparently had a CT scan which showed severe atrophy of the brain cortex.  Under such circumstances, performing a follow up MRI and/or PET scan would not be medically indicated because these more sensitive brain scans would not give her physicians any additional information (that is, MRI and PET scans would undoubtedly also show the same severe cortical brain atrophy).  

Consistent with this CT scan her EEG (which measures the electrical activity generated from her brain) has been reported to be 'flatline.'  This does not mean she is 'brain dead' (a provocative and medically useless term).  She is clearly not 'brain dead' because the 'lower' regions of her brain that control her breathing and heart beat are definitely functioning. Rather the EEG (like the CT scan) is a good measure of 'upper' brain function which includes rational thought, the use and interpretation of language, processing of visual and auditory input (sight and sound) and voluntary movement.

All of these 'upper' brain functions appear gone in this poor woman. Indeed Terri Schiavo is paralyzed not from spinal cord damage but from damage to these upper portions of the brain that control these voluntary movements.  In addition to being totally paralyzed she likely does not have any voluntary control over her bladder or bowel function, she likely cannot swallow, and she likely has difficulty coughing up or clearing her normal mouth and/or upper airway secretions.

It is difficult for any physician to determine whether this poor woman is feeling any pain. The regions of the brain which are largely responsible for processing pain stimuli are approximately midway between the upper and lower brain regions and no type of brain scan or EEG can be helpful in determining her level of pain. Some physicians who have examined her have suggested that Terri Schiavo is in an 'intermittently conscious' rather than a 'persistently vegetative' state and that she shows signs of being intermittently in  pain. Unfortunately, if there is any pain, then she likely has great difficulty in communicating to others that she is in pain/distress, which for all we know might be severe and excruciating. 

In determining the degree of medical intervention, it is best, in my mind, that the physician ignore political and religious dogma, set aside the political ramifications of this case,  forget any ulterior financial motives and the adultery of Terri Schiavo's husband,  and honestly try to determine what is the most decent, humane and compassionate approach to take with this  fellow human being, Terri Schiavo.

Should medical intervention (i.e. a feeding tube surgically placed through her skin into her stomach) be continued to indefinitely prolong the life of this woman,  who is totally helpless and paralyzed and likely nearly blind, who cannot swallow and enjoy any food, who cannot communicate with the loved ones around her and likely cannot even understand what they have to say to her, who is incapable of rational thought,  who may be in intermittent and perhaps severe pain and yet cannot get relief from this pain because she cannot communicate her distress to others,  and who has been in this state for the past 15 years with no hope for  recovery?  What would I want for myself in this situation?  What would I want for my children in this situation?  What is the most decent and humane and compassionate approach to take? 

In the case of Terri Schiavo in my mind the above issues are the only relevant questions — questions that unfortunately I fail to see being addressed  by the politicians, the religious sector, and the media pundits and columnists who have offered their varied opinions.

Dr. Steve Collins is  Medical Oncologist and Professor of Medicine at the Fred Hutchinson Cancer Research Center in Seattle

As an oncologist I frequently deal with the terminal care of patients and with end of life situations, and these are invariably complicated by the potential availability of medical interventions that can prolong life indefinitely. Such cases need to be individualized.  They are never easy, are invariably wrenching and take their emotional toll on everyone —patients, relatives, loved ones and myself. But in such difficult situations with enough thought and concern and empathetic communication between the patient, their relatives and the hospital or hospice staff, a course of action that is decent, humane and compassionate usually can be reached for each individual patient. 

Although I have not examined Terri Schiavo and do not have access to her medical records,  there are a number of pertinent medical facts that are clear from the videos I have seen of her and from the results of diagnostic studies that  have made their way into the news media.  A number of years ago she apparently had a CT scan which showed severe atrophy of the brain cortex.  Under such circumstances, performing a follow up MRI and/or PET scan would not be medically indicated because these more sensitive brain scans would not give her physicians any additional information (that is, MRI and PET scans would undoubtedly also show the same severe cortical brain atrophy).  

Consistent with this CT scan her EEG (which measures the electrical activity generated from her brain) has been reported to be 'flatline.'  This does not mean she is 'brain dead' (a provocative and medically useless term).  She is clearly not 'brain dead' because the 'lower' regions of her brain that control her breathing and heart beat are definitely functioning. Rather the EEG (like the CT scan) is a good measure of 'upper' brain function which includes rational thought, the use and interpretation of language, processing of visual and auditory input (sight and sound) and voluntary movement.

All of these 'upper' brain functions appear gone in this poor woman. Indeed Terri Schiavo is paralyzed not from spinal cord damage but from damage to these upper portions of the brain that control these voluntary movements.  In addition to being totally paralyzed she likely does not have any voluntary control over her bladder or bowel function, she likely cannot swallow, and she likely has difficulty coughing up or clearing her normal mouth and/or upper airway secretions.

It is difficult for any physician to determine whether this poor woman is feeling any pain. The regions of the brain which are largely responsible for processing pain stimuli are approximately midway between the upper and lower brain regions and no type of brain scan or EEG can be helpful in determining her level of pain. Some physicians who have examined her have suggested that Terri Schiavo is in an 'intermittently conscious' rather than a 'persistently vegetative' state and that she shows signs of being intermittently in  pain. Unfortunately, if there is any pain, then she likely has great difficulty in communicating to others that she is in pain/distress, which for all we know might be severe and excruciating. 

In determining the degree of medical intervention, it is best, in my mind, that the physician ignore political and religious dogma, set aside the political ramifications of this case,  forget any ulterior financial motives and the adultery of Terri Schiavo's husband,  and honestly try to determine what is the most decent, humane and compassionate approach to take with this  fellow human being, Terri Schiavo.

Should medical intervention (i.e. a feeding tube surgically placed through her skin into her stomach) be continued to indefinitely prolong the life of this woman,  who is totally helpless and paralyzed and likely nearly blind, who cannot swallow and enjoy any food, who cannot communicate with the loved ones around her and likely cannot even understand what they have to say to her, who is incapable of rational thought,  who may be in intermittent and perhaps severe pain and yet cannot get relief from this pain because she cannot communicate her distress to others,  and who has been in this state for the past 15 years with no hope for  recovery?  What would I want for myself in this situation?  What would I want for my children in this situation?  What is the most decent and humane and compassionate approach to take? 

In the case of Terri Schiavo in my mind the above issues are the only relevant questions — questions that unfortunately I fail to see being addressed  by the politicians, the religious sector, and the media pundits and columnists who have offered their varied opinions.

Dr. Steve Collins is  Medical Oncologist and Professor of Medicine at the Fred Hutchinson Cancer Research Center in Seattle