Key Legal Cases:
What Happens When Advance Directives Are Not Completed


An understanding of major court cases can help you better understand the pitfalls that caused other individuals and families problems. There are literally hundreds of court cases of related to advance directives and treatment decision-making, but only a few of the more notable cases are presented here. 

~ Karen Ann Quinlan, 1976. 
~ Nancy Beth Cruzan, 1983. 
~ Michael Martin, 1987. 
~ Theresa ("Terri") Maria Schindler Schiavo, 2005.

Karen Ann Quinlan was a 22-year-old woman who fell into a coma on April 15, 1975 following an apparent overdose of drugs and alcohol. She suffered severe brain damage from oxygen deprivation as she was unable to breathe properly following the overdose.  Upon arrival at a hospital, it was found that she could not maintain an adequate breathing rate, and so she was attached to a breathing machine (i.e., a "respirator" or "ventilator").

The coma did not improve, nor did her breathing, and Karen remained in an "persistent vegetative" state having never regained consciousness.  After many months, her physicians agreed that there was no hope for improvement and her family requested that the breathing machine be removed. 

Karen's physicians, however, were concerned about the legality of stopping a breathing machine in so young a patient, particularly when she was not otherwise in an immediately terminal condition.  So the courts were petitioned to authorize the removal of the respirator. 

This was the first time that any higher court had ever been required to address whether or not life-sustaining medical treatment could be stopped in a persistently vegetative (i.e., permanently unconscious) patient.  In 1976 the New Jersey court ruled that artificial life support could be discontinued in this case -- but only because Ms. Quinlan had previously and specifically made known her wish not to have her life maintained indefinitely by the use of a breathing machine.

Key Learning: The courts allowed the removal of the breathing machine specifically and only because there was appropriate evidence of Karen's prior wishes.   Of note, however, there was no such evidence about her wishes regarding the use of feeding tubes.  Therefore her father did not agree to have the tube feedings stopped, even though the court order also allowed for this. After more than a year of assisted breathing Karen's breathing reflexes had stabilized enough to sustain her lung function even after the breathing machine was removed.  Consequently, she lived an additional 10 years in her persistent vegetative condition, sustained by feeding tubes.

Nancy Beth Cruzan was a 33-year old woman who sustained severe brain damage following an automobile accident in January, 1983. In the accident, She not only suffered overwhelming head injuries, but she also landed face down in water at the roadside causing further brain damage from oxygen deprivation.

Nancy never regained consciousness and her life was sustained by the continuous use of tube feeding.  Over time her physicians concluded that she would never recover consciousness.  Four years later, her family requested that the tube feedings be stopped.  After the hospital refused, Nancy's parents petitioned the courts for the necessary authorization. 

During the hearings, however, the state argued persuasively against the family's request.  In particular it was noted that Ms. Cruzan had "never specifically told her friends or family that she would not want to be fed through such a tube." 

The family appealed to the United States Supreme Court. There it was ruled that a "constitutional right to refuse medical care, including feeding tubes" did exist. However, the Court also ruled that "a state could require 'clear and convincing evidence' that removal of the tube is what the patient would have wanted." 

It took the family until June of 1990 (almost seven years) to gather enough evidence from relatives, friends and others before the Courts finally ruled that sufficient evidence did exist.  Ms. Cruzan's feeding tube was then removed on December 15th, and she died on December 27th.

Key Learning: Clear and convincing evidence of ones wishes may well be required.  Therefore, you must speak plainly about what you do or do not want done if you wish to ensure that your desires will be honored.

Michael Martin:
On January 16, 1987, 35-year old Michael Martin was badly injured in a car-train accident, including major injuries to his brain. The injuries left him severely mentally impaired, unable to walk or talk, as well as dependent on the use of feeding tubes to sustain his life.  He was not, however, left in a "vegetative" condition.  He recovered to the point of being able to respond to some simple requests, and appeared able to recognize faces.
His wife, Mary, was appointed as his legal guardian. Five years passed, and Michael's condition did not improve. Mary noted that Michael had made numerous statements in the past about not wanting his life artificially sustained in a highly debilitated condition.  Thus, on March 19, 1992, Mary filed a petition in the courts requesting authorization to remove Michael's feeding tubes.
However, Michael's mother, Leeta Martin, and his sister, Patricia Major, opposed the request and filed a petition of their own, asking that Mary be removed as Michael's guardian.   Allegations were made that Mary only wanted the life-sustaining treatments discontinued in order to obtain settlement funds from a lawsuit against the railroad.  Mary countered that the money was not a factor, noting that the funds substantially increased over time and thus extending Michael's life would be the goal if that were the case. 
During the court proceedings, Mary testified that Michael was "a private but active person before the accident." She further explained that had always found it difficult to be around people "who were disabled or dependent on others" and had frequently stated that "he would rather die than be dependent on people and machines." His wife testified of several "discussions between Mike and me regarding...our wishes...if either of us was ever involved in a serious accident, had a disabling or terminal illness or was dying of old age." 
She noted that the discussions "began approximately eight years ago," and that they spoke of these things "on many different occasions." Specifically, "several were triggered by movies which we saw together. Mike's position was always the same: he did not want to be kept alive on machines and he made me promise that I would never permit it."
Two co-workers also testified that "he had remarked to them that "he would not want to continue living in a vegetative state."  However, Mr. Martin was not in a vegetative condition, and thus such testimony was deemed insufficient.
His sister also acknowledged that "Michael once told her that he would not want to be kept alive by a respirator if he were in a coma."  But, again, he was not now in a coma.
On October 30, 1992, the trial court ruled on the basis of Mary's testimony that "clear and convincing evidence had been presented," and the court appeared satisfied that Michael would not want his life artificially prolonged in this situation. 
However, the court further ruled that Michael's past wishes "could not be considered because they were not expressed in writing."  In addition, although the court specifically found that withdrawing the feeding tubes appeared to be "in Michael's best interests," his wishes could not be honored because he was not "terminally ill."  Therefore, the petition was denied. 
The case was appealed to the Michigan Court of Appeals (which ruled in favor of Mary), and from there to the Michigan State Supreme Court.  The state supreme court concluded that Michael's prior statements were insufficient to prove his wishes.
Specifically, his past statements were ruled "general, vague and casual..."  Regarding comments made to his wife after seeing debilitated people, movies, etc, it was noted that "...Michael's purported remarks...were 'no different than those that many of us might make..'" in such situations, but they could not be deemed conclusive statements as to his future wishes.  Thus, the court ordered that the tube feedings must be continued.

Key Learning: Casual statements made to loved ones may well not be sufficient evidence for your wishes to be honored.  Even the appearance of secondary motives (financial gain, etc) can greatly complicate the process, potentially causing other genuine concern.  It is essential, therefore, that you clearly document your wishes in a written advance directive, both to ensure that your desires are unequivocally known and will be honored and to protect those you love from unnecessarily painful negative allegations and distress.

The case of Theresa ("Terri") Maria Schindler Schiavo is unquestionably the best known of all legal end-of-life cases.  The case was pursued in the courts over the course of 12 years and was followed through the media by a world-wide audience.  

In February of 1990 at the age of 26, Terri reportedly collapsed at home. Because she was being treated for bulimia (an eating disorder), it was suggested that a related potassium imbalance may have caused her heart to stop.

Regardless, Terri suffered severe brain damage from a lack of oxygen, and was left unable to eat, walk, or talk, and required tube feeding to survive. 

In 1991 her husband, Michael Schiavo, flew Terri to California for experimental therapy. However, the therapy produced no measurable success. He also moved her at times from one nursing home to another in search of better rehabilitation and care.

For the first three years, all accounts indicate that Michael remained very involved in his wife's care and that he and her parents, the Schindlers, enjoyed an amicable relationship. 

However, the amicability apparently ended in 1993, shortly after Michael won a $1.3 million malpractice settlement over the treatment of Terri’s potassium imbalance.  $750,000 was awarded in Terri's name and for her care. The rest was awarded to Michael for his loss of "spousal consortium."

Michael claims that in February 1993 Terri's father came to him and requested "his share" of the award. Michael allegedly declined, stating that the funds were to be used for Terri's care. Terri's father disputes this account, stating he had only requested access to Terri’s funds to secure further rehabilitation, which he claimed Michael was no longer pursuing. 

Later, in July 1993, Terri's parents tried to have Michael removed as guardian and themselves appointed in his stead. They alleged poor care by Michael, and also voiced suspicions that he may have originally tried to strangle her. They speculated that this, rather than the potassium imbalance may have been the cause of her debilitating injury. They further alleged that Michael was the source of Terri’s bulimia, noting that Terri had been ‘heavy’ in high school and was extremely self-conscious about her weight. They claimed that Michael had pressured her to stay thin with statements such as, “If you ever get that fat again, I'll divorce you.”

Michael denied the allegations of assault and claimed he never made disparaging statements or threats. The case was ultimately dismissed. 

In 1998 Michael became engaged to a woman who was eventually to become his second spouse. Together they had two children. At this juncture the Schindlers again sued for guardianship. They based the suit upon grounds of adultery and upon renewed allegations of neglect and abuse. Their efforts again failed. By many accounts, Michael remained devoted to Terri and to her care. Indeed, it was noted by some that he was found more frequently her bedside than Terri’s other family members. 

Yet, there was no discounting the considerable concern and effort of the Schindlers. In particular they were devoted to Terri’s continuing rehabilitation. This aroused considerable controversy. Some professionals felt that the kinds of "stimulus-based" therapies they were pursuing could cause Terri unnecessary distress and disruption, and potentially do more harm than good. Eventually Michael sought to prevent Terri’s parents from further involvement in this regard.  Their response was to secure covert “telephone ‘tough love’ rehabilitation” when they were denied other options. 

As the years passed Michael became increasingly convinced that Terri’s condition would not improve. Drawing upon statements he claimed Terri had made to him, he petitioned the courts for removal of her feeding tube. In particular, he testified about a past conversation they'd had about a disabled uncle. During the discussion Terri had told him never to prolong her life in a severely disabled condition. A girlfriend of Terri’s provided additional supporting testimony. Thus, on February 11, 2000, 10 years after Terri’s original collapse, a circuit court judge approved the request. 

The parents sued for an injunction. They also cited prior conversations with Terri, along with her religious affiliation and beliefs. They added their own conviction that she was not truly comatose, and thus could yet improve, as injunctive grounds. They also produced testimony from a woman who had dated Michael between 1992 and 1993 who claimed to have once asked him what he knew about Terri’s wishes. She stated that he had responded, “We never spoke about this. My God, I was only 25 years old. ... We were young. We never spoke of this.” Finally, they alleged that Michael only wanted the feeding tube removed because he wanted to retain the remainder of the malpractice award. 

Over the next five years, a total of six court battles and multiple investigations ensued. Ultimately, 33 experts were sought out by the Schindlers to support their claim that Terri was still aware, able to communicate, and might yet benefit from rehabilitation. A similar number of counter-opinions were obtained from other experts, in rebuttal. Ultimately, by some reports, over half of the total funds awarded for Terri's care were eventually spent on legal fees.

A legal defense organization temporarily covered the Schindler's considerable legal costs for some two years, followed by additional funds and representation from a religiously-based legal group. One businessman offered Michael Schiavo $1 million to walk away from Terri, and a “pledge fund” was set up for a similar purpose which claimed $6 million in donations. Michael consistently declined any such offers. 

Equally devoted right-to-die groups took up Michael's cause and condemned all legal and government intrusions. The television media picked up the case along with the family's disputes. This resulted in endless news reports and finally culminated in appearances by Michael Schiavo on the television show "Larry King Live," and by Terri's sister on the "Oprah" television show. 

Over the years Terri's feeding tube was repeatedly removed and reinserted, depending upon current court orders. During one period of removal, the Florida governor’s office received upwards of 165,000 e-mails through a petition drive requesting that the governor intervene. Calls also came from disabled rights activist Joni Tada, from actor Mel Gibson, from Focus on the Family founder Dr. James Dobson, and from the Vatican. 

The result was "Terri's Law," passed in October 2003, which allowed Gov. Jeb Bush and the Florida Attorney General to step in.

The ACLU enjoined these efforts, and the Florida Supreme Court eventually struck down the law. In the Spring of 2005, state and federal congressional hearings were held and various bills proposed and passed. 

During the month of March of 2005 the 11th Circuit Court of Appeals, the Florida State Supreme Court, and the United States Supreme Court either denied appeals or refused to further intervene. Eventually Terri’s husband prevailed and her feeding tube was removed. On March 31, 2005, she died with Michael at her beside. 

After Terri's death a much anticipated autopsy was performed. The results: profoundly severe "atrophy" (withering away) of the brain, reduced to half its normal size; cortical (brain damage induced) blindness; and, findings consistent with a diagnosis of "persistent vegetative state."  It was concluded that no amount of therapy could correct the damage. Finally, it was also noted that there was no evidence of strangulation or other neck injury. 

Even so, the Schindlers issued a statement regarding the autopsy, noting that it had also confirmed that "Terri was not terminal, that Terri had no living will, that Terri had a strong heart, and that Terri was brutally dehydrated to death." An attorney (who was not also a physician) specializing in "medical ethics cases" also pointed out her belief that, "The frontal temporal and temporal poles and insular-cortex demonstrated relative preservation," and concluding by saying, "What this tells us is that her cortex retained function and that her brain was more normal in the area that controls higher-level thinking" -- in short, underscoring the parents' belief that Terri had retained the capacity for substantial cognitive awareness.

Clearly the court rulings and the autopsy did not end the controversy.

After all was said and done, perhaps the most enduring final words came from Michael Schiavo himself.  On Terri’s grave stone he had the following words engraved, "I kept my promise." 


Key Learning:  There is much to learn from this case. Failing to make your wishes openly known, particularly in writing, can pull your family apart and can cost you and your loved ones untold burdens in suffering, financial expense, public airing of private lives, and emotional burdens beyond measure.  

It remains possible that both parties to the litigation were "right" in that they believed in what they were doing.

Money, remarriage, emotional attachment, divergent religious views, and disagreements over recollections of statements can lead to very different perspectives. When this occurs, great sorrow and even outright injustice can be carried out by otherwise well-meaning participants.  

Regardless of who was right, three indisputable facts remain: 1) Terri lived for a decade and a half in a profoundly debilitated state; 2) Terri died after the removal of a medical treatment (feedings by tube) that could have been continued (if she had wished this); and, 3) of the $750,000.00 awarded for Terri's care, $456,816.00 was eventually expended on legal fees.  Even that was not the total cost involved, as many organizations, legal foundations, and private donors contributed many thousands more. 

Only by properly documenting your desires can such profound burdens and contentions be avoided.  

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