Terri Schiavo case

Terri Schiavo was born Theresa Marie Schindler to Mary (born 1941)[11] and Robert Schindler (1937–2009)[12] on December 3, 1963, in Lower Moreland Township, Montgomery County, Pennsylvania, a suburb of Philadelphia. She attended Bucks County Community College, where she met Michael Schiavo in 1982. The two began dating and married on November 10, 1984. They moved to Florida in 1986, following Terri's parents. Michael worked as a restaurant manager, while Terri took up a bookkeeping job with an insurance company.[13]

In the early morning of February 25, 1990, Terri Schiavo collapsed in a hallway of her St. Petersburg, Florida apartment. Firefighters and paramedics, arriving in response to her husband Michael's 9-1-1 call, found her face-down and unconscious. She was not breathing and had no pulse. They attempted to resuscitate her and she was transported to the Humana Northside Hospital. Paramedics had her intubated and ventilated.[14]

The cause of Terri Schiavo's collapse was determined to be cardiac arrest.[15] Her medical chart contained a note that "she apparently has been trying to keep her weight down with dieting by herself, drinking liquids most of the time during the day and drinking about 10–15 glasses of iced tea."[16] Upon admission to the hospital, she was noted as suffering from hypokalemia (low potassium levels): her serum potassium level was an abnormally low 2.0 mEq/L (the normal range for adults is 3.5–5.0 mEq/L). Her sodium and calcium levels were normal.[17] Electrolyte imbalance is often caused by drinking excessive fluids, and a serious consequence of hypokalemia can be heart rhythm abnormalities, including sudden arrhythmia death syndrome.[18] Schiavo was eventually switched from being fed by a nasogastric feeding tube to a percutaneous endoscopic gastrostomy (PEG) feeding tube.

Dr. Garcia J. DeSousa, board-certified neurologist in St. Petersburg, Florida, who previously treated Terri Schiavo, cared for her during her initial admission to Humana Northside; both he and Victor Gambone, an internist and Schiavo family physician, independently made the diagnosis of persistent vegetative state (PVS) within approximately one year after her sudden cardiac arrest.[15]

From 1990 to 1993, Michael Schiavo and the Schindlers (Terri Schiavo's parents) enjoyed an amicable relationship,[19] with the Schindlers allowing Michael to live rent-free in their condominium for several months.[20]

In November 1990, Michael Schiavo took Terri to the University of California, San Francisco, for experimental nerve stimulation with a thalamic stimulator. The treatment took several months and was unsuccessful. He returned to Florida with her in January 1991 and admitted her as an inpatient to the Mediplex Rehabilitation Center in Bradenton, Florida. On July 19, 1991, Terri Schiavo was transferred to the Sabal Palms Skilled Care Facility, where she received neurological testing and regular speech and occupational therapy until 1994.[2] In mid-1993, Michael Schiavo requested a do not resuscitate order for her after she contracted a urinary tract infection.

In 1992, Michael filed a malpractice suit against Terri's gynecologist on the basis that he failed to diagnose bulimia as the cause of her infertility.[21] Terri had gone to the doctor because she had stopped menstruating but the doctor had failed to take her medical history into account which might have revealed an eating disorder. During the case, one of Terri's friends testified that she knew Schiavo was bulimic. In November 1992, Michael won the case and was awarded $6.8 million by the jury, later reduced to $2 million as Terri was found partly at fault for her condition.[16] After attorneys' fees and other expenses, Michael received $300,000 and $750,000 was put in a trust fund for Terri's medical care. According to Michael, in early 2003 the Schindlers demanded that he share the malpractice money with them.[2]

On June 18, 1990, the court appointed Michael Schiavo as Terri Schiavo's legal guardian; this appointment was not disputed by the Schindlers at the time.[14] In May 1998, Michael Schiavo filed a petition to remove Terri Schiavo's feeding tube, which her parents opposed. Richard Pearse was appointed by the court as a second guardian ad litem (GAL), and on December 29, 1998, reported "Dr. Jeffrey Karp's opinion of the ward's condition and prognosis is substantially shared among those physicians who have recently been involved in her treatment." Pearse concluded from Karp's and Vincent Gambone's diagnosis of Persistent Vegetative State that Schiavo was legally in a persistent vegetative state as defined by Florida Statutes, Title XLIV, Chapter 765, §101(12). This includes the "absence of voluntary action" and an "inability to communicate or interact purposefully".[20][22]

Pearse found that there was no possibility of improvement but that Michael Schiavo's decisions might have been influenced by the potential to inherit what remained of Terri Schiavo's estate as long as he remained married to her. Due to a lack of a living will and questions regarding Michael's credibility, Pearse recommended denying his petition to remove her feeding tube. Pearse reported that the issue of conflict of interest applied to the Schindlers as well since, had Michael divorced Terri as they wanted him to, they would have inherited the remainder of Terri Schiavo's estate upon her death.[20]

Given the lack of a living will, a trial was held before Pinellas County Judge George Greer during the week of January 24, 2000, to determine what Terri Schiavo's wishes would have been regarding life-prolonging procedures.[23] Michael Schiavo was represented by attorney George Felos, who had won a landmark right-to-die case before the Florida Supreme Court in 1990.[24][25]

The trial included testimony from eighteen witnesses regarding her medical condition and her end-of-life wishes. Michael Schiavo claimed that his wife would not want to be kept on a machine where her chance for recovery was minuscule. According to Abstract Appeal Trial Order, her parents "claimed that Terri was a devout Roman Catholic who would not wish to violate the Church's teachings on euthanasia by refusing nutrition and hydration." Judge Greer issued his order granting the petition for authorization to discontinue artificial life support for Terri Schiavo in February 2000. In this decision, the court found that Terri Schiavo was in a persistent vegetative state and that she had made reliable oral declarations that she would have wanted the feeding tube removed.[23] This decision was upheld by the Florida Second District Court of Appeal[26] (2nd DCA) and came to be known by the court as Schiavo I in its later rulings.[27]

In March 2000, the Schindlers filed a motion to permit assisted feeding of Terri, which is not considered a life-prolonging procedure under Florida law. Since clinical records indicated that Terri Schiavo was not responsive to swallowing tests and required a feeding tube,[14] Judge Greer ruled that she was not capable of orally ingesting sufficient nutrition and hydration to sustain life, and denied the request.[28] The Medical Examiner in his postmortem report was more definitive and reaffirmed that Schiavo could not have swallowed.[29]

In 2000, the Schindlers again challenged Michael Schiavo's guardianship. The Schindlers suggested that he was wasting the assets within the guardianship account by transferring Terri Schiavo to a Pinellas Park, Florida, hospice "after it was clear that she was not 'terminal' within Medicare guidelines" for hospices. By this time, while still legally married to Terri Schiavo, Michael Schiavo was in a relationship with Jodi Centonze, and had fathered their first child. He said he chose not to divorce his wife and relinquish guardianship because he wanted to ensure her final wishes (not to be kept alive in a PVS) were carried out. The court denied the motion to remove the guardian, allowing that the evidence was not sufficient and in some instances, not relevant. It set April 24, 2001, as the date on which the tube was to be removed.[30]

In April 2001, the Schindlers filed a motion for relief from judgment citing new evidence of Terri Schiavo's wishes. Judge Greer denied the motion as untimely under Rule 1.540(b)(5) of the Florida Rules of Civil Procedure.[31] The Second District Court of Appeal upheld Greer's decision but remanded the issue in order to give the Schindlers an opportunity to file a new motion. On April 24, 2001, Terri's feeding tube was removed for the first time. The Schindlers filed a civil suit against Michael Schiavo alleging perjury, which was assigned to another court. The judge, Frank Quesada, issued an injunction against the removal of feeding tube until this was settled. The feeding tube was reinserted on April 26, 2001. On appeal by Michael Schiavo, the Second District Court of Appeal reversed Judge Quesada's order. In the same time frame, Michael Schiavo filed a motion to enforce the mandate of the guardianship court (that the feeding tube be removed). The Second District Court of Appeal denied the motion. These three decisions, all published in a single order by Florida's Second District Court of Appeal,[32] came to be known by the court as Schiavo II in its later rulings.

Left: CT scan of normal brain; Right: Schiavo's 2002 CT scan provided by Ronald Cranford, showing loss of brain tissue. The black area is liquid, indicating hydrocephalus ex vacuo.[33] The small white piece in the right image is the thalamic stimulator implanted in her brain.

On August 10, 2001, on remand from the Florida Second District Court of Appeal, Judge Greer heard a motion from the Schindlers claiming that new medical treatment could restore sufficient cognitive ability such that Terri Schiavo herself would be able to decide to continue life-prolonging measures. The court also heard motions from the Schindlers to remove the guardian (Michael Schiavo) and to require Judge Greer to recuse himself. Judge Greer denied the motions and the Schindlers appealed to the Second District Court of Appeals. On October 17, 2001, the Court of Appeal affirmed the denials of the motions to remove and recuse. The Court of Appeals acknowledged that their opinion misled the trial court, and they remanded the question of Terri Schiavo's wishes back to the trial court and required an evidentiary hearing to be held. The court specified that five board certified neurologists were to testify. The Schindlers were allowed to choose two doctors to present findings at an evidentiary hearing while Schiavo could introduce two rebuttal experts. Finally, the trial court itself would appoint a new independent physician to examine and evaluate Terri Schiavo's condition. (These decisions, all published in a single order by the Florida Second District Court of Appeal,[34] came to be known by the court as Schiavo III in its later rulings.) In October 2002, on remand by the Second District Court of Appeal, an evidentiary hearing was held in Judge Greer's court to determine whether new therapy treatments could help Terri Schiavo restore any cognitive function. In preparation for the trial, a new computed axial tomography scan (CAT scan) was performed, which showed severe cerebral atrophy. An EEG showed no measurable brain activity. The five physicians chosen were William Maxfield, a radiologist, and four neurologists: William Hammesfahr, Ronald Cranford, Melvin Greer and Peter Bambakidis.[35]

The five doctors examined Terri Schiavo's medical records, brain scans, the videos, and Terri herself. Cranford, Greer, and Bambakidis testified that Terri Schiavo was in a persistent vegetative state (PVS). Drs. Maxfield and Hammesfahr testified that she was in a minimally conscious state. As part of the court-ordered medical exam, six hours of video of Terri Schiavo were taped and filed at the Pinellas County courthouse. The tape included Terri Schiavo with her mother and neurologist William Hammesfahr. The entire tape was viewed by Judge Greer, who wrote, Terri "clearly does not consistently respond to her mother". From that six hours of video, the Schindlers and their supporters produced six video clips intended to support their case, totaling less than six minutes, and released those clips to public websites.[1] Judge Greer ruled that Terri Schiavo was in a PVS, and was beyond hope of significant improvement. The trial court order was particularly critical of Hammesfahr's testimony, which claimed positive results in similar cases by use of vasodilation therapy, the success of which is unsupported in the medical literature.[36] This ruling was later affirmed by Florida's Second District Court of Appeal, which stated that "this court has closely examined all of the evidence in the record", and "we have ... carefully observed the video tapes in their entirety." The court concluded that "if we were called upon to review the guardianship court's decision de novo, we would still affirm it." This decision by the Second District Court of Appeals[37] came to be known as Schiavo IV in later rulings.

Around the start of 2003, the Schindlers began to create more publicity by lobbying for their case to keep their daughter alive. On September 11, 2003, the Schindlers petitioned the court to forestall removal of the feeding tube in order to provide for "eight weeks' therapy". Accompanying the petition were four affidavits from members of the Schindler family and one from Dr. Alexander T. Gimon. At the hearing, the Schindlers' counsel read into the record additional affidavits from three speech professionals and two nurses. In particular, nurse Carla Sauer Iyer asserted that she was able to feed Terri Schiavo orally but that Michael characterized any such interaction as "therapy" and ordered her not to do so. Iyer claimed in her affidavit that her initial training in 1996 consisted solely of the instruction, "Do what Michael Schiavo tells you or you're terminated," and that standing orders were not to contact the Schindler family, but that she "would call them anyway".[38]

On September 17, 2003, Judge George Greer denied the petition, and wrote that "the Petition is an attempt by Mr. and Mrs. Schindler to re-litigate the entire case. It is not even a veiled or disguised attempt. The exhibits relied upon by them, clearly demonstrate this to be true." Regarding (Nurse) Iyer's[39] statements,[38][40][41] Greer wrote that they were "incredible to say the least" and that "Ms. Iyer details what amounts to a 15-month cover-up from April 1995 through July 1996, which include the staff of Palm Garden of Largo Convalescent Center, the Guardian of the Person, the guardian ad litem, the medical professionals, the police and, believe it or not, Mr. and Mrs. Schindler ... It is impossible to believe that Mr. and Mrs. Schindler would not have subpoenaed Ms. Iyer for the January 2000 evidentiary hearing had Iyer contacted them in 1996 as her affidavit alleges."[42]

On February 23, 2005, the Schindlers filed a motion for relief from judgment pending medical evaluations.[51] The Schindlers wanted Schiavo to be tested with an fMRI and given a swallowing therapy called VitalStim. The motion was accompanied by thirty-three affidavits from doctors in several specialties, speech-language pathologists and therapists, and a few neuropsychologists, all urging that new tests be undertaken.[52][53] Patricia Fields Anderson, the Schindler family attorney, still held out hope "that Terri might be able to take nourishment orally, despite past findings that she is incapable".[54] Judge Greer formally denied the motion and ordered the "removal of nutrition and hydration from the ward" and set the time and date for the removal of the feeding tube as "1:00 p.m. on Friday, March 18, 2005".[55]

On February 28, 2005, the Schindlers filed a motion, asking for permission to attempt to provide Schiavo with "Food and Water by Natural Means". This second motion asked for permission to "attempt to feed" Schiavo by mouth.[56] Judge Greer denied the second motion on March 8, saying "it has become clear that the second motion is part and parcel of the previous motion on medical evaluations. The same declarations are being used for both motions and the motion appears to be an alternative pleading to the previous motion. Both are asking for an experimental procedure."[57] The following day, Greer denied the first motion as well, citing that an affiant doctor for Michael cautioned that fMRI was an experimental procedure that should be conducted in an academic setting, because Schiavo had already undergone swallowing tests and failed, and because VitalStim had only been performed on patients who were not in a PVS. Greer noted that "most of the doctor affidavits submitted are based on their understanding of Schiavo's condition from news reports or video clips they have seen. Many are obviously not aware of the medical exams undertaken for the 2002 trial."[52]

Following Greer's order on March 18, 2005, to remove the feeding tube, Republicans in the United States Congress subpoenaed both Michael and Terri Schiavo to testify at a congressional hearing.[58] Greer told congressional attorneys, "I have had no cogent reason why the (congressional) committee should intervene." He also stated that last-minute action by Congress does not invalidate years of court rulings.[59][60]

President George W. Bush and Congressional Republicans anticipated Greer's adverse ruling well before it was delivered and worked on a daily basis to find an alternative means of overturning the legal process by utilizing the authority of the United States Congress. On March 20, 2005, the Senate, by unanimous consent, passed their version of a relief bill; since the vote was taken by voice vote, there was no official tally of those voting in favor and those opposed. Soon after Senate approval, the House of Representatives passed an identical version of the bill S.686, which came to be called the "Palm Sunday Compromise" and transferred jurisdiction of the Schiavo case to the federal courts. The bill passed the House on March 21, 2005, at 12:41 a.m. (UTC−5). Bush flew to Washington, D.C. from his vacation in Texas in order to sign the bill into law at 1:11 a.m.

While the bill had been proposed by Republican Senators Rick Santorum and Mel Martínez, it also had the support of Democratic Senator Tom Harkin due to disability rights concerns in the Schiavo case. Harkin had worked with disability rights groups for years and co-authored the 1990 Americans with Disabilities Act.[7] American disability rights groups traditionally tend to ally themselves with Democrats and the political left;[7] however, in the Schiavo case, they joined pro-life organizations in opposing the removal of her feeding tube and supporting the Palm Sunday Compromise.[61] According to Marilyn Golden, Harkin's support was necessary for passage of the bill, as any voice opposition by Democrats would have delayed it.[7]

As in the state courts, all of the Schindlers' federal petitions and appeals were denied, and the U.S. Supreme Court declined to grant certiorari, effectively ending the Schindlers' judicial options. At the same time, the so-called Schiavo memo surfaced, causing a political firestorm. The memo was written by Brian Darling, the legal counsel to Florida Republican senator Mel Martinez. It suggested the Schiavo case offered "a great political issue" that would appeal to the party's base (core supporters) and could be used against Senator Bill Nelson, a Democrat from Florida, because he had refused to co-sponsor the bill.[62] Nelson easily won re-election in 2006.

Republican majority leader and physician Bill Frist opposed the removal of her feeding tube and in a speech delivered on the Senate floor, challenged the diagnosis of Schiavo's physicians of Schiavo being in a persistent vegetative state (PVS): "I question it based on a review of the video footage which I spent an hour or so looking at last night in my office."[63] After her death, the autopsy showed signs of long-term and irreversible damage to her brain consistent with PVS.[64] Frist defended his actions after the autopsy.[65]

Schiavo's body was taken to the Office of the District 6 Medical Examiner for Pinellas and Pasco counties, based in Largo, Florida. The autopsy was conducted on April 1, 2005, and revealed extensive brain damage. The manner of death was certified as "undetermined." The autopsy was led by Chief Medical Examiner Jon R. Thogmartin. In addition to consultation with a neuropathologist (Stephen J. Nelson), Thogmartin also arranged for specialized cardiac and genetic examinations to be made. The official autopsy report[29] was released on June 15, 2005. In addition to studying Terri Schiavo's remains, Thogmartin scoured court, medical and other records and interviewed her family members, doctors and other relevant parties. Examination of Schiavo's nervous system by neuropathologist Stephen J. Nelson, revealed extensive injury. The brain itself weighed only 615 g (21.7 oz), only half the weight expected for a female of her age, height, and weight, due to the loss of a massive number of neurons. Microscopic examination revealed extensive damage to nearly all brain regions, including the cerebral cortex, the thalamus, the basal ganglia, the hippocampus, the cerebellum, and the midbrain. The neuropathologic changes in her brain were precisely of the type seen in patients who enter a PVS following cardiac arrest. Throughout the cerebral cortex, the large pyramidal neurons that comprise some 70% of cortical cells – critical to the functioning of the cortex – were completely lost. The pattern of damage to the cortex, with injury tending to worsen from the front of the cortex to the back, was also typical. There was marked damage to important relay circuits deep in the brain (the thalamus) – another common pathologic finding in cases of PVS. The damage was, in the words of Thogmartin, "irreversible, and no amount of therapy or treatment would have regenerated the massive loss of neurons."[67]

The cardiac pathologist who studied Schiavo's heart found it and the coronary vessels to be healthy, which excludes the possibility that her initial collapse was the result of myocardial infarction, although there was a localized area of healed inflammation (opening the possibility of myocarditis). Thogmartin found that "there was no proof that Terri Schiavo ever had an eating disorder such as bulimia." Regarding the possibility of strangulation or domestic violence as a cause of Schiavo's initial collapse, the report states: "No trauma was noted on any of the numerous physical exams or radiographs performed on Mrs. Schiavo on the day of, in the days after, or in the months after her initial collapse. Indeed, within an hour of her initial hospital admission, radiographic examination of her cervical spine was negative. Specifically, external signs of strangulation including cutaneous or deep neck injury, facial/conjunctival petechiae, and other blunt trauma were not observed or recorded during her initial hospital admission. Autopsy examination of her neck structures 15 years after her initial collapse did not detect any signs of remote trauma, but, with such a delay, the exam was unlikely to show any residual neck findings."[29]

Regarding the cause and manner of Schiavo's death, Thogmartin wrote, "Mrs. Schiavo suffered severe anoxic brain injury. The cause of which cannot be determined with reasonable medical certainty. The manner of death will therefore be certified as undetermined."[29]

Schiavo's gravemarker

Schiavo's body was cremated. Her parents organized a memorial Mass for her at the Holy Name of Jesus Catholic Church in Gulfport on April 5, 2005. Father Frank Pavone, the founder of the Priests for Life anti-abortion organization,[68] delivered the homily.[69]

On June 20, 2005, the cremated remains of Terri Schiavo were buried. The Schindlers' attorney stated that the family was notified by fax only after the memorial service; by then, the family had already started getting calls from reporters.[70] The ashes were interred at Sylvan Abbey Memorial Park in Clearwater, Florida.

The epitaph (pictured) reads:

Schiavo / Theresa Marie / Beloved Wife
Born December 3, 1963
Departed this Earth / February 25, 1990
At peace March 31, 2005
[Dove with olive branch image]
I kept my promise

The Schiavo case has been compared to the Karen Ann Quinlan case and Nancy Cruzan case, two landmark right-to-die cases.[71][72] Quinlan entered a persistent vegetative state in 1975, and her family was allowed to remove her from a ventilator in 1976 after a ruling by the New Jersey Supreme Court based on her right of privacy. She died of pneumonia in 1985.[73] Cruzan was diagnosed with PVS in 1983 and her legal case reached the Supreme Court, which ruled that "clear and convincing evidence" of her wishes to die under such circumstances was needed. Cruzan's family did not have enough evidence of that, but later produced more. She died after being removed from life support in 1990.[74]

The "Terri Schiavo case" actually refers to a series of cases. It differed from the Quinlan and Cruzan cases by involving settled law rather than breaking new legal ground on the right-to-die issue. In 2006, Shepherd said that it was "unclear" whether the Schiavo case represents a landmark decision.[75] The Schiavo case instead involved a dispute between family members over what Schiavo's wishes would have been for such a situation. According to medical ethicist Matthew Stonecipher, "The movement to challenge the decisions made for Terri Schiavo threatened to destabilize end-of-life law that had developed over the last quarter of the 20th century, principally through the cases of Karen Ann Quinlan and Nancy Cruzan."[72] The outcome of the Schiavo case was also in part determined by a 1990 Florida case, Guardianship of Estelle Browning.[25][76] In that case, George Felos, the attorney for Michael Schiavo in the Schiavo case, represented a Browning relative. Felos successfully argued before the Florida Supreme Court that Browning's feeding tube should be removed. The elderly Browning had expressed, in a living will, her wish not to be kept alive by any artificial means, including receiving food and water "by a gastric tube or intravenously." At that time, it was common to remove people from ventilators, but the law in Florida was not clear on removing them from feeding tubes. In a landmark ruling, the Florida Supreme Court decided that Browning had "the constitutional right to choose or refuse medical treatment, and that right extends to all relevant decisions concerning one's health."[25]

During the years of legal proceedings, disability rights groups and activists closely monitored and involved themselves in the case. In March 2003, twelve disability rights groups, led by Not Dead Yet, along with four other amici filed an amicus curiae brief in which they opposed the removal of Schiavo's feeding tube.[77] They also used the Schiavo case to advocate for federal review in cases where third parties decide to withdraw life support from patients unable to give consent.[7][61] They argued that persistent vegetative state is frequently misdiagnosed, and that the reasons for withdrawal of life support from a patient should be scrutinized since even family member surrogates can have conflicts of interest. The Palm Sunday Compromise granted the federal review they sought, but it was limited to only the Schiavo case.[7]

During the Terri Schiavo case in March 2005, a talking points memo on the controversy was written by Brian Darling, the legal counsel to Republican Senator Mel Martínez of Florida.[100] The memo suggested the Schiavo case offered "a great political issue" that would appeal to the party's base (core supporters) and could be used against Senator Bill Nelson, a Democrat from Florida who was up for reelection in 2006, because he had refused to co-sponsor the bill which came to be known as the Palm Sunday Compromise.[101]

Martínez stated that he had not read the memo before he inadvertently passed it to Iowa Senator Tom Harkin, a Democratic supporter of the Palm Sunday Compromise legislation which gave federal courts jurisdiction to review the Terri Schiavo case.[100]

After the existence of the memo was reported by ABC News and The Washington Post, Senate Majority Leader Bill Frist denounced the memo and asserted that the Republican Party's interest in the case was solely based on moral grounds. Darling remained silent about his authorship of the memo as commentators from the conservative magazine Weekly Standard and other publications questioned its authenticity.[102][103] The source of the memo had not been disclosed by either ABC News or The Washington Post. The Washington Post says that it neither implied that the memo originated from a Republican source nor that it was circulated by Republicans, though it did in fact make these assertions when it published the story by reporters Mike Allen and Manuel Roig-Franzia on its wire service on March 19, 2005. The authorship claim was removed before publication of the print version on March 20, 2005.[104][105] On April 6, 2005, Darling admitted to writing the memo, and resigned his position as legal counsel to Senator Martínez.[106]