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abandoning substituted judgment test used in Leach, but requiring clear and convincing proof that patient is in a persistent vegetative state or permanently unconscious, and will not recover
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No. G92-12-049.
Decided February 26, 1993.
Kaufmann Kaufmann and George R. Wertz, for petitioner Timothy Myers.
Western Reserve Legal Services of Ravenna and Carol J. Crimi; Western Reserve Legal Services of Akron and Ann Snyder, for petitioner Robin Myers.
Willis Linnen and Mark C. Willis, for Penny Myers.
Barbara J. Patterson, guardian.
Lynn Slaby, Prosecuting Attorney, and Patricia A. Cosgrove, Assistant Prosecuting Attorney; Kevin C. O'Neil and Jennifer A. Uebele, for Edwin Shaw Hospital.
Statement of the Case
On the night of October 25, 1992, Carla Myers, the minor incompetent ward herein, was involved in an automobile collision when the limousine she was riding in was struck in the passenger side by another automobile.
As a result of this collision, Carla suffered multiple injuries, including severe head injury. Records indicate that Carla lost consciousness during the collision, and arrived at Akron General Medical Center without regaining consciousness. Preliminary diagnosis indicated that Carla was in a comatose state due to the severe head injury.
Carla was transferred to Edwin Shaw Hospital for terminal care on November 24, 1992.
Carla had been receiving artificially administered nutrition and hydration from the beginning of her hospitalization. On November 30, 1992, after discussion with Dr. Michael Maggio, Carla's doctor, Timothy Myers, Carla's father, requested that the hydration and nutrition be removed. This was accomplished on December 2, 1992. On December 7, 1992, in response to objections raised by Robin Myers, Carla's mother, nutrition and hydration were again given to Carla through the use of a nasogastric tube.
A conflict had arisen between the natural parents of Carla Myers concerning continued artificially administered nutrition and hydration to Carla to sustain her existence. Both parents made independent application to this court for appointment as guardian for their daughter, Carla Myers.
On Wednesday, December 30, 1992, a hearing was held at which time this court, with agreement of Timothy Myers, Carla's father, Robin Myers, Carla's mother, and Penny Myers, Carla's stepmother, appointed Barbara Patterson, an attorney and former nurse with extensive experience in the field of emergency medical treatment, as Carla's legal guardian for the purpose of making recommendations to this court concerning all future medical decisions for Carla.
On January 15, 1993, attorney Patterson submitted a written report containing her recommendations. Subsequently, on January 20, 1993, at 10:00 a.m., a hearing was conducted to determine if this court should approve the report and recommendation of the guardian. In attendance at the hearing were Tim Myers, with counsel; Robin Myers, with counsel; and Penny Myers, with counsel. Also in attendance were Lynn Slaby, Summit County Prosecutor, and Edwin Shaw Hospital through legal counsel.
Testimony was taken in support of the guardian's report from Dr. Jon L. Weingart. Dr. Weingart, a neurologist, testified that he examined Carla Myers personally and reviewed her medical records. In response to Guardian's Exhibit 2-A, Weingart testified that a CAT scan of Carla's head showed a large subdural hematoma with an inordinate swelling of the left side of the brain which caused damage to the right side of the brain through restricted vessels, and that the injury had necessitated the removal of the left temporal portion of Carla's brain. Additionally, he stated that Carla was completely unresponsive to all levels of painful stimuli, and that all tests indicated no cortical function and only limited brain stem function in Carla. Dr. Weingart stated that, in his professional opinion and to a reasonable degree of medical certainty, Carla was in a persistent vegetative state. He stated, in response to questions from the court, that Carla's prognosis was very poor and that there was no chance for any meaningful recovery. He stated that Carla's future physical state would deteriorate, that the left arm would probably become hypertonic, and that the right arm and legs would probably remain in their present, flaccid state, with decreased muscle tone. He stated that Carla's bones would become more brittle, and atrophy would continue to occur. Carla would also sustain more skin breakdown and bed sores. Additionally, he stated that Carla's remaining brain tissue would deteriorate. In response to further questioning, Dr. Weingart stated that, due to Carla's youth and general good health prior to the accident, she could exist in this deteriorating state for years, and that the eventual cause of her death would most likely be infection brought on by her continued physical deterioration and increased immunity to antibiotics. Dr. Weingart also stated that his review and examinations of Carla showed no change in her condition from October 25 to date, and that, in his professional medical opinion, the present course of treatment, including nutrition and hydration, was only prolonging her death, not providing any meaningful comfort or care.
Counsel for Tim Myers, the natural father of Carla Myers, called Dr. Michael Maggio to testify. Dr. Maggio, a doctor of internal medicine, stated that he had observed and examined Carla on the average of three times per week since her admission. Dr. Maggio responded to the same questions concerning Carla's prognosis in the same general fashion as Dr. Weingart. He stated that, in his professional opinion and to a reasonable degree of medical certainty, Carla was in a persistent vegetative state. He stated that no cognitive function could reasonably be expected from Carla in the future. Dr. Maggio stated that sustaining Carla in her present state would require insertion of a gastrostomy tube for feeding through the stomach wall. He also stated that, if removal of hydration and nutrition was approved, Carla's death would occur in approximately two to three weeks, but that he would recommend continued pain medication and local moisture application during this process. He stated, also, that no indication of pain or discomfort was noted in Carla during the six days in December 1992, when hydration and nutrition had been removed. He stated that, in his professional opinion, these procedures should be stopped.
In addition to Dr. Weingart and Dr. Maggio, a second neurologist, Dr. G. Dean Timmons, examined Carla at the request of Carla's guardian. His report was introduced into evidence as Guardian's Exhibit No. 7. His examination and report confirmed the same prognosis and diagnosis as Dr. Weingart and Dr. Maggio. "It is certainly this examiner's impression that this child was in a chronic vegetative state * * *."
The court also took testimony from all other interested parties, specifically, Tim Myers, the natural father; Robin Myers, the natural mother; and Penny Myers, the former stepmother. In response to questions posed by the court, all named individuals stated that they were fully aware of the results if Carla was removed from hydration and nutrition, and that they were in support of removal of the procedures named. In addition, Tim Myers and Penny Myers testified that, on several occasions prior to the accident, Carla had stated that "she wouldn't want to go through life like that." These statements were purportedly made by Carla subsequent to separate incidents, specifically, after watching a movie concerning removal of life support systems, and again upon visiting a relative in the hospital who was on life support systems due to severe brain injury.
Upon inquiry of this court, Summit County Prosecutor Lynn Slaby stated that neither the state nor the county would find any criminal liability if removal of the hydration and nutrition was accomplished.
Findings of Fact and Conclusions of Law
Considering that there is no controverting evidence and that the evidence in support is straightforward and lacking in ambiguity, this court must find that there is clear and convincing evidence that the ward, Carla Myers, is in a persistent vegetative, or permanently unconscious, state, and that, with a reasonable degree of medical certainty, she will not recover from that condition.
The ward is not brain dead pursuant to R.C. 2108.30. She has not suffered an "irreversible cessation of all functions of the brain, including the brain stem." Carla Myers's brain stem is still functioning. Loss of cortical and retention of brain stem functions is an essential part of the diagnosis of persistent vegetative state. Position of the American Academy of Neurology, Aspects of the Persistent Vegetative State (Jan. 1989), Neurology 125.
It is the further finding of this court that the medical procedure or treatment of providing Carla with nutrition and hydration through a nasogastric tube is the principal reason for her remaining in a vegetative state or alive. Without that treatment, Carla will die within a short period of time.
The guardian, Barbara Patterson, has recommended to this court that the nasogastric tube be removed and Carla be allowed to die. The guardian maintains that the medical treatment in question serves no purpose other than to delay the dying process of the ward.
A decision to remove life supports in circumstances such as Carla's, which will result in death, is not a routine decision for a guardian, or a court under whose authority a guardian operates. It is a decision that should be approached with caution and reflection. It is a decision that must meet the standards and procedures embodied in the law, that is, the law pertaining to removal of life-sustaining treatment and to guardianships. Therefore, a review of that law and application to the case at hand are necessary before this court may approve of the guardian's treatment decision.
The law pertaining to removal of life-sustaining treatment from individuals in a persistent vegetative, or permanently unconscious, state is relatively undeveloped due to the newness and advancement of life-sustaining procedures. The 1976 New Jersey case of Karen Ann Quinlan ( In re Quinlan, 70 N.J. 10, 355 A.2d 647) was the first in a long series of case dealing with removal of life supports. Like Quinlan, removal of a respirator was the life-sustaining treatment in question in the majority of those early cases. John F. Kennedy Mem. Hosp., Inc. v. Bludworth (Fla. 1984), 452 So.2d 921; In re Storer (1981), 52 N.Y.2d 363, 438 N.Y.S.2d 266, 420 N.E.2d 64; Leach v. Akron Gen. Med. Ctr. (1980), 68 Ohio Misc. 1, 22 O.O.3d 49, 426 N.E.2d 809. See, also, Annotation, Judicial Power to Order Discontinuance of Life-Sustaining Treatment (1986), 48 A.L.R.4th 67. Based on that series of cases and statutory law, it is, possibly without exception, the rule in the United States that once an individual is diagnosed as being in a persistent vegetative state, that person may be removed from a respirator without any negative legal consequences. Quinlan, supra.
A second group of removal-of-life-support cases emerged during the early 1980s. The only fact distinguishing these cases from the Quinlan line of decisions is that the life support to be removed was nutrition and hydration. The unanimity for removal as exists in the Quinlan respirator cases does not appear to exist in this second group of cases. A small minority of courts would not sanction removal of nutrition and hydration. Cruzan v. Harman (Mo. 1988), 760 S.W.2d 408; Vogel v. Forman (1986), 134 Misc.2d 395, 512 N.Y.S.2d 622. However, a majority of jurisdictions have allowed removal of nutrition and hydration. In re Estate of Longeway (1989), 133 Ill.2d 33, 139 Ill.Dec. 780, 549 N.E.2d 292; In re Jobes (1987), 108 N.J. 394, 529 A.2d 434; In re Gardner (Me. 1987), 534 A.2d 947; Rasmussen v. Fleming (App. 1986), 154 Ariz. 200, 741 P.2d 667; Corbett v. D'Alessandro (Fla.App. 1986), 487 So.2d 368; In the Matter of Conroy (1985), 98 N.J. 321, 486 A.2d 1209; Barber v. Superior Court (1983), 147 Cal.App.3d 1006, 195 Cal.Rptr. 484. A possible reason for the variance is that the removal of a respirator is more acceptable and conjures up fewer images of suffering, while removal of nutrition and hydration implies starvation and all the extreme negative images associated with that debilitating process in a normal and healthy body. Those images are based on a misconception and do not reflect an accurate understanding of the condition of a person in a persistent vegetative state, his ability to feel pain, or the process of dying by dehydration. Cranford, Neurologic Syndromes and Prolonged Survival: When Can Artificial Nutrition and Hydration Be Forgone? (1991), 19 Law, Medicine Health Care 51; Conroy, supra. Nor does it properly weigh the possible years of torturous deterioration and body deformation, and eventual death, caused by allowing someone to remain in a persistent vegetative state as opposed to a brief and relatively painless death caused by removal of nutrition and hydration. When a more accurate understanding is developed, even in the minority jurisdictions, it appears that, either by statute or new case decisions, those jurisdictions have reversed, or are reversing, their positions on removing nutrition and hydration from those in persistent vegetative states. In re Chetta (May 1, 1987), Sup.Ct. Nassau Cty., N.Y., No. 1986/87, unreported, cited in Delio v. Westchester Cty. Med. Ctr. (1987), 129 A.D.2d 1, 516 N.Y.S.2d 677, impliedly overruling Vogel, supra. See, also, Meisel, The Right to Die, Nutrition and Hydration (1989) 124-125, Section 5.10.
The United States Supreme Court, in Cruzan v. Missouri Dept. of Health (1990), 497 U.S. 261, 110 S.Ct. 2841, 111 L.Ed.2d 224, addressed the constitutional issues of removal of nutrition and hydration. While the court found that a state could regulate the procedures in making the decision to remove, it found no legal or constitutional prohibition against removal. It is clear from the foregoing that removal of nutrition and hydration from a person in a persistent vegetative state is rapidly becoming a legally accepted practice in the United States.
Ohio's laws on removal are in line with national decisions. Leach, supra, a 1980 opinion of this court, was the first precedent for removal of life support or life-sustaining treatment. Leach dealt with the removal of a respirator. The first precedent in Ohio dealing with removal of nutrition and hydration was Couture v. Couture (1989), 48 Ohio App.3d 208, 549 N.E.2d 571. In Couture, the Court of Appeals for Montgomery County refused to uphold a trial court decision to allow removal of nutrition and hydration. The Couture court based its decision on legislative intent to set public policy. The court interpreted a durable power of attorney health care statute, R.C. Chapter 1337, that did not allow for removal of nutrition and hydration as setting public policy and not allowing removal under guardianship law. The Couture decision was questionable precedent when decided. Ohio's Modified Uniform Rights of the Terminally Ill Act, R.C. Chapter 2133, and an amended R.C. Chapter 1337 were passed by the legislature after, and in response to, the Couture decision. With its enactment, the legislative public policy of Ohio is to allow removal of nutrition and hydration in situations involving a persistent vegetative state or permanent unconsciousness. Since the public policy basis of Couture is unfounded, there can be no question that it is now unacceptable and unusable precedent.
That position was taken by the Franklin County Probate Court in In re Guardianship of Crum (1991), 61 Ohio Misc.2d 596, 580 N.E.2d 876. The court in Crum, in a case similar to this case, that is, removal of nutrition and hydration from a minor ward, found Couture not to be persuasive, and based on Leach, the Ohio Revised Code, and guardianship law, permitted nutrition and hydration to be removed. The facts distinguishing Crum from the case at bar are that the parents were in agreement for removal from the inception of the petition for guardianship, the minor in Crum had been in a vegetative state for a considerably longer period (five and one-half years as opposed to three months in this case), and Crum was decided prior to the effective date of R.C. Chapter 2133, Ohio's Modified Uniform Rights of the Terminally Ill Act. The Crum case was the last case in Ohio to deal with the question of removing nutrition and hydration. See, also, In re Swan (Me. 1990), 569 A.2d 1202.
From the foregoing review of law, there is a substantial precedent for recognizing, in either the case of a minor or adult individual with a medically determined diagnosis of a persistent vegetative or permanently unconscious state, that nutrition and hydration are medical treatment, and that removal is not a violation of either civil or criminal law. While that principle is accepted precedent, the procedural law, that is, when, who, and what standards are to be used to make decisions for removal, is not as clear.
Two problems that exist specifically in Ohio which have an impact on the procedure for the case at bar are, first, the effect of R.C. Chapter 2133, that is, whether the procedures of that chapter must be followed in this case, and, second, which test or decisional process should be used, i.e., the substitute judgment test or the best interest test.
R.C. Chapter 2133 is a very lengthy Act that sets out the guidelines for removal of life supports, including nutrition and hydration, for those adults who have an advance directive and for those who do not. In the legislature's desire to ensure appropriate removal of life supports, a complicated and, at times, burdensome system of procedures is imposed on the decision to remove, especially for non-declarants. Greve, S.B. 1: A Hospital Attorney's Perspective (May/June 1992), Probate Law Journal of Ohio 93-97; Bernal, The Ohio Advance Directive Law: Analysis (Spring 1992), Bioethics Network of Ohio Newsletter 4, 6.
One of the most difficult provisions of R.C. Chapter 2133 is R.C. 2133.09(B)(2). Under that section, prior to the removal of nutrition and hydration from a non-declarant, twelve months must elapse from the inception of a permanently unconscious state. Applying that provision to this case, an additional nine months would have to be endured by Carla and her family before life supports could be removed. Since Carla's diagnosis and non-recovery are unquestioned, an additional nine-month wait serves no purpose. Carla's diagnosis will not change in nine months. Such a requirement, under the circumstances of this case, has no rationale to support it, and appears to be an arbitrary time requirement. The requirement is unreasonable. R.C. 1.47(C) states that when interpreting legislation, it must be assumed that "[a] just and reasonable result is intended." A construction of R.C. Chapter 2133, directly or by implication or as public policy, that finds its provisions are applicable to all cases of removal of life supports, including the case at bar, is neither reasonable nor within the plain meaning of the statute.
Therefore, this court finds that R.C. 2133.09(B)(2) or the other provisions of R.C. Chapter 2133 are not binding, for the following reasons:
1. Application of specific sections such as R.C. 2133.09(B)(2), in all cases, would bring an unreasonable result, and would be contrary to rules of legislation construction.
2. The statute is applicable to adults. Carla Myers is a minor and, therefore, is excluded from its requirements.
3. The statute is non-binding in that there are neither sanctions nor penalties, nor a mandate that its provisions must be followed. The only sanction provided is under R.C. 2133.11 where it is stated that, if its provisions are not followed, the specific statutory immunity or defense given under the statute cannot be raised in civil or criminal litigation.
Ohio's Modified Uniform Rights of the Terminally Ill Act was devised as a "carrot" approach to legislation, as opposed to mandatory and binding law. While R.C. Chapter 2133 may provide some guidance, this court is not bound, nor is its guardian bound, to follow the provisions of the statutes.
As previously indicated, the second procedural question deals with the standard, test or decisional process the guardian and this court must use in making decisions for the ward, Carla Myers. Carla Myers is a ward of this court, and this court's power or jurisdiction to hear and dispose of the removal question is based upon the probate court's exclusive guardianship jurisdiction under R.C. 2101.24(A)(1)(r). R.C. Chapter 2111 specifically delineates the court's and guardian's powers. R.C. 2111.13(C) gives the guardian power to make medical decisions for a ward unless the probate court "provides otherwise." R.C. 2111.50(B) gives this court the power to make any decisions the ward could make for himself, and Paragraph (C) further gives the court, as superior guardian, the right to remove from the guardian any decisional powers granted by law.
Lastly, R.C. 2111.50(F) gives the probate court full parens patriae powers: "When considering any question related, and issuing orders for, medical or surgical care or treatment of incompetents or minors subject to guardianship, the probate court has full parens patriae powers unless otherwise provided by a section of the Revised Code."
From the foregoing, there can be no mistake that this court has the full power to make or approve medical treatment decisions for a ward, including life and death issues of removing life supports or life-sustaining treatment. What are the constraints on that power? The court's power is not arbitrary. One of the most important is the limiting test or decisional process used to arrive at a decision for the ward.
However, there is conflicting authority as to which of two methods or tests should be used when removing life-sustaining treatment. Guardianship law has traditionally recognized two methods, the best interest test, that is, what is in the best interest or welfare of the ward, and "substitute judgment." The best interest test is an objective test. "Substitute judgment" involves attempting to make the same decision as the ward would have made, if competent, through the use of evidence, mainly statements of the ward prior to incompetency, to determine the ward's state of mind or wishes. 53 Ohio Jurisprudence 3d (1984) 90, Guardian and Ward, Section 87. Both have been used in Ohio for removal of life supports.
See In re Drabick (1988), 200 Cal.App.3d 185, 245 Cal.Rptr. 840; and Conroy, supra, 486 A.2d at 1231-1233. Both cases apply the best interest test in removal of life supports.
Substitute judgment is used in Leach; Ohio's Durable Health Care Statute, R.C. Chapter 1337; and in Ohio's Modified Uniform Rights of the Terminally Ill Act, R.C. Chapter 2133. The best interest test is used in Crum; Ohio's Durable Health Care Statute, R.C. Chapter 1337, which also uses substitute judgment; and R.C. 2111.50(C), covering decisions made for a ward under guardianship. In addition, Ohio's juvenile courts, in making life-threatening medical decisions for minors, use the best interest test. Juv.R. 13(A) and (B). See, also, In re Clark (C.P. 1962), 21 O.O.2d 86, 185 N.E.2d 128.
This court adopts the best interest test. The court's rationale for abandoning its use of the substitute judgment test, as it did in Leach, is:
1. The reason for the use of substitute judgment is no longer valid. This court did use substitute judgment as the basis of its decision in Leach. Like Leach, a number of removal cases have used substitute judgment, in part because of the constitutional right-to-privacy basis of the court's findings, and the rationale of substitute judgment lends itself to exercising a constitutional right that is exclusive to the individual. The failure of the United States Supreme Court in Cruzan to find the constitutional right to privacy as the basis for removal of life supports removed, or at least questioned, the constitutional-rights concept as a basis for removal and, thus, the need to use a substitute judgment test.
Current life support cases base their findings on the common-law right of an individual to decide medical treatment or statutory provisions of state law, as opposed to constitutional law. See Conroy, Longeway, and In re Storer, supra.
While it is clear from Cruzan that the right of privacy is not applicable to removal cases under the federal Constitution, it has not been determined as to whether such a right exists under the Ohio Constitution. The Right to Refuse Medical Treatment Under the State Constitutions (1988), 5 Cooley L.Rev. 313; State v. McAfee (1989), 259 Ga. 579, 580, 385 S.E.2d 651, 652; Experimenting with the "Right to Die" in the Laboratory of the States (1991), 25 Ga.L.Rev. 1253.
2. The best interest test has been the historic and traditional guardianship standard ( Long v. Mulford, 17 Ohio St. 484; Clark, supra), and the traditional parens patriae test in juvenile medical treatment cases in Ohio.
3. The substitute judgment test is difficult to apply when the ward has always been incompetent, there is no evidence of the ward's desires, or the ward's desires are unreasonable. See Meisel, supra, Standards for Surrogate Decision-Making, Section 9.14, Application to Never Competent Patients, at 275, 428; and Superintendent of Belchertown State School v. Saikewicz (1977), 373 Mass. 728, 370 N.E.2d 417. This difficulty of application leads to complicated and meaningless variations of the substitute judgment test such as are provided under R.C. Chapter 2133, specifically R.C. 2133.08(D)(3)'s character and life-style test. The best interest test can be applied to all removal cases.
4. Last, and possibly most important, R.C. 2111.50(C), which was enacted after Leach, mandates the use of the best interest test in all medical decisions for a ward, including life-sustaining treatment cases.
This court, having found that best interest is the test to be applied, must now apply that test to the evidence presented in this case.
To apply the best interest test, this court must weigh and analyze the treatment options, their benefits and non-benefits, and arguments in favor of, and against, either removal, as recommended by the guardian, or continuation of life-sustaining treatment, nutrition and hydration. Due to the medical profession's understandable inability to replace Carla's damaged brain, those are, unfortunately, the only possible medical treatment choices.
The arguments that may be made against removal are that Carla's life will end, and that removal would require starvation or dehydration, which is inhumane treatment.
The arguments for, and benefits of, removal are:
1. Removal of life-sustaining treatment will end Carla's vegetative state and allow her to die.
The diagnosis of persistent vegetative state is one that is abhorrent. It means that all higher cognitive brain functions or processes of thought and communication are gone. It means that only those body functions associated with the brain stem, that is, basic reflexes, remain. It is not a coma. It is not a static condition. It is a continuing process in which the body becomes deformed and degenerates. The remainder of the upper brain becomes soft, the limbs become rigid, the bones become brittle and break, and the skin breaks down causing continuing bedsores. The unceasing demand of the primeval brain stem reflexes are met not by conscious choice or desire of the mind, but by the minds of others who, by the use of modern medical technology, keep answering the mindless drive of the body's automatic reflexes. What remains of the body waits until an infection or other cause defeats the demand of the brain stem, and death occurs. "Vegetative state" is truly an appropriate and descriptive term for the condition.
To require someone to remain in that 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, when there is no hope for recovery, is not only against the best interest, but is inhumane.
2. There is some evidence that Carla would not wish to be maintained on life supports. While Carla is considered legally incompetent as a minor, her age and apparent maturity permit this court to give some weight to her prior statements on removal. Several witnesses, her father and stepmother, at hearing, indicated conversations in which Carla, while discussing a television program dealing with life supports and the use of life-sustaining treatment for close relatives, indicated a displeasure and negative feeling towards their use.
3. Carla's parents, both mother and father, and her stepmother, agree that Carla should be removed. While all have surrendered any right to make the decision themselves by agreeing to an independent guardian, their judgment must be considered. They are the ones who know Carla best, who have suffered with her, who have consulted with her doctors, who have watched her deterioration, and who have the natural instinct of parents for her best interest. All agree that Carla would not want to continue on life supports and, in their own judgment, separate from hers, feel she should be allowed to die.
4. The guardian has recommended removal. The guardian was appointed by this court to make recommendation for medical treatment. She was appointed because of her expertise and experience as an attorney, as a nurse, and in the field of emergency medicine. She is certainly qualified to evaluate the necessity for continuing medical treatment. She has evaluated Carla's medical condition and interviewed her parents, with the result that her recommendation is for removal. Considering her background and abilities, this court must give deference and weight to her conclusions.
When the benefits of treatment and arguments for and against the two possible courses of treatment are weighed and analyzed, only one conclusion can be drawn. The removal of life-sustaining treatment is in the best interest of the ward.
The argument that death will result when the medical technology is removed has little merit or weight when considered against the alternative of continuance in an abhorrent persistent vegetative state.
The argument that removal of nutrition and hydration is inhumane is also without merit. If this court approves the removal of nutrition and hydration, the process of death is estimated at taking two to three weeks. The discomfort will be minimal and it is questionable whether any pain will be experienced by Carla. Her body will dehydrate, but, with proper comfort care, the effects can be minimized. It is unfortunate that Carla, or what remains of Carla's body and mind, must experience death in this fashion. Certainly, this court, the guardian, and her parents would wish otherwise. Nonetheless, a three-week dying process, under those conditions, does not outweigh the years of inhuman and torturous existence in a vegetative state with a certain dying process of unknown duration at its end.
The benefits and arguments are overwhelmingly in favor of removal. It is time to remove the invasive and futile medical technology. It is time to let Carla die.
So ordered.