Date: 11/13/2008
By ARIEL DAVID
Associated Press Writer
ROME (AP) _ Italy’s highest court ruled Thursday in favor of a man’s request to disconnect his daughter’s feeding tube and allow her to die after 16 years in a vegetative state.
Courts, politicians and the Vatican have weighed in on the fate of Eluana Englaro, who fell into a vegetative state following a car accident in 1992, when she was 20.
The Court of Cassation said it had rejected an appeal by prosecutors against a lower court ruling in July in favor of Beppino Englaro. The father had said his daughter visited a friend in a coma shortly before her accident and expressed the will to refuse treatment in the same situation.
Italy does not allow euthanasia using methods such as fatal doses of drugs. Patients have a right to refuse treatment, but no law allows them to have a living will in case they become unconscious.
Beppino Englaro had fought a decade-long court battle to disconnect his daughter’s feeding tube.
The decision “confirms that we live under the rule of law,” he was quoted as saying by the ANSA news agency.
Catholic and anti-euthanasia groups had protested the ruling by the lower court in Milan in front of the city’s Duomo.
Conservative politicians reacted angrily to Thursday’s ruling, saying that the courts had overstepped their bounds. Enrico La Loggia, a lawmaker in Permier Silvio Berlusconi’s party, likened the decision to a “death sentence.”
The Vatican’s top health official, Cardinal Javier Lozano Barragan, was quoted by the Apcom agency as saying that disconnecting a feeding tube amounts to “killing a person.”
Eluana Englaro has been kept in a hospital and fed artificially in the northern city of Lecco. Doctors have called her condition irreversible.
Her case has evoked comparisons to that of Terry Schiavo, the American woman at the center of a right-to-die debate until her death in 2005. Schiavo was diagnosed as being in a persistent vegetative state after her heart stopped in 1990.
Schiavo’s husband, who wanted her feeding tube removed against her parents’ wishes, prevailed in a polarizing battle in the United States that reached Congress, President Bush and the Supreme Court.
Copyright 2008 The Associated Press.
CA surgeon to stand trial in organ donation case
Date: 11/2/2008 5:28 PM
By GREG RISLING
Associated Press Writer
LOS ANGELES (AP) — Ruben Navarro loved horror movies. He watched the “Nightmare on Elm Street” and “Friday the 13th” series with his mother, Rosa, and liked to visit Knott’s Berry Farm when it was transformed every October to “Knott’s Scary Farm.”
Since his death 2½ years ago, Rosa Navarro says she has been living a real-life nightmare without her only child. Ruben Navarro, who had multiple medical problems, died in a San Luis Obispo hospital following a heart attack, and then was taken off a ventilator and prepared for organ donation.
The circumstances surrounding that death will be center stage as opening statements are scheduled to begin Monday in the trial of Dr. Hootan Roozrokh, a San Francisco transplant surgeon who is accused of hastening Navarro’s death so his organs could be harvested.
“He was my world,” Rosa Navarro told The Associated Press on Thursday. “It’s been very, very hard for me. He didn’t die with respect and integrity.”
Roozrokh, 34, faces one count of felony dependent adult abuse. Two other felony counts were dismissed by San Luis Obispo County Superior Court Judge Martin J. Tangeman in March.
If convicted, he could face four years in prison.
Defense lawyer M. Gerald Schwartzbach has said Roozrokh did nothing wrong, saying he did not endanger Navarro’s health or life. Schwartzbach did not respond to an e-mail message for further comment.
The case against Roozrokh is believed to be the first such criminal action brought against a transplant doctor in the U.S.
Navarro, 25, died in February 2006 at Sierra Vista Regional Medical Center in San Luis Obispo. He had a debilitating neurological disease and was in a coma after suffering the heart attack.
His kidneys and liver were never harvested because he didn’t die within a time frame when those organs would have been considered viable.
The hospital has said it had Rosa Navarro’s permission to remove her son from life support, but she disputes that.
Statements to police by nurses present in the operating room indicated Roozrokh improperly ordered excessive doses of morphine and a sedative for Navarro. State law says transplant surgeons must wait until a potential donor is dead before participating in procedures.
But Tangeman said in his ruling dismissing the other two charges that there was no evidence Roozrokh administered or ordered a combination of morphine and the sedative. The judge also noted that doctors and nurses present when Navarro died gave conflicting accounts of what happened.
Roozrokh, a surgeon at Kaiser Permanente’s now-closed kidney transplant program, was working at the time on behalf of a group that procures and distributes organs.
The case is being watched closely by physicians and others in the medical field, said Arthur Caplan, a professor of medical ethics at the University of Pennsylvania who worries that a conviction could hurt prospects for expanding organ donation.
“It’s a trust issue,” Caplan said. “It’s such a moral taboo to give the appearance of hastening a death through organ donation. Were he to be found guilty, it would be a thunderclap heard through the organ procurement field.”
Navarro, who weighed about 80 pounds, was born with a neurological disorder known as adrenoleukodystrophy and also had cerebral palsy. He lived in a home for mentally and physically challenged adults in the year before his death.
The hospital and its parent company settled a lawsuit last year filed by Rosa Navarro for $250,000. Under terms of the settlement, the hospital acknowledged no wrongdoing.
Copyright 2008 The Associated Press.
By GREG RISLING
Associated Press Writer
LOS ANGELES (AP) — Ruben Navarro loved horror movies. He watched the “Nightmare on Elm Street” and “Friday the 13th” series with his mother, Rosa, and liked to visit Knott’s Berry Farm when it was transformed every October to “Knott’s Scary Farm.”
Since his death 2½ years ago, Rosa Navarro says she has been living a real-life nightmare without her only child. Ruben Navarro, who had multiple medical problems, died in a San Luis Obispo hospital following a heart attack, and then was taken off a ventilator and prepared for organ donation.
The circumstances surrounding that death will be center stage as opening statements are scheduled to begin Monday in the trial of Dr. Hootan Roozrokh, a San Francisco transplant surgeon who is accused of hastening Navarro’s death so his organs could be harvested.
“He was my world,” Rosa Navarro told The Associated Press on Thursday. “It’s been very, very hard for me. He didn’t die with respect and integrity.”
Roozrokh, 34, faces one count of felony dependent adult abuse. Two other felony counts were dismissed by San Luis Obispo County Superior Court Judge Martin J. Tangeman in March.
If convicted, he could face four years in prison.
Defense lawyer M. Gerald Schwartzbach has said Roozrokh did nothing wrong, saying he did not endanger Navarro’s health or life. Schwartzbach did not respond to an e-mail message for further comment.
The case against Roozrokh is believed to be the first such criminal action brought against a transplant doctor in the U.S.
Navarro, 25, died in February 2006 at Sierra Vista Regional Medical Center in San Luis Obispo. He had a debilitating neurological disease and was in a coma after suffering the heart attack.
His kidneys and liver were never harvested because he didn’t die within a time frame when those organs would have been considered viable.
The hospital has said it had Rosa Navarro’s permission to remove her son from life support, but she disputes that.
Statements to police by nurses present in the operating room indicated Roozrokh improperly ordered excessive doses of morphine and a sedative for Navarro. State law says transplant surgeons must wait until a potential donor is dead before participating in procedures.
But Tangeman said in his ruling dismissing the other two charges that there was no evidence Roozrokh administered or ordered a combination of morphine and the sedative. The judge also noted that doctors and nurses present when Navarro died gave conflicting accounts of what happened.
Roozrokh, a surgeon at Kaiser Permanente’s now-closed kidney transplant program, was working at the time on behalf of a group that procures and distributes organs.
The case is being watched closely by physicians and others in the medical field, said Arthur Caplan, a professor of medical ethics at the University of Pennsylvania who worries that a conviction could hurt prospects for expanding organ donation.
“It’s a trust issue,” Caplan said. “It’s such a moral taboo to give the appearance of hastening a death through organ donation. Were he to be found guilty, it would be a thunderclap heard through the organ procurement field.”
Navarro, who weighed about 80 pounds, was born with a neurological disorder known as adrenoleukodystrophy and also had cerebral palsy. He lived in a home for mentally and physically challenged adults in the year before his death.
The hospital and its parent company settled a lawsuit last year filed by Rosa Navarro for $250,000. Under terms of the settlement, the hospital acknowledged no wrongdoing.
Copyright 2008 The Associated Press.
Brain Injury and Locked-In Syndrome
In yesterday’s blog, I talked about the exception to my skepticism about miracle recoveries, years post a coma causing event. The exception is in the cases of “locked in syndrome”. The National Institute of Health contains this definition of Locked-Iin Syndrome:
What is Locked-In Syndrome?_Locked-in syndrome is a rare neurological disorder characterized by complete paralysis of voluntary muscles in all parts of the body except for those that control eye movement. It may result from traumatic brain injury, diseases of the circulatory system, diseases that destroy the myelin sheath surrounding nerve cells, or medication overdose. Individuals with locked-in syndrome are conscious and can think and reason, but are unable to speak or move. The disorder leaves individuals completely mute and paralyzed. Communication may be possible with blinking eye movements
Is there any treatment?
There is no cure for locked-in syndrome, nor is there a standard course of treatment. A therapy called functional neuromuscular stimulation, which uses electrodes to stimulate muscle reflexes, may help activate some paralyzed muscles. Several devices to help communication are available. Other treatment is symptomatic and supportive.
What is the prognosis?
While in rare cases some patients may regain certain functions, the chances for motor recovery are very limited.
What research is being done?
The NINDS supports research on neurological disorders that can cause locked-in syndrome. The goals of this research are to find ways to prevent, treat, and cure these disorders.
See http://www.ninds.nih.gov/disorders/lockedinsyndrome/lockedinsyndrome.htm
Why do I feel that locked-in syndrome is an exception to the no hope scenario in long term coma recovery? Because these are cases where the person was fully aware, despite the inability to communicate. What is so tragic when such cases are discovered after the fact, is that the person was there, so to speak, the whole time, just no one was listening. If a PET scan or fMRI had been done, it would have been clear from the beginning that such person’s brain was functioning. Instead, like the character in the anti-war story that galvanized my youth, Johnny Got His Gun, the mind of the survivor was totally isolated.
Another interesting example of a locked in type syndrome is the House episode where it begins with the seemingly persistent vegetative individual driving his wheel chair into a swimming pool. http://en.wikipedia.org/wiki/Meaning_(House_episode)
See also: http://en.wikipedia.org/wiki/Locked-In_syndrome
What is Locked-In Syndrome?_Locked-in syndrome is a rare neurological disorder characterized by complete paralysis of voluntary muscles in all parts of the body except for those that control eye movement. It may result from traumatic brain injury, diseases of the circulatory system, diseases that destroy the myelin sheath surrounding nerve cells, or medication overdose. Individuals with locked-in syndrome are conscious and can think and reason, but are unable to speak or move. The disorder leaves individuals completely mute and paralyzed. Communication may be possible with blinking eye movements
Is there any treatment?
There is no cure for locked-in syndrome, nor is there a standard course of treatment. A therapy called functional neuromuscular stimulation, which uses electrodes to stimulate muscle reflexes, may help activate some paralyzed muscles. Several devices to help communication are available. Other treatment is symptomatic and supportive.
What is the prognosis?
While in rare cases some patients may regain certain functions, the chances for motor recovery are very limited.
What research is being done?
The NINDS supports research on neurological disorders that can cause locked-in syndrome. The goals of this research are to find ways to prevent, treat, and cure these disorders.
See http://www.ninds.nih.gov/disorders/lockedinsyndrome/lockedinsyndrome.htm
Why do I feel that locked-in syndrome is an exception to the no hope scenario in long term coma recovery? Because these are cases where the person was fully aware, despite the inability to communicate. What is so tragic when such cases are discovered after the fact, is that the person was there, so to speak, the whole time, just no one was listening. If a PET scan or fMRI had been done, it would have been clear from the beginning that such person’s brain was functioning. Instead, like the character in the anti-war story that galvanized my youth, Johnny Got His Gun, the mind of the survivor was totally isolated.
Another interesting example of a locked in type syndrome is the House episode where it begins with the seemingly persistent vegetative individual driving his wheel chair into a swimming pool. http://en.wikipedia.org/wiki/Meaning_(House_episode)
See also: http://en.wikipedia.org/wiki/Locked-In_syndrome
Coma Help and Prognosis
My last blog contained an email from one of the charter contributors to http://waiting.com waiting.com was created to provide help for those who were waiting for someone to awake from a coma. With the creation of that page, the phone calls began to come into our office asking perhaps the most terrible question a person can ever ask themselves, at what point do we decide to withdraw life support.
I am not a doctor but a lawyer who spends his life representing people who have survived a brain injury. I have no medical training to qualify me to second guess the advice of a doctor who has properly considered this horrible question, in light of the full diagnostic criteria as it has evolved in current medical science. I wish that physicians would give a fully informed answer to this question. At no time, do family members need a more thoughtful, fully informed discussion. Sadly, the answer in 90% of coma cases is: We Will Just Have to Wait and See.
That is the easy answer of course. It may even be the technically correct answer. After all, there is no predicting when a person will emerge from a coma. But, current medical research does tell us considerably more about coma prognosis than that. The literature contains clear diagnositic criteria, which will help to shed some light on prognosis. Of course, no family really wants to hear the bad news, so saying nothing specific, may be easier for the doctor. But is that the right thing to do?
I believe that hope is important, that hope is essential, but there comes a time, when a family does need to start to deal with the horrible realities of what may lie ahead. What has always frustrated me is why doctors don’t offer the functional imaging option. For more than a decade, researchers have been calling for PET scans or SPECT scans, to help identify whether there is any meaningful brain activity, inside the comatose brain. What is functional imaging? It is a scan that can tell us how much the brain is actually working.
The PET scan and SPECT scan use a radioactively tagged glucose (sugar) molecule. If the glucose is being used to any significant degree, the brain must be working. In the 10 years since the first calls for routine functional imaging in coma cases, the functional imaging technology has grown exponentially. Not only are PET scans now more available and have radically improved quality and resolution, but fMRI has now readily available, at almost any major imaging center. fMRI is actually uses a conventional MRI scanner, but can measure the extent of brain activity, not by the sugar used, but by the oxygenation changes within the brain. A working brain must not only use glucose, it must also use oxygen.
Without any meaningful activity, there is little likelihood of emergence, and even if there is emergence, little chance of a satisfactory recovery. But if there is activity, then more radical measures should be undertaken to stimulate the brain, and more patience is warranted. I have instructed my medical power of attorney to insist on a functional imaging test if I am ever in that position.
We all hear about the news reports of the miracle emergence after 7 years in a coma. For a discussion of what it means to emerge from a coma, click here. I will always remain skeptical of such late emergency stories, unless those people were not truly comatose, but “locked in.” (I will discuss “locked in syndrome” later this week, but essentially that is a state where a person is fully awake, but there neurological damage leaves them incapable of overt communication. Locked In Syndrome is something that could absolutely be determined by a PET or other functional imaging scan, is someone bothered to order the test. ) But where a person is truly comatose, I believe that the longer the coma persists, the less the likelihood of any emergence, and if there is an emergence, little or no chance of a satisfactory recovery. Most of those who have traumatic injuries and do have a satisfactory recovery, have emerged within one month of their injury. Coma’s that persist longer than two months, leave a very marginal chance of a satisfactory recovery.
If the hours and weeks of waiting have gone on to long, it is time to demand better answers and active diagnostic interventions to give some solid answers.
I am not a doctor but a lawyer who spends his life representing people who have survived a brain injury. I have no medical training to qualify me to second guess the advice of a doctor who has properly considered this horrible question, in light of the full diagnostic criteria as it has evolved in current medical science. I wish that physicians would give a fully informed answer to this question. At no time, do family members need a more thoughtful, fully informed discussion. Sadly, the answer in 90% of coma cases is: We Will Just Have to Wait and See.
That is the easy answer of course. It may even be the technically correct answer. After all, there is no predicting when a person will emerge from a coma. But, current medical research does tell us considerably more about coma prognosis than that. The literature contains clear diagnositic criteria, which will help to shed some light on prognosis. Of course, no family really wants to hear the bad news, so saying nothing specific, may be easier for the doctor. But is that the right thing to do?
I believe that hope is important, that hope is essential, but there comes a time, when a family does need to start to deal with the horrible realities of what may lie ahead. What has always frustrated me is why doctors don’t offer the functional imaging option. For more than a decade, researchers have been calling for PET scans or SPECT scans, to help identify whether there is any meaningful brain activity, inside the comatose brain. What is functional imaging? It is a scan that can tell us how much the brain is actually working.
The PET scan and SPECT scan use a radioactively tagged glucose (sugar) molecule. If the glucose is being used to any significant degree, the brain must be working. In the 10 years since the first calls for routine functional imaging in coma cases, the functional imaging technology has grown exponentially. Not only are PET scans now more available and have radically improved quality and resolution, but fMRI has now readily available, at almost any major imaging center. fMRI is actually uses a conventional MRI scanner, but can measure the extent of brain activity, not by the sugar used, but by the oxygenation changes within the brain. A working brain must not only use glucose, it must also use oxygen.
Without any meaningful activity, there is little likelihood of emergence, and even if there is emergence, little chance of a satisfactory recovery. But if there is activity, then more radical measures should be undertaken to stimulate the brain, and more patience is warranted. I have instructed my medical power of attorney to insist on a functional imaging test if I am ever in that position.
We all hear about the news reports of the miracle emergence after 7 years in a coma. For a discussion of what it means to emerge from a coma, click here. I will always remain skeptical of such late emergency stories, unless those people were not truly comatose, but “locked in.” (I will discuss “locked in syndrome” later this week, but essentially that is a state where a person is fully awake, but there neurological damage leaves them incapable of overt communication. Locked In Syndrome is something that could absolutely be determined by a PET or other functional imaging scan, is someone bothered to order the test. ) But where a person is truly comatose, I believe that the longer the coma persists, the less the likelihood of any emergence, and if there is an emergence, little or no chance of a satisfactory recovery. Most of those who have traumatic injuries and do have a satisfactory recovery, have emerged within one month of their injury. Coma’s that persist longer than two months, leave a very marginal chance of a satisfactory recovery.
If the hours and weeks of waiting have gone on to long, it is time to demand better answers and active diagnostic interventions to give some solid answers.