Thrown Back

Terri's "Exit Protocol" Discovered In Hospice Documents

Cheryl Ford, RN, a nurse from Tampa who has been very active in the efforts to save Terri's life, recently undertook, on behalf of the Schindlers, a review of medical records from when Terri was first admitted to Woodside Hospice. Woodside Hospice is run by Hospice of the Florida Suncoast. It is of interest to note that Michael Schiavo's attorney, George Felos, was a member of the Board of Directors of Hospice of the Florida Suncoast until the Terri Schiavo case began to attract widespread public attention a few years ago.

In her research, Ms. Ford found a document titled "Exit Protocol" in Terri's file. The document is on Hospice of the Florida Suncoast "Patient Care Notes" stationery, and is dated April 19, 2001. This document lays out, in clinical detail, the procedures to be followed in bringing about Terri's death by starvation and dehydration.

I reproduce here, in entirety and verbatim, the contents of this document. It was sent to me in the form of an Adobe PDF document. It is not yet available on the web, but as soon as it becomes available I will post a link to it.

The text of the document is in black type, my comments and explanations will be presented in red type


Exit Protocolxxxxxxxxxxxx00038

Patient Care Notesxxxxxxxxxxxxx The Hospice
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxOf The Florida Suncoast

Date

4/19/01xxxxxxxxxxxxxClinical Pharmacy
xxxxxxxxxxxxxxRe: Medication review and symptom management


Pt. is a 37 yo woman in a vegetative state with no apparent signs of distress. Enteral tube-feeding to be discontinued on 4/20/01.

Current Medications:

1. antacid suspension 1-2 tablespoons prn [prn = "as needed"]

2. Naproxen suspension 375 mg Q8* prn menstrual cramps. [Q8* prn = "every 8 hours as needed". Naproxen is a pain-relieving and anti-inflamatory drug. ]

3. Vitamin liquid daily.

Upon discontinuation of enteral feeding the following signs/symptoms may or may not occur. The following is a brief list of symptoms for which to monitor and recommended interventions.

1. d/c ["discontinue"] antacid. d/c Naproxen suspension.

2. d/c Vitamin liquid

3. Monitor symptoms of pain/discomfort. If noted, medicate with Naproxen rectal suppository 375 mg Q8* prn.

Wait a minute! George Felos, Michael Schiavo, and all the other advocates of feeding-tube removal have been saying repeatedly that dying by denial of nutrition & hydration is "peaceful" and "painless". They've both said so in interviews and press conferences, such as on Larry King Live. So if dying by denial of nutrition and hydration is, as Michael said, "painless and probably the most natural way to die", then why is medication needed for pain and discomfort?

4. Signs of compromised skin integrity — continue vigilant skin care, provide moistener to lips, consult wound-care specialist if needed.

As the body dehydrates, the skin loses its tone and dries out. Left untreated, this will lead to cracking and bleeding. The lips are even more sensitive in this respect. "Vigilant skin care" is the liberal use of lotions and moisteners to mask these symptoms. The lips must be continually swabbed with special moisteners, and have lip balm applied to them. In the last stages, though, in spite of such measures, skin breakdown often occurs. Because of the body's debilitated state, normal healing mechanisms do not function. Hence the need to consult wound-care specialists to deal with ulcers and open sores.

5. Signs of dehydration
(A) dry lips, mouth. Swab saliva substitute inside mouth prn. (see next page)

After a few days without water, the body stops producing saliva, necessitating the use of a "saliva substitute" to avoid ulceration in the mouth, and a characteristic foul odor on the patient's breath. The cessation of salivation also leads to other complications which appear in the "pulmonary" section.



xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx00039

Patient Care Notesxxxxxxxxxxxxx The Hospice
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxOf The Florida Suncoast

Date

4/19/01xxxxxxxxxClinical Pharmacy Note — continued

xxxxxxxxxxxxxSigns of dehydration — continued

(B) decreased urinary output - no change in care plan.

While there may be "no change in care plan", one of the effects of dehydration is incontinence. The patient's diapers or "chux" pads will need to be changed more frequently, until such output ceases entirely.

6. Pulmonary
(A) Inability to clear secretions - reposition and swab mouth, consider scopolamine patch behind ear every 3 days.

Dehydration causes the natural mucus secretions of the mouth, nose, and throat to thicken, as the body struggles to protect these delicate membranes. The lack of saliva exacerbates this problem, preventing the normal swallowing of these secretions. These thick deposits can interfere with breathing. The use of the scopolamine patch promotes drying of these secretions, which prevents their build-up, but hastens the breakdown of the tissues.

(B) dyspnea ["difficulty in breathing"] — nebulize low dose 2-5 mg morphine sulfate Q4* prn.

In the last stages of dehydration/starvation, the patient's breathing will become difficult and labored. He or she may even begin gasping for breath, as even the lungs' ability to effect transfer of gases is compromised. Morphine nebulized into a fine spray relaxes bronchial passages and relieves these symptoms. However, because of the resultant decrease in respiratory efficiency, this may hasten death.

7. Multifocal myoclonus or terminal agitation (sometimes caused by electrolyte imbalance). Consider diazepam rectal administration 5-10 mg. May repeat in 4 hours if not resolved then daily - twice daily as needed.

Myoclonus is twitching or spasm of the muscles. Multifocal means "occurring in many different parts of the body". This is usually the result of imbalance in electrolytes, the chemicals, such as salt, potassium, and calcium, which make your bodies internal electrical "batteries" work. Nerve impulses and muscle contractions are governed by electro-chemical reactions utilizing these chemicals. Dehydration causes these chemicals to be out of balance, interfering with normal nerve and muscle function. This can result in nerves and muscles "firing off" uncontrollably, causing spasm. The patient will writhe and become extremely agitated. If you have ever had muscle cramps resulting from strenuous exercise (especially when you have sweat profusely), you have some idea what this feels like. Imagine having this happen all over your body, repeatedly. Diazepam (more commonly known as Valium) is a muscle relaxant

8. Grand Mal seizure, which is highly unlikely given current conditions and lack of contributing factors (meds). Recommend diazepam 15 mg rectally as indicated in seizure management orders.

In the final stages of starvation and dehydration, the same electrolyte imbalances which can cause muscle spasm can also lead to uncontrolled firing of neurons in the brain, according to a similar mechanism. This results in seizures.

Thank you for the opportunity to collaborate regarding this patient's care.

I would observe, in conclusion, that most of the "treatments" described in this Exit Protocol are in fact not directed at easing the patient's true condition, but in masking the symptoms of dying by starvation and dehydration. These treatments are designed to create the appearance of a peaceful "slipping away", when nothing of the sort is happening. The medications hide the fact that the patient undergoes a lengthy and painful deterioration, in which his/her body wastes away cruelly. Remember this the next time you hear or read someone say that Terri should be "allowed" to die.

Not Dead Yet

One organization that has emerged as a leading advocate for Terri Schiavo is Not Dead Yet, a disability-rights organization. Not Dead Yet was founded 1996, as a response to Jack (Dr. Death) Kevorkian, after he was acquitted in the assisted suicides of two women with non-terminal disabilities.

Not Dead Yet, in conjunction with other disability-rights groups, filed two Amici Curiae ("friend of the court") briefs in the recent Florida Supreme Court case concerning "Terri's Law".

Diane Coleman, the president of Not Dead Yet, published an editorial in Tuesday's Florida Today.

From Coleman's perspective, Terri's case is about the rights and dignity of the disabled:

...The life-and-death issues surrounding Terri Schiavo are first and foremost disability rights issues -- issues that ultimately affect millions of Americans, old and young.

These issues apply directly and immediately to thousands of people with disabilities who, like Schiavo, cannot currently process information or articulate their views to the extent that health-care providers require, and so must rely on others as substitute decision-makers.

Coleman, along with other disabled-rights advocates and myself, also sees that the legal process is being used to run roughshod over the rights of the disabled:

In the modern-day United States, bioethicists are working to dismantle the due process part of the Bill of Rights that has previously protected people in guardianship from wrongful decisions to withhold life-sustaining medical treatment.

They would misuse the right of privacy to supplant the right of due process, so that they may kill behind the closed doors of a room in a hospital or nursing home.

With abortion, and, increasingly with regard to those whose lives are for one reason or another considered not worth living, the "right to privacy" has become the "right to kill".

Statement of Not Dead Yet President At Tallahasse Debate

On Monday night, Not Dead Yet President Diane Coleman, along with Patricia Anderson, attorney for Terri's parents Bob And Mary Schindler, participated in a debate opposite "right-to-die" advocate Bill Allen and others at Florida State University in Tallahassee.

I reproduce here the text of Diane Coleman's opening remarks at that debate. The text was sent to me in an e-mail and is not yet, as far as I know, available on the Web. As soon as it becomes available I will link it.


Opening Statement of Diane Coleman at Tallahassee Debate

I've been a health care advocate for a couple decades, sometimes joining protests against government health cuts. One mission of the end-of-life care movement is to educate health care providers about how to provide good end-of-life care, but another mission is to shape public policy on health care. It appears that a certain line of thought in bioethics has pretty much taken over the policy-making work. This line of thought involves a lifeboat approach, deciding who gets thrown out.

The lifeboat bioethicists seem to think of themselves as progressives, but oddly they never spend much energy on ways to cut unnecessary costs before cutting lives. My sister just started a new career as a medical assistant at a practice with 25 doctors. She says that four days out of five, she doesn't have to buy lunch anymore because it's catered in by a pharmaceutical company. But rather than spending all that professional brain power on conquering the waste and inhumanity of a profit-driven health care system, these bioethicists are pushing new health care decisions laws to kill disabled people who aren't going to die soon enough without a little push.

Last year, one of the leaders of the end-of-life care movement, Dr. Ira Byock, was interviewed by Ragged Edge Magazine, a leading disability rights publication. He stated that Partnership for Caring and Last Acts, national leaders in the movement, had excluded the disability perspective, and that this exclusion was "deliberate and irresponsible." What's especially disturbing is that they have set up surrogate decision-making protocols to end the lives of people with intellectual disabilities, without seeking the input of such individuals and the established organizations that address issues of self-determination for people who have less typical ways of receiving, processing and communicating information.

What might other disability groups bring to the discussion table?

I just read a journal article about the problems with advanced directives. A consistent finding in several funded studies is that people change their minds about what treatments they want, and what level of disability they will accept, as they move through the experience of having increasing disabilities. The disability community has a response to that, to use a popular phrase, "well, DUH."

And you may have seen reports of a new Alzheimer's study in the last few weeks. It confirmed previous studies that caregivers have a lower opinion of their relative's quality of life with Alzheimer's than the persons themselves have, and found an explanation for the discrepancy. It seems that the caregivers project their own feelings of the burden of care-giving onto the person they care for. Once again, the disability community response is "well, DUH." And these are the very caregivers who make life-ending decisions.

This is our point. We have expertise to bring. But we also have an attitude about disability that diverges from the mainstream, especially the mainstream of bioethics. And, frankly, I think that's why we were deliberately excluded.

Professor Peter Singer, who holds an endowed chair in bioethics at Princeton, believes that legal personhood should be subject to a cognitive test. Those who don't pass are eligible for killing if their families prefer, or for society's greater good.

At least two of my co-panelists here are working to implement theories like Peter Singer's. In the California case of Robert Wendland, all parties admitted that Mr. Wendland was conscious, what they called "minimally" conscious, and that he had not left clear evidence of his wishes, but Dr. Cranford and Mr. Eisenberg, then representing 43 bioethicists, argued that his wife hould be able to starve and dehydrate him anyway. What Dr. Cranford and Mr. Eisenberg have done, and continue to do here in the Schiavo case, is a direct assault on people with disabilities and the disability rights movement, which demands equal protection of the law, regardless of our health or disability.

Did you see last week's report of a case in which the Kentucky Supreme Court ruled that a public guardian may deprive life sustaining treatment from a man labeled mentally retarded, despite the financial conflict of interest for a state guardian of a ward on Medicaid?

Basically, the bioethicists have warped the end-of-life care movement into a life-ending movement. They've had tens of millions of dollars to work with, and they've used it to build a steamroller that's decimating the civil and constitutional rights of people in guardianship. This affects more than the disability community of today, it affects everyone, directly or through family, sooner or later. There are rules being made for who lives and who dies, but the rule-making and the medical killing are happening behind closed doors. We can't ignore it. It's time to call "time out," to go back to the table and talk about how to build a good end-of-life care system, one that respects us all. Let's do that before this goes any further.

LifeNews.com Also Thinks Court Tipped Its Hand

In an article posted at LifeNews.com, Steven Ertelt observed that the justices "sharply questioned" attorneys for Governor Bush.

But the attorneys for the Governor point out that behind the legal issues lie Judge Greer's bizarre rulings, and the appellate courts' unwillingness to expose those rulings to the light of scrutiny:

Clearly, Schiavo seeks to have this Court accept his incompetent, extra-record allegations as fact, while depriving the Governor of the opportunity to rebut the extra-record claims and prove or disprove the truth of his claims," the brief explains.

Florida Supreme Court Hears Arguments in Terri's Law Case

I was able to watch the oral arguments over "Terri's Law" in the Florida Supreme Court yesterday morning. Nothing very surprising was said by either side. George Felos, the attorney seeking Terri's death on behalf of husband Michael Schiavo, argued that Terri's Law is unconstitutional because it interferes with a person's right to make his own decisions regarding refusing medical treatment. Felos argued that the law, by allowing the governor to intervene, violated Terri's "right to privacy", that is Terri's "right" to decide to die.

Of course, Felos's argument rests on a legal fiction, that Michael, in his guardianship of Terri, is representing Terri's wishes and her best interests. But that Michael can in any sense be said to represent or act on Terri's behalf is a doubtful proposition. One of the problems throughout Terri's legal proceedings is that she has never had an independent guardian ad litem to represent her throughout a case. Both guardians ad litem, Richard Pearse and Jay Wolfson, were discharged by none other than Judge Greer. Oddly enough, these discharges happened after they pointed out things which were uncongenial to Judge Greer or George Felos, such as the fact that Michael stood to inherit Terri's settlement fund if she died. But Felos's case rests on another fiction, namely Judge Greer's ruling of "fact" that Terri would not want to go on living in her current state. As I have written in my Crisis Magazine article Killing Terri Schiavo, the representation that Terri "wouldn't want to go on" is highly dubious, and that Michael didn't raise this contention until several years after Terri was placed on the feeding tube is downright suspicious.

But Felos is staking his whole legal case on this fiction. And because, as I have also written before, the legal system is very reluctant to revisit rulings of fact, he stands a good chance of succeeding.

Felos, I observed, was able to expatiate at some length in response to the Supreme Court justices' questions. It seemed to me that Ken Connor, the attorney representing Governor Bush, was hardly able to get a word in edgewise in response to the badgering he received from some of the justices. As this New York Times article relates, Justice Charles Wells "said he was troubled because he had to conclude that `Terri's Law', passed last October, was designed to sidestep a trial court ruling that found "clear and convincing evidence" Schiavo would not want to be kept alive artificially."

Justice Wells apparently takes Judge Greer's findings at face value. He's also apparently already made up his mind about this case. It's said that the law is blind. I don't know about the law, but I'd say that Justice Wells is certainly blind. It seems to me to require an almost wilfull blindness to be able to read the evidence in Terri's case, see how Judge Greer violated civil trial procedure to allow Michael's assertion that Terri "wouldn't want to go on" into evidence, and then conclude that this farrago of confabulation met the standard of "clear and convincing" evidence.

The attorneys for Gov. Bush argue that Terri's Law is not an unwarranted intrusion of the Executive Branch into matters exclusively under the authority of the courts:

"The Legislature gave this power to the governor because the governor ... is the ultimate defender of people's civil rights in the state," [Bush attorney Robert] Destro said. Another Bush lawyer, Ken Connor, said the courts do not have the "exclusive domain" of protecting the rights of disabled people.

These ideas would seem to be common sense to many. But don't count on too many judges agreeing with them. This case is about judges protecting their hieratic powers to decide life, death, right, wrong, and the meaning of the universe, as much as it is about Terri Schiavo.

The case of Terri Schiavo is also an object lesson in the untold mischief wrought by the so called "right to privacy" recognized by the Supreme Court in the 1965 Griswold decision. Of course, the Constitution doesn't actually say anything about a right to privacy, but the Court found "emanations" of privacy in the "penumbra" of the rights defined by the Constitution.

So, under the right to privacy, women have the "right" to abort their children, people have a "right" to engage in sodomy, parents do not have a right to be informed if their child seeks an abortion, etc. Now, the right to privacy has been twisted to include the right of a husband to end his disabled wife's life, basically because he says so.

If the Florida Supreme Court rules against Terri's Law, it will effectively give guardians and the courts untrammeled power to end the life of anyone who is disabled and cannot speak for himself. It will also mean that, at least in Florida, there is no meaningful remedy for a judge's erroneous, biased, or even bizarre rulings of fact.

Judges, even Judge Greer, as Ann Coulter pointed out, can make mistakes. And Judge Greer's mistakes have cost innocent people their lives before. But this case is about judges never having to admit their mistakes. If Terri dies at the stroke of a judge's pen, it also will be about judges being able, literally, to bury theirs.

Judge Greer Re-Elected

Judge George Greer, the "unjust judge" of the Terri Schiavo case, was re-elected to the Pinellas County Circuit Court yesterday. Judge Greer won over challenger Jan Govan by a 65% to 35% margin (you'll have to scroll down a ways on the linked page to find the results).

Govan, unfortunately, was not able to prevail over Judge Greer's campaign war chest and the support of the legal establishment.

The message Judge Greer's victory should send is this: Pinellas County, Florida is not a good place to get sick in. It's certainly not a place you'd want to become disabled in.

While Schindlers Are Threatened With Contempt of Court,

Michael Schiavo's Lawyer Gets Set To Clean Up Financially


On the eve of the Supreme Court arguments over Terri's Law, Deborah Bushnell, one of Michael Schiavo's attorneys, sent Pat Anderson, attorney for the Schindlers, two letters in as many days, threatening legal action against Bob and Mary Schindler if videos of Terri are not removed from the family’s web site.

Citing a July 2002 court order, attorney Bushnell, states that videos of Terri may not be disseminated by her family and promises that she will pursue a contempt of court action against the family if videos are not immediately removed.

It is important to note that these videos of Terri were never sealed by the court and, therefore, are public record.

In the meantime, Attorney George Felos has been picked upo as a speaker by Eagles Talent Connection, Inc., a Speakers and Entertainers Bureau in New Jersey. In their online booking site, Eagles Talent offers the speaking services of Mr. Felos for fees ranging from $10,000 to $15,000. Felos joins the Eagles Talent roster with such celebrities as Catherine Crier and Star Jones. Among the topics listed as presented material, Mr. Felos includes “The Terri Schiavo Saga – From Family Fight to Constitutional Crisis”.

I guess it's not enough that Felos has collected more than $500,000 in legal fees from Terri's malpractice settlement fund. Those funds, by the way, were awarded to Terri as a means to provide health care and rehabilitation services. Instead, Michael Schiavo, with the ongoing connivance of Judge Greer, used this money to pay Felos’s legal fees in the ongoing case to end her life.

Day Nine Of The Novena For Terri

Holy Mary, Mother of God, and our Mother, hear our prayers on behalf of Terri Schiavo, and all whose lives are in danger from the Culture of Death. By your gracious intercession, may the Florida Supreme Court be guided by the Spirit of Justice, Counsel, and Fear of the Lord. May the people of Pinellas and Pasco Counties choose judges who will respect life, and use their power for the vindication of the innocent. Amen.

C-SPAN To Broadcast Terri's Law Oral Arguments

According to the C-SPAN website, C-SPAN 2 will broadcast the Oral Arguments in the "Terri's Law" case LIVE, tomorrow morning at 9:00 AM EDT.

Attorney George Felos will represent Michael Schiavo in arguing that Terri's Law is unconstitutional. Ken Connor will represent Florida Governor Jeb Bush, arguing that Terri's Law provides necessary protection for the disabled who are unable to speak for themselves, and that crucial issues and facts were never heard in the original court case which ruled, among other things, that Terri is in a Persistent Vegetative State. He will also argue that Circuit Judge Douglas Baird should not have ruled against Terri's Law without a trial.

I'll be tuning in and praying. I hope you do too.

In Spite Of His Advantage, Judge Greer Can Be Defeated

As I mentioned last week, Judge Greer has the advantage over challenger Jan Govan in organization and money. But good voter turnout in this election is almost certain to help Govan far more than Greer.

A reader writes to tell me:

The election on the 31st is a primary. Florida judicial elections are non-partisan. If no one wins a clear majority in the primary, then the general election in November is essentially a run-off. If someone gets a clear majority in the primary, then they're automatically elected.

Judge Greer has never been opposed in an election before. While the media and a portion of the legal community are behind him, by no means could he be called a popular jurist. There is no groundswell of "pro-Greer" sentiment out there. And, as a recent article on LifeNews.com reports, " pro-life advocates and disability rights activists...have rallied around Terri and are supporting Govan. They've distributed thousands of brochures and fliers on his behalf."

The bottom line is this: judicial elections traditionally have pretty low voter turnout. So mobilizing pro-lifers to get to the polls tomorrow can put Govan over the top. If you live in Pinellas or Pasco County, get out to vote tomorrow! If you know someone who does, get them out to vote! And if you don't, then pray that tomorrow is a day of victory for Govan, and the cause of the dignity of human life.

Day Eight Of the Novena For Terri

Tomorrow, of course, is the decisive day. The Terri's Law case will be heard by the Florida Supreme Court. Judge Greer's fate will rest in the hands of Pinellas County's voters. Let us pray for the triumph of Mercy and Justice!

Holy Mary, we beg you intercede for Terri Schiavo, and all those whose lives are in danger due either to their disability or the fact that their lives are considered meaningless or burdensome. By your prayers, and those of all the faithful united with you, may the Florida Supreme Court see the justice of Terri's Law, and see it as the protection of the weak and innocent it truly is. May Judge Greer be defeated in tomorrow's election, and the courts again become a place where the voiceless and defenseless can be vindicated. Amen.