Who Gets to Decide When Life Has Ended?
You may be familiar with the story of the 13-year-old California girl who experienced cardiac arrest following a routine, elective surgery to remove her tonsils on December 9th. The child initially recovered from the procedure, however she developed unexpected profuse bleeding soon after, leading to the cardiac arrest. The girl was maintained on life-support at the same hospital where the surgery was performed. She was declared brain dead on December 12th.
In the state of California, once declared brain dead, a person is considered “legally and physiologically dead.” This means decisions about further care are made not by the family, but by the doctors in charge of the patients’ care.
In this case, doctors decided to remove the child from life support, as she had zero chance for recovery. The family of the girl went to court to obtain an appeal against the hospital’s decision. In the meantime, several facilities have offered long term care for the girl. However, they require the surgical placement of both breathing and feeding tubes prior to her admission.
Doctors at the hospital where the cardiac arrest took place refused to place the tubes. The chief of pediatric medicine stated plainly that the hospital “does not believe that performing surgical procedures on the body of a deceased person is an appropriate medical practice.”
The girl was released from the hospital to the care of her mother on January 5th. As of the time this article is being written, it appears she is still on a ventilator, but may not have a feeding tube in place.
I find it fascinating how the law transects with human medicine so differently from veterinary medicine. For people, despite legal precedents to guide professionals towards what is considered the “right” thing to do, the myriad of complex emotions surrounding difficult cases such as the one outlined above create much more of a public stir and pause in the overall decision making process.
For pets, in all but a few atypical situations and despite the overwhelming belief by owners that they are family members, animals are considered property in the eyes of the law. This means, with rare exception, that owners are the sole individuals responsible for making healthcare decisions for their pets.
I am in no way trying to belittle the horrible circumstances regarding the young girl above, nor am I trying to suggest that we should compare animals and humans as “apples to apples.” Yet, if the circumstances above occurred in an animal, there would be no way for me as a doctor to make a decision regarding removing life support. This choice would always remain in the owner’s hands.
Euthanasia is considered a “gift” for terminally sick animals, and veterinarians are entrusted with relieving suffering and alleviating pain. People are never afraid to let me know they feel euthanasia is a “terrible” part of my job. For most cases, it’s actually not such an awful thing to consider. Yet, making the recommendation to euthanize pets can be one of the most difficult and least clear-cut choices I'm faced with.
If I knew a pet were brain dead, with absolutely no chance of recovery, and required constant medical care in order to sustain a biological functioning state, euthanasia would certainly be the only option in my opinion. I would not need a judge or a court order to tell me the “right” thing to do. Unlike our human counterparts, we would not remove life support and sit and wait for the pet to die on it’s own — we would facilitate the passing with the dignity euthanasia affords.
In veterinary oncology, the circumstances surrounding a decision of euthanasia are much less black and white. Nearly every owner I meet would list their pet’s quality of life as their main concern regarding any decisions about their care. Yet, most find it difficult to understand that for the majority of animals I see, I cannot provide a distinct “line in the sand” where their quality of life goes from good to bad. The transition between the two extremes is so incredibly gray, so incredibly variable, and so incredibly subjective, it’s simply impossible for me to say the best time to “stop.”
My heart aches for the family of the little girl who died and for their struggle to maintain hope in the face of insurmountable grief. The law stripped them of their ability to have a choice in deciding her future. They will not be the ones to say, “It’s time to stop.”
I empathize with the doctors who were entrusted with the child’s care; possessing the medical knowledge to know she will never recover, but as mere mortals, lacking the ability to foresee precisely what would happen to her should supportive care continue.
These are the struggles we face each and every day that we pass our arms through the sleeves of our esteemed white coats.
These are the complex issues we are forced to shed as we travel from appointment to appointment.
These are the thoughts that pervade our lives outside of the exam room.
These are the events that keep doctors human.
Dr. Joanne Intile