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March 24, 2007

Doctor said Terri Schiavo was Aware and Felt Pain

Topics: Remembering Terri, The Truth About PVS

While the media continues to get the facts about Terri Schiavo wrong, we recall news of a doctor who saw Terri Schiavo and suggested she seems to be aware of what's going on and appears to feel pain. [pdf file]

William Polk Cheshire, Jr., M.D,. M.A, F.A.A.N.is a neurologist practicing the State of Florida who believes that it can be ethically permissible to discontinue artificially provided nutrition and hydration for persons in a permanent vegetative state. He writes,

Having now reviewed the relevant facts, having met and observed Ms. Schiavo in person, and having reflected deeply on the moral and ethical issues, I would like to explain why I have changed my mind in regard to this particular case.
He explains that Terri was found by court appointed doctors to be in a state of PVS, meaning wakefulness without awareness and lacking the integrated function of the cerebral cortex. Related to Terri's PVS diagnosis he suggests,
There remain, in fact, huge uncertainties, in regard to Terri's true neurological status. Although exploring such questions may be uncomfortable, I believe that medicine has an obligation to ascertain the neurological facts to the highest possible degree of certainty.
One of his first statements in the seven page document addresses the lack of adequate medical imaging for the purpose of diagnosis. He states,
Although Terri has undergone structural imaging studies of her brain (such as the CT scan which I have reviewed). She ahas not, to my knowledge, undergoing functional imaging studies, such as positron emission topography (PET) or functional magnetic resonance imaging (fMRI). The structural studies have shown substantial loss of cerebral cortex which was deprives of blood supply for more than 40 minutes in 1990, but there does remain some cerebral cortex.
He follows with a lengthy summary of his direct examination of Terri, medical records, and hours of video tape. I've (roughly) reproduced it below (emphasis mine).

Based on my review of extensive medical records documenting Terri's care over the years, on my personal observations of Terri, and on my observations of Terri's responses in the many hours of videotapes taken in 2002, she demonstrates a number of behaviors that I believe case a reasonable doubt on the prior diagnosis of PVS.
  1. Her behavior is frequently context-specific. For example, her facial expression brightens and she smiles in response to the voice of familiar persons such as her parents or her nurse. Her agitation subsides and her facial demeanor soften when quiet music is played. When jubilant piano music is played, her face brightens, she lifts her eyebrows, smiles, and even laughs. Her lateral gaze toward the tape player is sustained for many minutes. Several times I witnessed Terri briefly, albeit inconsistently, laugh in response to a humorous comment someone in the room had made. I did not see her laugh in the absence of someone else's laughter.
  2. Although she does not seem to track or follow visual objects consistently or for long periods of time, she does fixate her gaze on colorful objects or human faces for some 15 seconds at a time and occasionally follow with her eyes at least briefly as these objects move from side to side. When I first walked into her room, she immediately turned her head toward me and looked directly at my face. There was a look of curiosity or expectation in her express, and she maintained eye contact for about half a minute. Later, when she again looked at me, she brought her lips together as if to pronounce the letter "O", and although for a moment it appeared that she might be making an intentional effort to speak, her fade then fell blank, and no words came out.
  3. Although I did not hear Terri utter distinct words, she demonstrates emotional expressivity by her use of single syllable vocalizations such as "ah," making cooing sounds, or by expressing guttural sounds of annoyance or moaning appropriate to the context of the situation. The context-specific range and variability of her vocalizations suggest at least a reasonable probability of the processing of emotional thought within her brain. There have been reports of Terri rarely using actual words specific to her situational context. The July 25, 2003 affidavit of speech pathologist Sara Green Mele, MS, on page 6, reads, "The records of Mediplex reflect the fact that she has said 'stop' in apparent response to a medical procedure being done to her." The Adult Protective Services team has been unable to retrieve those original medical records I this instance.
  4. Although Terri has not consistently followed commands there appear to be some notable exceptions. In the taped examination by Dr. Hammesfahr from 2002, when asked to close her eyes she began to blink repeatedly. Although it was unclear whether she squeezed her grip when asked, she did appear to raise her right leg four times in succession each time she was asked to do so. Rehabilitation notes from 1991 indicated that she tracked inconsistently, and although did not develop a yes/no communication system, did follow some commands inconsistently and demonstrated good eye contact of family members.
  5. There is a remarkable moment in the videotape of the September 3, 2002 examination by Dr. Hammesfahr that seemed to go unnoticed at the time. At 2:44 p.m., Dr. Hammesfahr had just turned Terri onto her right side to examine her back with a painful sharp stimulus (a sharp piece of wood), to which Terri had responded with signs of discomfort. Well after he ceased applying the stimulus and had returned Terri to a comfortable position, he says to her parents, "So, we're going to have to roll her over ...," Immediately Terri cries. She vocalizes a crying sound, "Ugh, ha, ha, ha," presses her eyebrows together, and sadly grimaces. It is important to note that, at that moment, no one is touching Terri or causing actual pain. Rather, sh4e appears to comprehend the meaning of Dr. Hammesfahr's comment and signals her anticipation of pain. This response suggests some degree of language processing and interpretation at the level of the cerebral cortex. It also suggest that she may be aware of pain beyond what could be explained by simple reflex withdrawal.
  6. According to the definition of PVS published by the American Academy of Neurology, "persistent vegetative state patients do not have the capacity to experience pain or suffering. Pain and suffering are attributed of consciousness requiring cerebral cortical functioning, and patients who are permanently and completely unconscious cannot experience these symptoms." And yet, in my review of Terri's medical records, pain issues keep surfacing. The nurses at Woodside Hospice told us that she often has pain with menstrual cramps. Menstrual flow is associated with agitation, repeated or sustained moaning, facial grimacing, limb posturing, and facial flushing, all of which subside once she is given ibuprofen. Some of the records document moaning, crying, and other painful behavior in the se4tting of urinary tract infections.

    [snip]

    If Terri is consciously aware of pain, and therefore is capable of suffering, then her diagnosis of PVS may be tragically mistaken.


  7. To enter the room of Terri Schiavo is nothing like entering the room of a patient who is comatose or brain-dead or in some neurological sense no longer there. Although Terri did not demonstrate during our 90 minutes visit compelling evidence of verbalization, conscious awareness, or volitional behavior, yet the visitor has the distinct sense of the presence of a living human being who seems at some level to be aware of some things around her.

    As I looked at Terri, and she gazed directly back at me, I asked myself whether, if I were her attending physician, I could in good conscience withdraw her feeding and hydration. No, I could not. I could not withdraw life support if I were asked. I could not withhold life-sustaining nutrition and hydration from this beautiful lady whose face brightens in the presence of others.

In summary, Terri Schiavo demonstrates behaviors in a variety of cognitive domains that call into question the previous neurological diagnosis of persistent vegetative state. Specifically, she has demonstrated behaviors that are context-specific, sustained, and indicative of cerebral cortical processing that, upon careful neurological consideration, would not be expected in a persistent vegetative state.

Based on this evidence, I believe that, within a reasonable degree of medical certainty, there is a greater likelihood that Terri is in a minimally conscious state than a persistent vegetative state. This distinction makes an enormous difference in making ethical decisions on Terri's behalf. If Terri is sufficiently aware of her surroundings that she can feel pleasure and suffer, if she is capable of understanding to some degree how she is being treated, then in my judgement it would be wrong to bring about her death by withdrawing food and water.


Posted by tim at March 24, 2007 12:42 PM


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