Autopsy on Terri Schiavo

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June 15, 2005

Schiavo's Brain Was Severely Deteriorated, Autopsy Says

By TIMOTHY WILLIAMS

An autopsy on Terri Schiavo, the severely brain damaged woman whose death sparked an intense debate over a person's right-to-die, showed that her brain was severely "atrophied," weighed less than half of what it should have, and that no treatment could have reversed the damage.

During a televised news conference in Largo, Fla., the Piniellas-Pasco Medical Examiner, Jon Thogmartin, also said the autopsy showed that Ms. Schiavo's condition was "consistent" with a person in a persistent vegetative state. That point had become a key issue in the debate over whether to prolong Ms. Schiavo's life and whether she had a chance to recover normal brain function.

Dr. Thogmartin said that recovery was not possible because of the massive brain damage that occurred after Ms. Schiavo collapsed in 1990. Her brain weighed 615 grams at the time of her death on March 31.

"This damage was irreversible," said Dr. Thogmartin. "No amount of therapy or treatment would have regenerated the massive loss of neurons."

. Dr. Thogmartin said Ms. Schiavo technically died of "marked dehydration" - not starvation - after her feeding tube was removed.

But he said the underlying mystery at the heart of her case - why she suddenly collapsed 15 years ago -- could not be answered. He said he considered the manner of her death to be "undetermined."

Instead, the medical examiner discussed some factors that did not appear to lead to Ms. Schiavo's illness.

The autopsy, for instance, showed that physical abuse or poison did not play a role in her collapse , he said. Ms. Schiavo's parents, Bob and Mary Schindler, had accused their daughter's husband, Michael Schiavo, of abusing her, which he has steadfastly denied. Dr. Thogmartin also said there was no evidence she had had an eating disorder before she collapsed, although a disorder was widely suspected because she had diminished levels of potassium in her blood.

And despite a widely televised video that appeared to show Ms. Schiavo responding to voices and other movement in her room, the autopsy said that Ms. Schiavo was blind in her final days. The medical examiner said she would not have been able to eat or drink had she been fed by mouth, as her parents had requested. The autopsy found no evidence that she suffered a heart attack, or that she had been given harmful drugs that may have accelerated her death.

Asked about persistent vegetative state, Dr. Stephen Milton, a neuropathology expert who joined Dr. Thogmartin at the news conference, said that term referred to a clinical diagnosis, not a pathological diagnosis. But, he said, "There was nothing in the autopsy that is inconsistent with persistent vegetative state."

The lawyer for the Schindlers said at a news conference today that the parents continue to believe their daughter was not in a persistent vegetative state and thus should not have had her feeding tube removed.

"If Teri Schiavo had wanted to die, she had a lot of opportunities to die," said the lawyer, David Gibbs III.

Ms. Schiavo's parents sought the autopsy to determine the cause of Ms. Schiavo's mysterious collapse the night of Feb. 25, 1990. She had suffered extensive brain damage when her heart stopped beating and she lacked a pulse for more than one hour by the time emergency medical personnel arrived.

After her collapse, she had been able to breathe on her own and had periods of wakefulness, but most doctors agreed that Ms. Schiavo was in a "persistent vegetative state" and incapable of thought or emotion. Her parents however, argued that their daughter was minimally conscious and could recover through an intensive therapeutic regimen. The question of whether Ms. Schiavo should have been allowed to die, as her husband said she wanted, or be turned over to the care of her parents, who wanted to keep her alive, went on for seven years, and reached the Vatican, the White House, Congress and various state and federal courts, before finally reaching the Supreme Court, which declined to hear her case.

Her death on the last day of March came 13 days after a feeding tube that was keeping her alive had been removed. Her husband had sought the removal of the tube over the objection of the Schindlers.

At various times, the Schindlers accused Mr. Schiavo of physically abusing his wife, and suggested that poisoning or strangulation may have led to her collapse. Mr. Schiavo has repeatedly denied abusing his wife, and the medical examiner said several times today that there was no evidence of trauma consistent with physical abuse before her collapse.

At one point during the drawn-out dispute, President Bush returned to the White House from a Texas vacation late on a Sunday night solely to sign a law that allowed Ms. Schiavo's parents to seek a federal court review of the facts of the case. He praised Congress for "voting to give Terry Schiavo's parents another opportunity to save their daughter's life."

Ms. Schiavo's husband and parents, once close, battled over her fate since 1998, when Mr. Schiavo asked a state court's permission to remove life support.

Courts also found credible Mr. Schiavo's testimony that his wife, who left no written directive, had said on several occasions that she would not want life-prolonging measures to be used for her.

Mr. Schiavo's lawyer, George Felos, said today that his client was "pleased to hear the results" of the autopsy because it confirmed many of the points Mr. Schiavo has argued for several years. Mr. Felos also said that Mr. Schiavo had decided to release autopsy photos of his wife's brain in order to dispel any notion that she could have recovered.

He feels it is important to show "what is so apparent from these photographs," said Mr. Felos.

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Many Still Seek One Final Say on Ending Life

By JOHN SCHWARTZ and JAMES ESTRIN

Interest in living wills - the documents that let people specify what medical measures they want or do not want at the end of life - has surged in the aftermath of the fierce nationwide battle over the fate of Terri Schiavo, lawyers and other experts on all sides of the issue say.

While interest peaked around the time of Ms. Schiavo's death on March 31, it is still strong, these experts say.

Many people are filling out the forms for the first time. Others are taking a new look at forms they filled out some time ago. Most living wills describe the conditions for withdrawing life support, but others demand the fullest extent of treatment.

The results of Ms. Schiavo's autopsy, released on Wednesday, underscored the need to make one's wishes known, said Dr. Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania. He noted that politicians had been eager to intervene in her case even though it was now evident that her brain was irredeemably damaged.

"The movement to say, 'You've got to have Tom DeLay act as a third-party surrogate witness before you can have medical treatment stopped' seemed to be irrefutably silenced by the autopsy report," Dr. Caplan said.

Since March, Aging With Dignity, a nonprofit group in Florida devoted to supporting end-of-life wishes, has received requests for more than 800,000 copies of its do-it-yourself form, known as Five Wishes, which blends the statement of wishes and the appointment of a medical proxy, a relative or friend with the power to make life-or-death decisions.

That is a 60 times the normal number of requests, said the group's president, Paul Malley. "Mail is coming to us by the truckloads," he said.

Christina Lesco of Long Beach, N.Y., said that as she watched the television coverage of the final days of Ms. Schiavo - the brain-injured Florida woman who spent 15 years unable to express her wishes about treatment or end-of-life care - she felt sadness for the family and determination that the same thing should never happen to her own family.

So Ms. Lesco, a 45-year-old jewelry executive, went to see her lawyer and filled out the forms she needed to describe her wishes and to name her brother as her representative for making tough medical decisions if she is incapacitated.

"They explain in detail what all the words mean," she said. "Some of the words are scary for you. It's a scary thing to go through, to write about. But you have to do it."

Dr. Cecil B. Wilson, an internist in Winter Park, Fla., who is a board member of the American Medical Association, said many of his own elderly patients had already filled out such forms but added that recently they were pressing him to go over the forms and make sure they were clear and binding.

The number of visitors to the part of the association's Web site devoted to end-of-life issues jumped to 25 times the usual during the Schiavo controversy, Dr. Wilson said - though he added that it was hard to say how many people would act on their interest. Any rise in the actual use of the forms is not likely to be felt any time soon, since people filling them out today may not need them for years to come.

Bill Saunders, a senior fellow in bioethics at the Family Research Council, a Christian group that vigorously opposed the removal of Ms. Schiavo's feeding tube, said, "In various forums across the country, I have seen heightened interest" in living wills and proxy forms.

Donna R. Bashaw, a lawyer in Laguna Hills, Calif., who is vice president of the National Academy of Elder Law Attorneys, said the living will, long "almost a throwaway" document slipped into the folder of estate papers for clients to fill out, was now being asked for specifically.

For people who do not want to be kept alive in a greatly diminished state, there is a new sense of urgency, said Barbara Coombs Lee, president of the Compassion in Dying Federation, a group in Portland, Ore., that favors greater latitude for people to make end-of-life choices, including doctor-assisted suicide.

"People are afraid if they don't document their wishes in the most unambiguous way, some politician will try and thwart them," she said.

There are two main types of the forms known broadly as advance directives. Living wills describe kinds of medical treatment, including life-support measures like machine-assisted breathing and feeding tubes, and allow people to say what they find acceptable or unacceptable.

The second form, the durable power of attorney for health care, appoints a family member or friend as a proxy to make medical decisions if the patient cannot. Because no one can anticipate every situation, many experts say the proxy is more important than the living will.

The Schiavo case has encouraged people to talk about advance directives, said Mr. Malley of Aging With Dignity. The Schiavo case and the interest in forms like living wills have led to increased openness to having talks on death and dying, Mr. Malley said.

"People used to think this conversation was only relevant in the emergency room or the lawyer's office," he said. "Today those end-of-life conversations are happening around dining room tables and in living rooms."

The Rev. Dr. Paul Smith, senior minister at the First Presbyterian Church in Brooklyn Heights, whose own living will calls for withdrawal of food and fluids if his medical case is futile, says that is as it should be.

"Death isn't the grim reaper - we live, we die. It is a normal process," he said. "The more we talk about it, the more comfortable we get with the topic."

Marilyn Saviola, a polio survivor who is the director of advocacy at Independence Care System, a long-term-care program, said, "My advance directive says that I want heroic measures."

She went on, "We're a very disposable society, and I don't want to be considered disposable."

So her form says, "I want everything to be done as long as I'm not brain-dead and there's a chance that I would have full or partial recovery," she said. It gives instructions to stop treatment if she is in a persistent vegetative state for five years.

Because death is as varied as life, a range of organizations now offer or recommend forms that reflect their philosophies. Mr. Saunders of the Family Research Council suggests the use of a durable power of attorney instead of a living will, which "locks you in."

The Islamic Medical Association of North America offers an advance directive that balances the Islamic prohibitions against suicide with a sense of not wanting life to be prolonged at all costs.

Under the Koran, "euthanasia, assisted suicide, all those things would be totally out of line," said Dr. Shahid Athar, a physician on the faculty of Indiana University School of Medicine and chairman of the Islamic Medical Association. But at the same time, "nothing is to be done to prolong the dying process." His own living will is based on those beliefs, he said.

Andrea Albanese, a 27-year-old employee of the Catholic Diocese of Arlington, Va., recently filled out the form offered by the diocese because she wanted to ensure that loved ones would not take steps to end her life, even if she was in pain.

"There is value in suffering," Ms. Albanese said. "In the Catholic perspective, we can offer up our sufferings to Christ. And it will be a benefit to us, our souls, in the next life."

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Blind Man's Love

The lesson of Terri Schiavo's autopsy.

By William Saletan

According to Terri Schiavo's autopsy report, her "lateral geniculate nucleus (visual) demonstrated transneuronal degeneration with gliosis." Or, as the medical examiner put it in plainer English, "Her vision centers of her brain were dead. Therefore, Mrs. Schiavo had what's called cortical blindness. She was blind, could not see."

That isn't what Schiavo's parents, pro-lifers, and congressional Republicans told us all these years. They said videos showed her eyes following people and objects. "In the video footage, which you can actually see on the Web site today, she certainly seems to respond to visual stimuli," Senate Majority Leader Bill Frist declared three months ago as he spearheaded a congressional invasion of the case.

To pro-lifers, the meaning of the videos was as plain as the eyes on your face. "Streaming video of Terri Schiavo apparently glad to see her mom," one Web site advertised. "Terri looks over, sees her mom and gets a huge smile on her face," reported another. "As you can readily see, Terri is obeying commands," said a third. Several sites posted a common list of video links that began with Terri watching a balloon and Terri's alert eyes. "Seeing is believing," they concluded. "Now that you have seen, do you believe that this woman deserves to be starved and dehydrated to death?"

But now we know she was blind. She didn't see her mom. She didn't see the balloon. Her eyes weren't alert. We didn't see in her what we thought we saw.

How did we get it wrong? We know what blinded her. But what blinded us?

Let's look back at some of those videos. Start with Terri watching a balloon. It shows her eyes gliding up, down, this way, and that as a doctor entreats her:

Look over here. Terri? Terri?there you go. Can you follow that, Terri? There you go. Can you follow that at all? Terri? Come on. Terri, no, no. Over?come on. I'm using both sound and?can you follow that? Huh? Can you see that? Okay. Look over here. Look over here. That's fine. Look over here. Okay. Look over here. That's it. Look at there. Now, come on over here. Now, come on over here. Oh, you see that, don't you, huh? You do follow that a bit, don't you, huh? Okay. Look up here. That's good.

You can watch the video and draw your own conclusions. But what's striking in retrospect is what you can't see: the balloon. Without it, you can't tell whether she's following it. In fact, her eyes dart back and forth too quickly to reflect the movements of a balloon, even if it were jerked by a human hand. It's easy to overlook this, because your brain succumbs to the audio: "You see that, don't you, huh? You do follow that a bit, don't you?" You didn't see her eyes following the balloon. You heard that you saw it. And when you see the full text of the doctor's words?"Terri? Come on. Terri, no, no. ? I'm using both sound and"?you can catch the warning signs you didn't initially hear.

Then there's the clip Schiavo's parents made, edited, and released two years ago in violation of a court order. Pro-lifers said this video "shows Terri apparently interacting with her mother and trying to speak." But watch it closely. Schiavo's mother stands off to the left, pleading with her daughter: "Can you look over here? ? Come on. Over here. Look over at Mommy. Hi. Can you look this way? Huh? Can you look this way? Hey." The reason Schiavo's mom keeps pleading is that Schiavo doesn't respond.

Again, the bigger story is what you can't see. In this case, it's the four-plus hours of video from which Schiavo's parents and their supporters selected clips like these. Reporters who have watched the whole video series say it's largely a wasteland. "For nearly an hour, her parents and the doctor tell her to open her eyes, close her eyes, look this way, look that way?with little apparent response," says the St. Petersburg Times. The Times posts a sample clip in which Schiavo's mom, leaning in from the right, asks her daughter, "Can you turn over here and see me? Can you turn over here and see me? Okay. Hey, Sweetheart. Ter." A doctor tells the mother, "Ask her to look at you, would you, Mary?" Schiavo's mom obliges: "Terri? Can you look at Mommy? Can you look at Mommy? Over here. Ter." Nothing happens.

Same thing with the balloon clip. The judge in the Schiavo case notes that elsewhere on the hours of videotape her father "tried several more times to have her eyes follow the Mickey Mouse balloon but without success." The Times reports that at one point

her father gets gruff while trying unsuccessfully to get her to follow [the] balloon. "Come here, Terri, no more fooling around. No more fooling around with your dad." He pokes her in the forehead to make sure she's awake. "No more fooling around with your dad. Listen to me. You see the balloon? You see Mickey?" Later, he apologizes, telling her others have admonished him for his tone.

This is what happens when you deny reality. First you lose your senses, then your mind, then your soul. It isn't Terri Schiavo who's refusing to see what's happening in that awful scene. It's her dad. And it isn't her defect, or her husband's sin, that's revealed in the autopsy report. It's ours. We were blind. We could not see.

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Gov. Bush Seeks Another Inquiry in Schiavo Case

By ABBY GOODNOUGH

MIAMI, June 17 - Gov. Jeb Bush asked a state prosecutor on Friday to investigate the circumstances of Terri Schiavo's collapse, saying a new autopsy report revealed a possible gap between when Ms. Schiavo fell unconscious and when her husband called paramedics.

"It's a significant question that during this entire ordeal was never brought up," Governor Bush told reporters in Tallahassee after faxing a letter to Bernie McCabe, the state attorney in Pinellas County, where Ms. Schiavo suffered extreme brain damage when her heart temporarily stopped beating in 1990.

In a statement on Friday, Ms. Schiavo's husband, Michael, called Governor Bush's actions "sickening" and said he had called 911 promptly.

The governor's letter could further prolong an exhaustively fought case that even many of his fellow Republicans said it was time to close after the autopsy found no evidence of foul play in Ms. Schiavo's collapse nor any sign that further treatment would have restored the functions of her withered brain.

Governor Bush, who vehemently fought the court-ordered removal of Ms. Schiavo's feeding tube, said he decided to seek an investigation after speaking with Dr. Jon R. Thogmartin, the medical examiner who conducted the autopsy, on Tuesday, a day before his report was released. According to records, the report says, a 911 call was placed about 5:40 a.m. on Feb. 25, 1990.

But Mr. Schiavo said in an interview with CNN's Larry King in 2003 that he found his wife on the floor outside their bedroom about 4:30 a.m. and quickly called 911.

The governor said that Mr. McCabe, a Republican, had agreed to open an investigation. The prosecutor did not return a telephone call seeking comment.

The question of whether Ms. Schiavo's husband purposely delayed seeking help was never a significant issue in the case. A lawyer for Ms. Schiavo's parents, Robert and Mary Schindler, mentioned it after the autopsy report came out on Wednesday and said he had pointed it out in a letter to Dr. Thogmartin shortly after Ms. Schiavo's death, at age 41, on March 31.

The autopsy did not determine why Ms. Schiavo's heart stopped in 1990. But it generally supported Mr. Schiavo's contention that her brain damage rendered her unaware and incapable of recovering. And it countered arguments by her family, who fought Mr. Schiavo's decision to remove his wife's feeding tube and found a powerful and passionate ally in Governor Bush, that she was responsive and could improve.

Mr. Schiavo, who almost always directs his lawyer to speak on his behalf, issued his own response to the governor's action on Friday. He said that his memory had always been fuzzy and that the timing of his 911 call had never been questioned.

"I have consistently said over the years that I didn't wait but 'ran' to call 911 after Terri collapsed," Mr. Schiavo said in a news release. He said he was not "wearing a watch or looking at a clock" that night.

The release included excerpts of responses Mr. Schiavo gave to various lawyers and to Mr. King about when he found his wife.

"I'd say, about 4:30 in the morning, I was, for some reason, getting out of bed and I heard a thud in the hall," he told Mr. King on Oct. 27, 2003. "I race out there, and Terri was laying in the hall. I went down to get her. I thought, 'Well, maybe she just tripped or whatever.' I rolled her over and she was lifeless. And it almost seems like she had this last breath. So I held her in my arms, and I'm trying to shake her up. I ran over, I called 911."

According to his statement, Mr. Schiavo agreed with lawyers who, during a 1992 malpractice suit he filed against his wife's doctor, asked whether he found her on the floor "about 5:00 in the morning." He also said that during a trial in 2000 over his request to remove his wife's feeding tube, he testified, "I'm not good with dates and times."

The Schindlers' lawyer, David Gibbs, said on Friday that for years they had focused on fighting to prolong their daughter's life, but that the autopsy report rekindled their curiosity about the time inconsistencies.

"This brings the focus back to what caused an otherwise healthy 26-year-old to collapse in a hallway for no apparent reason," Mr. Gibbs said, "and why Michael Schiavo, the only eyewitness, has given all these inconsistent statements on what should be a fairly memorable event."

State Senator Michael S. Bennett, of Bradenton, was among nine Republican senators who helped block legislation in March that could have stopped the removal of Ms. Schiavo's feeding tube. He said he was shocked that Mr. McCabe agreed to review the case, adding that any impropriety would have been discovered during the prodigious court review.

"What evidence was there ever presented by anybody," Mr. Bennett asked, "that would even cause them to go on this escapade?"

Governor Bush is a Catholic and abortion opponent. Larry J. Sabato, director of the Center for Politics at the University of Virginia, said he thought the governor's latest move was "a product of his own personal beliefs" but also, possibly, an attempt to win political points.

Although religious conservatives applauded Mr. Bush's earlier efforts to keep Ms. Schiavo alive, they sharply criticized him for not seizing custody of her in the days before she died, an option he said was not legal.

"Were he interested in running for president or being put on the 2008 ticket as vice president, this would pay dividends," Mr. Sabato said.

It was not clear on Friday how a new investigation could yield information that years of legal proceedings had failed to. Governor Bush acknowledged the difficulty of the task in his letter to Mr. McCabe but said it was worth pursuing.

"I understand that these events took place many years ago, and that you may not be able to collect all the relevant records and physical evidence," he said. "However, Mrs. Schiavo's family deserves to know anything that can be done to determine the cause and circumstances of her collapse 15 years ago has been done. The unanswered questions may be unanswerable, but the attempt should be made."

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