Thursday, March 24, 2005

Neurologists Say: Recording of Terri Shows She's Not PVS

You'll recall the audio recordings of Terri and her father which were posted at the Matt Drudge and the Family Research Council websites earlier this week. These recordings (actually two different versions of the same recording) were made last year, and include Terri's father, Bob Schindler, talking to Terri, and Terri making noises which seem to be efforts to respond.

I sent the recordings to the four neurologists I interviewed for my National Review Online article from last week, "Starving For A Fair Diagnosis": Dr. Mack Jones, a neurologist in Florida; Dr. Thomas Zabiega, a neurologist in Chicago; Dr. William Bell, a professor of neurology at the Wake Forest University Medical School; and Dr. Peter Morin, a neurologist researching degenerative brain diseases.

Three of the four neurologists reported that they believed that Terri was responding to her father, and was attempting to form words. The fourth, Dr. Peter Morin, demurred, saying that he did not want to venture an opinion based on an audio recording without accompanying video.

The remaining neurologists all expressed confident opinions regarding what they heard in Terri's recording. Dr. Mack Jones said "She does appear to be responding to her father's questions and attempting to form words." Dr. Bell concurred, saying that Terri "did respond [to her father's voice] as she seems to pace her vocalization to his voice and not the reverse (his voice to
her vocalizations)."

Dr. Jones added: "If she responds in a like fashion to other close members of her family and not to strangers, it would be even more convincing that she recognizes her family and therefore demonstrates evidence of higher brain function."

According to the neurologists, if Terri verbalizes, that is, attempts to form words, that is clear evidence that she cannot be in a PVS. Dr. Bell explained:
Verbalization in general requires two phonemes with the intent of communication. "Papa" is two syllables and two phonemes and so is a verbalization regardless who is present to hear it, but "pa" would be meaningful if she said it if only her father was in the room. Just vocalizations that do not have set phonemic patterns are problematic, but if there is a definite vocalization to a question and silence when there is silence then this becomes a pattern in itself and this suggests at least conscious awareness and responses compatible with the minimally conscious state. The minimally conscious state suggests that portions of the cerebral cortex are still functioning.

Dr. Bell said that at one point he believes that Terri did verbalize, saying "hi". He added that "none of this is surprising," since, in his judgment, "she is not PVS, but in a minimally conscious state, despite what the courts say."

Dr. Zabiega expressed the strongest opinion, saying:
I believe she is making verbalizations on the tape.  In fact, around 45 seconds, when she is asked "How are you doing" she definitely changes her voice and says "good".  She appears to say "yeah" several times... then at the end of the tape when she is asked "do your ears hurt" she definitely says "no". Even if none of the words were discernible, the fact that her voice changes during the tape to different questions suggests she is understanding what is being said to her.  A patient in PVS does not respond and does not have any changes in verbal output. 

Dr. Zabiega adds, "Any clear-headed neurologist would rule out PVS just based on this audio tape. What she may actually have is aphasia, an inability to respond to questions which she understands.  Many people who are completely functional have aphasia after a stroke, and it can be tragic how they cannot communicate with others.  But we don't put them to death for it."

Indeed we don't , doctor. At least, not yet.

As It wrote in my NRO article, the history of the Terri Schiavo case is that of Michael Schiavo, George Felos, and Judge Greer attempting to prevent additional information from being presented and considered by the authorities. For the 2002 evidentiary hearing, the Schindlers submitted affidavits by speech pathologists who testified that Terri did try to speak. Now these neurologists say much the same thing. Will they too be ignored?

Updated! New Version of Terri's "Exit Protocol"

With Additional Pages and Information

Documents Now Available for Download

Terri Now Without Food & Water for 135 Hours

I have received an updated version of Terri's "Exit Protocol", the document prepared by the staff of Hospice of the Suncoast, the organization that runs the Woodside Hospice where Terri is kept. the documents have been re-scanned, and the new scans are more complete. They now include the signatures of the clinical pharmacist and the doctor who prepared them.

There are also some pages that were not included in the original scans that were sent to me. the additional pages are:
The clinical pharmacist's notes of her conversation with Terri's physician of record, Dr. Victor Gambone.

The orders for medications signed by Dr. Victor Gambone

These documents are now available for download, so you can examine them for yourself. The links to the documents are included toward the end of this post.

Michael and Felos have appeared on national television several times, and told viewers that Terri wasn't going to be starved to death, but that she was going to be "allowed to die". I suppose in some Orwellian alternate universe that might be true, but now, in regards to Terri, it is a monstrous, flat out lie. Michael Schiavo said that Terri would peacefully slip away. That too is false. Terri will die a horrible, prolonged death. The documents I reproduce below demonstrates that.

The document I reproduce below was prepared by the hospice at which she resides, by their own doctors and pharmacists. It was produced in anticipation of the first time Terri's feeding tube was removed, in 2001. Anyone reading it with a rudmimentary knowledge of medicine will recognize that in Terri's case, and the cases of many others in similar situations, the so-called "treatment" that is given is in fact not treatment at all. It is a regimen of medication intended to perpetrate an illusion: the illusion that someone is peacefully "slipping away", when in fact they are dying in a painful and brutal way.

The document was given a name by those who wrote it. They called it Terri's "Exit Protocol".

I first published this document last September, when it first came to light. I republish it here so that all can see the truth of what is being done to her.

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 "Symptom Management Orders" stationery. It is dated April 19 & 20, 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 the contents of this document. They are presented verbatim, except in several places where the notes duplicate themselves. It was sent to me in the form of an Adobe PDF document. The links for downloading it appear toward the end of this post.

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


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.


Patient Care Notesxxxxxxxxxxxxx The Hospice
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxOf The Florida Suncoast


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.

Date: 4/19/01xxxxxxxxxxPatient Name: Schiavo, Theresa

Physician/Staff Name/Title (print) Lisa Miller xxxMedical Record # 123235

Physician/Staff Signature (signed) Lisa Miller, Pharm. D
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxTeam Woodside

[Document 2]

Clinical PharmacyxxxxxxxRe: communication with physician

This document essentially reiterates some of the points which preceded, including:

2. Naproxen 375mg suppositories; 1 rectally Q8* prn signs of discomfort.
Once again Terri is prescribed pain medication.

3. Saliva subsitute to swab dry mouth prn. DO NOT SPRAY IN MOUTH. Presumably, this instruction is intended as a precaution against Terri aspirating the saliva substitute.

4. Rectal Diazepam 5-10 mg may repeat in 4 hours then once or twice daily prn multifocal myoclonus or terminal agitation.
Again, the possibility of "terminal agitation" would call into question the "peaceful" death that Felos and his water-carriers have rhapsodized about.

[Document 3— Symptom Management Orders]

This document is the actual medical orders, dated 4/20/01, 1:00 PM, submitted by Terri's physician of record at Hospice of the Suncoast, Dr. Victor Gambone. He is the same doctor that, in 2001, "certified" that Terri was terminally ill, and likely to die within six months. This document has a series of check boxes for different treatments under different headings. In certain places Dr. Gambone has added written remarks/instructions.


[checked] Morphine (MSIR) 5-10 mg IM (IM = intra-muscular; that is, injected into a large muscle such as the buttocks.) or by rectal suppository.

[checked] If no relief after reaching upper range, repeat dose in 1 hour and increase subsequent doses by 50% q 3 hour prn.

This goes beyond the use of morphine for improving breathing, as mentioned above. Here morphine is specifically being prescribed for pain — the pain she isn't supposed to be feeling.


[checked] Lorazepam (Ativan) 0.5 - 1 mg IM q 6 hours prn.

Physician Name (please print)Victor Gambone xxPt. Name Theresa Schiavo

Date 4/20/01 (signed) xxxxxxxMedical Record #123235
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxTeam Woodside

These documents can be downloaded as two Adobe PDF files. You can obtain them here:

Terri's Exit Protocol Part One

Terri's Exit Protocol Part Two — With Medical Orders

It seems to me that this document, especially in it's fuller form here, when taken in conjunction with Dr. Gambone's certification that Terri was "terminal", is at least suggestive of a tendency for the people involved at Hospice of the Suncoast to play fast and loose with the facts. Personally, I think it is suggestive of far more, because of the potential deception involved. Could this be evidence of a conspiracy to commit medical homicide?

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.

Would An Anullment Help Terri?

A number of people have e-mailed me over the last couple of days asking if an ecclesiastical anullment of Terri's marriage to Michael would help.

There are several problems with such an approach:

Firstly, tribunals in the United States ordinarily require that a civil divorce have been granted before the proceedings for an anullment may begin. I'm pretty sure that's just a procedural norm rather than anything essential. That's a good question for someone like canon lawyer extraordinaire Pete Vere to weigh in on, though.

Secondly, in order for an anullment to be granted, Terri or Michael would have to petition for one. Terri obviously can't, and I don't see how Michael could be induced to seek one. Michael is not Catholic, and I doubt he cares one whit what the Church thinks of his marriage.

I am unaware of any possibility of a mechanism by which an anullment may be sought for someone by proxy. Once again, that's a question a canonist like Pete Vere could answer.

Finally, though, and most crucially, an ecclesiastical anullment has no effect under civil law. Pronouncements by Church tribunals simply have no standing in the eyes of the government. So the Church could anull Michael and Terri's marriage, and in the eyes of the State of Florida, they'd be just as married as ever.

Tuesday, March 22, 2005

Another Explanation For Refusal To Restore Feeding Tube

A reader writes me to provide an alternate explanation for Judge Whittemore's refusal to restore Terri's feeding tube:

"If he denies motion, there can be immediate appeal with an almost automatic order to reinsert feeding tube."

Either that, he says, or Whittemore wants to avoid giving an opinion on the case. If he avoids making a substantive judgment, then he won't be on the record regarding his views on Terri's case.

"In short, he's a coward", my reader says.

Terri's 14th Amendment Rights Are Being Violated

In a post at NRO's The Corner this morning, O. Carter Snead, general counsel for the President's Council on Bioethics, says that the federal judge's ruling this morning violates Terri's fourteenth amendment right to due process:
The state of Florida, through its judiciary, has ordered the termination of Terri Schiavo's life. This is an interest clearly protected by the due process clause of the 14th Amendment. Thus, before Florida can order such action, it must accord Schiavo with the full measure of process that is due to her. Unfortunately, a review of the record shows that such process was never provided...

...The procedural irregularities that tainted the handling of Ms. Schiavo's case include:
The court's failure to appoint a guardian ad litem (following 1998);
The court's usurpation of the guardian's role (in direct violation of Florida law)...

These irregularities make it impossible to conclude that T. Schiavo's wishes under the present circumstances were proven by "clear and convincing" evidence, particularly in light of the presumption (under Florida law) that she would have chosen to receive life sustaining treatment...

And, most importantly for present purposes, it empowers the federal court to determine, DE NOVO, "any claim of a violation of any right of T. Schiavo within the scope of this Act, NOTWITHSTANDNG ANY PRIOR STATE COURT DETERMINATION AND REGARDLESS OF WHETHER SUCH A CLAIM HAS PREVIOUSLY BEEN RAISED, CONSIDERED, OR DECIDED IN STATE COURT PROCEEDINGS."

Thus, its seems highly improper for the federal court to determine on the basis of a two hour hearing that the Schindler family would not likely be successful on the merits in an entirely new trial, complete with extensive discovery, etc.

The law passed was intended to give Terri a de novo hearing — that is, one which would re-open all the issues of the case for consideration. It would seem that once again a judge is attempting to frustrate the intent of a duly elected legislature.

Monday, March 21, 2005

The Guardian's Report and Terri's Bedsores

Several people have e-mailed me, and a couple of bloggers, Bill McCabe and Steve Ely, have been arguing, about an apparent conflict between Jay Wolfson's guardian ad litem report and my National Review Online article.

In his report, Jay Wolfson wrote, as evidence of his belief that Terri had high quality care, that "It is notable that through more than thirteen years after Theresa's collapse, she has never had a bedsore."

Whereas I wrote: "She also developed decubitus (skin) ulcers [bedsores] on her buttocks and thighs... The presence of these easily preventable ulcers is a classic sign of neglect."

These statements would certainly appear to be in conflict. But this conflict is only apparent.

Jay Wolfson issued his report on December 1, 2003. He may very well have been completely accurate in his contention about Terri having had no bedsores up to that point. I will not dispute that.

However, Terri did develop bedsores, and I reported that fact, in March of 2004. This was over three months after Wolfson issued his report. So there is in fact no conflict.

Also, in relation to the larger charge of neglect, I think the evidence for that is substantial, as both my NRO piece and the blog post linked above make clear. For the neglect I do not fault the hospice: I fault Michael, for the hospice acts upon his instructions.

Federal Judge Declines To Rule Immediately:

Terri Now Without Food & Water For 74 Hours

Judge James Whittemore, after a more than 2 hour hearing, said he would not rule immediately on the Schindlers' request to re-insert her feeding tube pending new litigation. He did not indicate when he would issue his ruling.

Frankly, I am not surprised by this turn of events. I didn't think the judge would issue an immediate ruling. At the very least, one has to admit that the judge has had a great deal thrown at him in a very short time.

But what does disturb me is this quote from the judge:
"I will not tell you when, how or how long it will take,'' Whittemore said.

Do I detect a little judicial arm-flexing here? I'm certain that many judges, even those uninvolved in the Schiavo case, resent the hell out of Congress' legislation last night. But I'd like to believe that the judge isn't posturing while a woman's life hangs in the balance.

Haunting Audio of Terri's Voice

Matt Drudge and the Family Research Council have an mp.3 file of Terri making noises, which seem to be in response to her father's promptings. The recording was made last year.

Right now both the FRC and Drudge sites are loading very slowly, probably due to the heavy traffic of everyone trying to download these large files. Because of that, I'm linking to an alternate download site here, until the traffic on FRC and Drudge lets up. The mp.3 I link to is the FRC version, which is higher in quality and clearer. Thanks to Austin's Blog for the alternate source.

Now, I am no speech expert or neurologist, but in my opinion:

A. Terri does seem to be responding to her father's promptings. The noises she makes seem to be in response to her father's statements. They do not seem random. IF they are truly responses to her father, no matter how inarticulate, Terri cannot be in a Persistent Vegetative State.

B. Based on my conversations with the neurologists I have interviewed, Terri's noises seem consistent with their descriptions of vocalizations. True vocalization cannot be reflexive because it involves several different commands involving several different brain centers, all of a higher order.

I have sent the audio file to the neurologists with whom I consult, and asked for their opinion. When I receive replies, I will post the results.

Congressional Source: Bobby Schindler Was "Very Persuasive"

I have developed a couple of sources in Congress of late, and one of them was in a meeting of about 15 Congressmen last night with Terri's brother, Bobby Schindler. He has been in Washington for the past week lobbying for legislative action to save Terri.

My source said that Bobby was "very persuasive" in his meeting with the legislators. As he laid out the details of Terri's case, several times audible gasps could be heard in the room as they heard of the string of injustices and errors which have led to the judicially-ordered starvation of an innocent woman.

I have no doubt about Bobby's persuasiveness: He's a sharp guy, and knows the issues in his sister's case backwards and forwards. He could stand his ground with just about anyone in a debate about Terri. And the fact is, he's a genuinely good man.

Not to mention, he has the truth on his side.

House Passes Bill — Terri Can Get A New Hearing

I'm sure by now most of you have already heard, around 12:30 AM this morning, the US House of Representatives passed Senate Bill 686, "For the Relief of the Parents of Theresa Marie Schiavo".

The vote was 203 for, 58 against.

Take note of the 58 against, and remember those names come election time...

I personally would have been happier with a broader bill, similar to the original House version, which remedied the status of a larger class of persons who are in situations similar to Terri. But, on the whole, this is a victory.

Now the Schindlers have to convince a Federal judge to order the re-insertion of Terri's feeding tube, and to agree to hear the merits of their case.

And there will almost certainly be a constitutional challenge to this law. But in the meantime, the Florida legislature can repair the defects in Florida law which are the underlying reason for this whole situation.

It's not over yet...