Legally Speaking
Advance Directives - the Legacy of Karen Ann Quinlan

By Tim Brouillette

On the night of April 15, 1975, for reasons still unclear, Karen Ann Quinlan ceased breathing for at least two 15-minute periods. Shortly thereafter, she received some ineffectual mouth-to-mouth resuscitation from her friends. She was then taken by ambulance to Newton Memorial Hospital in New Jersey and was placed indefinitely on a respirator.
Month after month, Quinlan remained hooked up to the respirator in a persistent vegetative state, with no signs of improvement. After six months and thousands of dollars in medical care, Quinlan's family realized her condition would not improve and discussed the possibility of removing her from the respirator knowing it would cause her death in a short period of time.

The doctor and hospital, after initially agreeing, changed their minds and refused to remove her from the respirator. Quinlan, while on the respirator, was described as emaciated, having suffered a weight loss of at least 40 pounds and undergoing a continuing deteriorative process. Her posture was described as fetal-like and grotesque; extreme flexion-rigidity of the arms, legs and related muscles and her joints were severely rigid and deformed.
The family brought suit to win the right to remove her from the respirator and the case made its way to the New Jersey Supreme Court. In 1976, the same court gave the Quinlan family the right to remove the respirator. Karen Quinlan was eventually removed from the respirator. Unexpectedly, she continued to live in a vegetative state for another ten years with the assistance of nutrition and hydration tubes.

The Quinlan case was highly publicized and, as a result, brought death to the forefront of the nation's attention. After the Quinlan case, a term known as "advanced directives" emerged as a legal device for an individual to state his or her wishes concerning death.

An advance directive is another word for a written document intended to let your family and medical practitioner know what your wishes are concerning life-sustaining treatment. These wishes are only effective if you fall into a state where you are no longer able to communicate your desires concerning life sustaining treatment.

There are basically two types of advanced directives in Nebraska - the living will and the power of attorney for health care. A living will is a statement signed by an individual that declares an individuals wishes concerning the withdrawing or withholding of life-sustaining treatment if they were ever in a persistent vegetative state. This statement is typically signed before a notary public or witnessed by two witnesses.

A power of attorney for health care not only includes a person's wishes on life sustaining treatment, but also gives another person, called an "agent," the power to make sure their wishes are adhered to. The power of attorney is typically signed before a notary public.

There are important restrictions under Nebraska law concerning who may witness or notarize a living will or power of attorney for health care and the relevant law should be carefully reviewed by an attorney before executing a living will or power of attorney for health care.

Under current federal law, all health care institutions are to make available to patients information about their rights to make an advance directive for their medical treatment. Most care facilities in Nebraska ask a new patient upon admission about the patients advanced directives and in some cases even provide forms for advanced directives. In addition, most care facilities and medical practitioners have a designated area in a patient's medical file for copies of advanced directives signed by the patient.

One of the continuing debates in the advanced directive area is the withdrawal or withholding of, nutrition and hydration tubes from a dying patient. In Nebraska, if it is a person's desire to include the removal of food and water tubes (nutrition and hydration), such desire must be specifically mentioned in the advanced directive. There is some debate in the medical community regarding whether or not the removal of nutrition and hydration tubes, or the starving of a person to death, will cause the patient discomfort. Some practitioners argue that if a patient is in a persistent vegetative state, they have no mental concept of pain or discomfort and therefore nutrition and hydration tubes take the form of a utility or a machine as opposed to a necessity. However, other practitioners state that science is not able to accurately test the concept of pain under these circumstances and to die as a result of starvation is not a proper avenue for termination of life regardless of the condition of the patient.

If a patient in a hospital changes their mind about life sustaining treatment, there is a very simple procedure for revoking an advanced directive. Under Nebraska law, a patient's advanced directive may become void based upon the oral representations of the patient. In other words, if you have an advanced directive saying you do not want to be kept alive by machines, you may revoke that advanced directive at any time by letting your physician or other medical practitioner know that you no longer desire it to be effective.

If you are considering the signing of an advanced directive, you should consult not only your family members, but also your attorney, and your medical practitioner. In addition, a person considering an advanced directive may wish to reflect upon their religious beliefs and possibly contact a clergy member as many faiths have suggestions or guidelines on the extent they will recognize an advanced directive.