Barbara Anderson – “Schiavo debate relived in Valley”

Schiavo debate relived in Valley
Sanger woman in coma center of wide dispute.

Barbara Anderson | July 26, 2008

Three years after the fight over Terri Schiavo pulled the nation into the end-of-life debate, the case of a comatose Fresno County woman is reopening old wounds — and could prove even more inflammatory.

The family of Janet Rivera, 46, wants to keep her alive in a Fresno hospital. The county, acting as her legal guardian, wants the issue decided in court.

Among the questions her situation has raised: Should a government agency be able to overrule family members and withhold life support when the patient’s wishes are unknown?

The Schiavo family has taken an interest in this case. The Terri Schindler Schiavo Foundation helped find a lawyer to represent the Rivera family, said Schiavo’s brother, Bobby Schindler.

Rivera’s situation is more alarming than his sister’s, he said.

“We had a family dispute,” he said. “This is a family in agreement.”

Schiavo, 41, of Florida was the subject of a well-publicized debate over the removal of her feeding tube. Doctors said she was in a persistent vegetative state, and her husband, Michael Schiavo, decided to have the feeding tube removed. The Schindlers wanted her kept alive and went to court. After a lengthy court fight, the feeding tube was removed in 2005. She died 13 days after food and water were withdrawn.

In Rivera’s case, the county became involved after the hospital where she was staying contacted the Public Guardian’s Office. According to court records, one of the concerns was that Rivera’s conservator at the time — her husband — was not making decisions related to his wife’s health.

Dr. David Hadden, the county’s coroner, public administrator and guardian, has said the county did not seek to become conservator. He said he decided to seek a judge’s opinion because five doctors have said Rivera’s condition is untreatable and irreversible.

The county removed life support July 11 but had it reinstated Tuesday. The family had complained when it was removed, but Hadden said he restored life support because Rivera was surviving longer than expected and he wanted to hear a judge’s opinion. A Fresno County judge on Wednesday granted a temporary order for life support to continue until the case is heard this week.

A hearing Tuesday in Fresno County Probate Court could decide whether the Sanger woman remains on life support.

Rivera’s case won’t be the last legal battle over end-of-life issues, say medical ethicists and legal experts.

“There’s no nationwide consensus on this,” said William Winslade, who teaches bioethics at the University of Texas Medical Branch in Galveston and is co-author of the book “Clinical Ethics.”

End-of-life decisions are complex, said Dr. Michael Nisco, medical director at Saint Agnes Hospice and Hinds Hospice in Fresno.

“One of the reasons we’re still in this situation is this is a diverse country, and what is the right decision for one person may not be the right decision for another person,” Nisco said.

Rivera has been comatose for two years following a heart attack. It’s unclear what Rivera’s preferences about life support would be.

“We never really talked about life and death things much,” said Rivera’s brother, Michael Dancoff of Berkeley.

Experts agree that the county is taking a chance by trying to make an end-of-life decision for Rivera without knowing her wishes.

It’s unusual for a conservator to argue for removing life support without evidence that’s what the patient would want, said David Magnus, director of the Stanford Center for Biomedical Ethics and co-chair of the hospital’s ethics committee.

And there’s reason for the hesitancy. In one case, the California Supreme Court ruled a public-appointed guardian had to have a clear understanding of a patient’s wishes to order the end of life support. In that case, the patient was not permanently unconscious. Whether this would apply to Rivera would be up to the courts to decide.

The cost of Rivera’s care also has become part of the discussion.

While Hadden says financial considerations have played no role in whether to keep her on life support, her family contends Rivera might not be in this situation if she had more money or better health-care coverage. Rivera’s medical bills are being paid by Medi-Cal, the state-federal insurance program for low-income families.

Some bioethicists say that regardless of whether money is an issue in Rivera’s case, her situation raises a question that’s impossible to ignore in the end-of-life debate: how to decide whether it’s worth spending limited resources to maintain life support in an apparently hopeless case.

“The stewardship of scarce resources does require us to take resources into account,” said Ben Rich, a University of California at Davis bioethics professor. “But it has to be done carefully.”

Hadden said Wednesday that Rivera had a hospital bill of $200,000 that had not been paid when his office reinstated her Medi-Cal benefits after it took over conservatorship. The county is not responsible for the bill.

The DeWitt Community Subacute Center had called the Public Guardian’s Office amid concerns over her finances and the risk of medical coverage lapsing, according to a court document. This was in addition to concerns that her husband — Jesus Rivera — was not making decisions related to his wife’s care.

On Friday, Hadden said financial issues are unrelated to the end-of-life decisions being made.

Wesley J. Smith, a Castro Valley attorney who was an adviser to the Schindler family in the Terri Schiavo case, said there is a “potential for tremendous discrimination” if finances are ever taken into consideration in cases such as Rivera’s.

“If HMOs did this, people would be screaming,” Smith said. “If we’re going to do it because of public financing, people should be screaming also.”

Initially, the Rivera family did not object to the public guardian’s appointment as conservator, but they now want a cousin of Rivera’s appointed instead.

Dancoff said that if his “little sister was famous and had a lot of money, they wouldn’t be doing this to her.”

Rich, of UC Davis, said these cases drive home an important lesson: “Every adult should have an advanced directive that speaks to these issues” and spells out the person’s wishes.

“People need to understand, if you don’t have an advanced directive, they are truly rolling the dice.”

Published in: on July 27, 2008 at 8:53 PM  Leave a Comment  

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