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After studying the course materials located on Module 6

After studying the course materials located on Module 6: Lecture Materials & Resources page, answer the following:

1) Read ERD 32, 33, 34, 56, 57, 58 and make a summary. 

1) Cure / Care ethical analysis. 

2) What is a Swallow Test? When is it indicated? 

3) What is Enteral Nutrition (EN)? 

4) Describe:  

NJ tube 

5) NG tu;leral Nutrition (PN)? 

6) Describe:  

Total parenteral nutrition 

Partial parenteral nutrition 

7) What is the basic principle of N/H? Briefly describe the two exceptions. 

8) Make a summary of Terri Schiavo’s case. Provide the key details, in your own words. 

9) Provide an ethical analysis of Terri Schiavo’s case: should we continue with the PEG or not? Why yes or why not? You must support your answers with the bioethical analysis, terminology, and all the information you have learned. 

Instructions

The work is to be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.

If references are used, please cite properly according to the current APA style. Refer to your syllabus for further detail or contact your instructor.

References: (only use them)

Ethical and Religious Directives (ERD) for Catholic Health Care Services (6th ed.). (2018)

Cioffi, A. (2018, March 24). BIO 603 3 24 18 [Video file]. Retrieved from

BIO 603 3 24 18 (youtube video)

NUTRITION and HYDRATION

CURE / CARE

BASIC CARE:

• NUTRITION • HYDRATION • SHELTER • HUMAN INTERACTION

SWALLOW TEST (THICKENED FLUIDS)

MEDICALLY ASSISTED N/H

ENTERAL NUTRITION (EN) (GI TRACT)

NUTRITION / HYDRATION (N/H)

PARENTERAL NUTRITION (PN) (LINE; PORT)

ENTERAL NUTRITION (TUBE FEEDING):

• NASO-GASTRIC TUBE (NG TUBE) • NASO-JEJUNAL TUBE (NJ TUBE) • PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)

EXAMPLES OF

ENTERAL ACCESS

NPO = NOTHING PER ORAL (6-12 HRS)

PURPOSE:

• PREVENT ASPIRATION PNEUMONIA

• UNDERGO GENERAL ANESTHESIA

• WEAK SWALLOWING REFLEX

• GASTRO-INTESTINAL BLEEDING OR BLOCKAGE

PARENTERAL NUTRITION (INTRAVENOUS = IV):

• PARTIAL PARENTERAL NUTRITION (PPN) • TOTAL PARENTERAL NUTRITION (TPN)

VASCULAR ACCESS TO

PARENTERAL NUTRITION

(VENOUS CIRCULATION)

TPN solutions :

• Concentrated • can cause thrombosis of peripheral veins • central venous catheter usually required

TPN not used routinely in patients with an intact GI tract

disadvantages:

• It causes more complications • It does not preserve GI tract structure and function as well (PERISTALSIS) • It is more expensive

Indications

TPN may be the only feasible option for patients who do not have a functioning GI tract or who have disorders requiring complete bowel rest.

NUTRITION / HYDRATION

IN PRINCIPLE, ORDINARY CARE

MEDICALLY ASSISTED N/H

ENTERAL NUTRITION (EN) (GI TRACT)

NUTRITION / HYDRATION (N/H)

PARENTERAL NUTRITION (PN) (LINE; PORT)

PEG

ERD 56. A person has a moral obligation to use ordinary or proportionate means of preserving his or her life. Proportionate means are those that, in the judgment of the patient, offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community.

ERD 57. A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that, in the patient's judgment, do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.

ERD 58. There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient.

N/H, IN PRINCIPLE, ARE ORDINARY MEANS OF LIFE SUPPORT

2 EXCEPTIONS:

• WHEN N/H CAN NO LONGER BE ABSORBED OR ASSIMILATED

• WHEN, IN THE ESTIMATION OF THE DYING PATIENT,

N/H BECOMES AN EXCESSIVE BURDEN

CASE STUDY: TERRY (SCHINDLER) SCHIAVO

(1963 – 2005; AGED 41)

TERRI SCHIAVO TIMELINE

“QUALITY OF LIFE” (SUBJECTIVE)

VS

“SANCTITY OF LIFE” (OBJECTIVE)

SACRED QUALITY OF HUMAN LIFE

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1963 BORN 3-Dec-63
Theresa (Terri) Marie Schindler is born in Pennsylvania.
10-Nov-84
1984 MARRIED Terri Schindler, 20, and Michael Schiavo, 21, are married at Our Lady of Good Counsel Church in Southhampton, Pennsylvania. The union is now among the "celebrity marriages" featured at About.com, a Website about marriage.
(20 Y/O) 1986
The couple move to St. Petersburg, where Ms. Schiavo's parents had retired.
25-Feb-90
1990 COLLAPSE Ms. Schiavo suffers cardiac arrest, apparently caused by a potassium imbalance and leading to brain damage due to lack of oxygen. She was taken to the Humana Northside Hospital and was later given a percutaneous endoscopic gastrostomy (PEG) to provide nutrition and hydration. Police report
PEG 12-May-90
(26 Y/0) Ms. Schiavo is discharged from the hospital and taken to the College Park skilled care and rehabilitation facility.
18-Jun-90
Court appoints Michael Schiavo as guardian; Ms. Schiavo’s parents do not object.
30-Jun-90
Ms. Schiavo is transferred to Bayfront Hospital for further rehabilitation efforts.
Sep-90
Ms. Schiavo’s family brings her home, but three weeks later they return her to the College Park facility because the family is "overwhelmed by Terri’s care needs.”
Nov-90
Michael Schiavo takes Ms. Schiavo to California for experimental "brain stimulator” treatment, an experimental "thalamic stimulator implant” in her brain.
Jan-91
The Schiavos return to Florida; Ms. Schiavo is moved to the Mediplex Rehabilitation Center in Brandon where she receives 24-hour care.
19-Jul-91
Ms. Schiavo is transferred to Sable Palms skilled care facility where she receives continuing neurological testing, and regular and aggressive speech/occupational therapy through 1994.
May-92
Ms. Schiavo’s parents, Robert and Mary Schindler, and Michael Schiavo stop living together.
Aug-92
1992 1/4 M AWARD Ms. Schiavo is awarded $250,000 in an out-of-court medical malpractice settlement with one of her physicians.
Nov-92
1992 1 M AWARD The jury in the medical malpractice trial against another of Ms. Schiavo's physicians awards more than one million dollars.  In the end, after attorneys’ fees and other expenses, Michael Schiavo received about $300,000 and about $750,000 was put in a trust fund specifically for Ms. Schiavo’s medical care.
(750Th TRUST) 14-Feb-93
Michael Schiavo and the Schindlers have a falling-out over the course of therapy for Ms. Schiavo; Michael Schiavo claims that the Schindlers demand that he share the malpractice money with them.
29-Jul-93
Schindlers attempt to remove Michael Schiavo as Ms. Schiavo’s guardian; the court later dismisses the suit.
1-Mar-94
First guardian ad litem, John H. Pecarek, submits his report.  He states that Michael Schiavo has acted appropriately and attentively toward Ms. Schiavo.
6-May-97
Michael Schiavo's attorney Deborah Bushnell writes to the Circuit Court to request that the Schindlers receive notice of all filings in the guardianship proceeding, in anticipation of a forthcoming request to withdraw Ms. Schiavo's PEG tube.
May-98
~1990 INFIDELITY  Michael Schiavo was in a relationship with Jodi Centonze, and had fathered their first child. He said he chose not to divorce his wife and relinquish guardianship because he wanted to ensure her final wishes (not to be kept alive in a PVS) were carried out.
1998 MICHAEL Michael Schiavo petitions the court to authorize the removal of Ms. Schiavo’s PEG tube; the Schindlers oppose, saying that she would want to remain alive.  The court appoints Richard Pearse, Esq., to serve as the second guardian ad litem for Ms. Schiavo.
PET PEG OUT 20-Dec-98
1998 TERRI The second guardian ad litem, Richard Pearse, Esq., issues his report in which he concludes that Ms. Schiavo is in a persistent vegetative state with no chance of improvement and that Michael Schiavo’s decision-making may be influenced by the potential to inherit the remainder of Ms. Schiavo’s estate.
PVS OFFICIAL January 24-27, 2000
Trial begins with Pinellas-Pasco County Circuit Court Judge George Greer presiding.
2000 JUDGE GREER 11-Feb-00
REMOVE PEG Judge Greer rules that Ms. Schiavo would have chosen to have the PEG tube removed, and therefore he orders it removed, which, according to doctors, will cause her death in approximately 7 to 14 days.
2-Mar-00
2000 SCHINDLERS The Schindlers file a petition with Judge Greer to allow "swallowing” tests to be performed on Ms. Schiavo to determine if she can consume—or learn to consume—nutrients on her own.
PET SWALLOW 7-Mar-00
2000 GREER Judge Greer denies the Schindlers’ petition to perform "swallowing” tests on Ms. Schiavo.
DENIES SWALLOW 24-Mar-00
2000 GREER Judge Greer grants Michael Schiavo’s petition to limit visitation to Ms. Schiavo as well as to bar pictures.  Judge Greer also stays his order until 30 days beyond the final exhaustion of all appeals by the Schindlers.
STAY PEG 30 DYS Greer Stay and Order Limiting Visitation
24-Jan-01
2001 2DCA Florida’s Second District Court of Appeal (2nd DCA) upholds Judge Greer’s ruling that permits the removal of Ms. Schiavo’s PEG tube.
REMOVE PEG 22-Feb-01
2001 SCHINDLERS The Schindler family’s motion for an Appellate Court rehearing is denied.
APPEAL 12-Mar-01
2001 MICHAEL Michael Schiavo petitions  Judge Greer to lift his stay, issued March 24, 2000, in order to permit the removal of Ms. Shiavo’s PEG tube.
REMOVE STAY 29-Mar-01
2001 GREER Judge Greer denies Michael Schiavo’s motion to lift stay issued on March 24, 2000; Michael Schiavo can remove Ms. Schiavo’s PEG tube at 1 p.m. on April 20.
REMOVE PEG 1 APR 10-Apr-01
The 2nd DCA denies the Schindlers’ motion to extend Judge Greer’s stay, which is scheduled to expire April 20, 2001.
12-Apr-01
2001 SCHINDLERS The Schindlers file a motion requesting that Judge Greer recuse himself.
REMOVE GREER The Schindlers petition the Florida Supreme Court to stay the removal of Ms. Schiavo’s PEG tube.
16-Apr-01
2001 GREER Judge Greer denies the Schindlers’ motion to recuse himself.
REMOVAL DENIED 18-Apr-01
2001 FL SUPREME The Florida Supreme Court chooses not to review the decision of the 2nd DCA.
REFUSE REVIEW 2DCA In re Schiavo, 789 So. 2d 248 (Fla. 2001).  Case No.: SC01-559
20-Apr-01
2001 FED CT JD LAZZARA Federal District Court Judge Richard Lazzara grants the Schindlers a stay until April 23, 2001, to exhaust all their possible appeals.
PEG STAY 4/23/01 23-Apr-01
2001 SUPREME CT KENNEDY Justice Anthony M. Kennedy of the United States Supreme Court refuses to stay the case for a review by that Court.
REFUSE STAY 24-Apr-01
4/23/01 PEG 1 REMOVED By order of trial court Judge Greer, and upon issuance of a 2nd DCA mandate, Ms. Schiavo’s PEG tube is removed
26-Apr-01
4/26/01 SCHINDLERS The Schindlers file an emergency motion with Judge Greer for relief from judgment based upon new evidence, which includes a claim that a former girlfriend of Michael Schiavo will testify that he lied about Ms. Schiavo’s wishes; Judge Greer dismisses the motion as untimely. Also on this date, the Schindlers file a new civil suit that claims that Michael Schiavo perjured himself when he testified that Ms. Schiavo had stated an aversion to remaining on life support.  Pending this new civil trial, Circuit Court Judge Frank Quesada orders Ms. Schiavo’s PEG tube to be reinserted.
4/26/01 JD QUESADA
REINSERT PEG 1
4/30/01 MICHAEL 30-Apr-01
APPEALS Michael Schiavo files an emergency motion with the 2nd DCA to allow the removal of Ms. Schiavo’s PEG tube.
9-May-01
The 2nd DCA announces a date for the hearing of oral arguments regarding Michael Schiavo’s motion of April 30, 2001.
11-Jul-01
7/11/01 2DCA The 2nd DCA remands the case back to Judge Greer.  (1) The 2nd DCA informs the Schindlers that they must address both their desire to have new evidence heard and their perjury claim against Michael Schiavo within the original guardianship proceeding; further, the Schindlers are instructed to file a new motion for relief from judgment in the guardianship proceeding. (2) The 2nd DCA instructs Judge Greer to weigh the Schinders’ new evidence in making a new determination of what Ms. Schiavo would have wanted. (3) The 2nd DCA denies Michael Schiavo’s request to discontinue the PEG tube.
CASE BACK TO GREER 7-Aug-01
After the 2nd DCA remands the case back to Judge Greer, he again finds that Michael Schiavo may remove Ms. Schiavo’s PEG tube on August 28.
10-Aug-01
AUG/10/01 GREER Judge Greer denies the Schindlers' motion (1) to have their own doctors examine Ms. Schiavo, (2) to remove Michael Schiavo as her guardian, and (3) to disqualify himself from the proceedings.
REMOVE PEG 29 AUG 17-Aug-01
AUG/17/01 GREER Judge Greer delays the removal of Ms. Schiavo's PEG tube until October 9 in order to allow the Schindlers time to appeal.
PEG STAY OCT/9/01 3-Oct-01
OCT/3/01 2DCA The 2nd DCA delays the removal of the PEG tube indefinitely.
PEG STAY INDEF 17-Oct-01
OCT/17/01 2DCA The 2nd DCA rules that 5 doctors should examine Ms. Schiavo to determine if she can improve with new medical treatment.  The Schindlers and Michael Schiavo are to choose 2 doctors each, and the court is to appoint a doctor.  The appeals court also affirms Greer’s denial of the motion to disqualify himself
RULE 5 MD EXAM 1-Nov-01
The 2nd DCA denies Michael Schiavo’s motion to rehear the case.
14-Dec-01
DEC/14/01 MICHAEL Michael Schiavo petitions the Florida Supreme Court to stay the October 17, 2001, ruling of the 2nd DCA.  He states that he and the Schindlers will attempt to mediate the dispute in lieu of further litigation.
PET FL SUPREME CT Michael Schiavo’s Notice of Appeal to the Florida Supreme Court
19-Dec-01
Attorneys meet with a mediator to determine which tests doctors should run on Ms. Schiavo.
10-Jan-02
JAN/10/02 FL SUPREME State Supreme Court stays all legal proceedings pending mediation; it orders attorneys to report on the status of mediation in sixty days.
STAY ALL TILL MED 13-Feb-02
FEB/13/02 MED FAILS Mediation between the Schindlers and Michael Schiavo fails.
14-Mar-02
The Florida Supreme Court denies Michael Schiavo’s petition to review the 2nd DCA’s ruling allowing 5 doctors to examine Ms. Schiavo.
October 12-22, 2002
The trial court holds a new hearing on new potential medical treatments.
15-Nov-02
The Schindlers contend that Michael Schiavo might have abused Ms. Schiavo and this abuse led to her condition. They ask the court for more time to collect evidence, and to remove Michael Schiavo as guardian.
22-Nov-02
Judge Greer rules that Ms. Schiavo’s PEG tube should be removed January 3, 2003.
13-Dec-02
Judge Greer stays his November 22 ruling: Ms. Schiavo should not have her PEG tube removed until an appeals court can rule on the case.
23-Dec-02
The 2nd DCA denies a motion Michael Schiavo filed seeking permission to remove the PEG tube.
6-Jun-03
6-06-03 Court Opinion
9-Jul-03
The 2nd DCA refuses to reconsider its decision.
22-Aug-03
FL SUPREME The Florida Supreme Court declines to review the decision.
30-Aug-03
Ms. Schiavo’s parents file a federal lawsuit challenging the removal of Ms. Schiavo’s PEG tube.
17-Sep-03
Judge Greer orders the removal of the PEG tube to take place on October 15, 2003. He also rejects the Schindlers’ request that Ms. Schiavo be given therapy to learn how to eat without the tube.
7-Oct-03
GOV BUSH Governor Jeb Bush files a federal court brief in support of the Schindlers’ effort to stop the removal of the PEG tube.
10-Oct-03
Federal Court Judge Richard Lazzara rules that he lacks the jurisdiction to hear the federal case.
14-Oct-03
The 2nd DCA refuses to block Judge Greer’s order to remove the PEG tube.
15-Oct-03
OCT/15/03 PEG 2 REMOVED Ms. Schiavo’s PEG tube is once again removed.
17-Oct-03
The Florida Circuit Court in Pinellas County and the First District Court of Appeal refuse to grant a request by "supporters" of the Schindlers to direct Gov. Bush to intervene in the case.
19-Oct-03
The Advocacy Center for Persons with Disabilities, Inc. files a federal court lawsuit that claims that the removal of Ms. Schiavo’s PEG tube is abuse and neglect.
20-Oct-03
FL HOUSE The Florida House of Representatives passes a bill, "Terri’s Law,” that allows the governor to issue a "one-time stay in certain cases.”
"TERRI'S LAW" House Bill 35-E
21-Oct-03
The Florida Senate passes the bill; Governor Bush issues an executive order directing reinsertion of the PEG tube and appointing a guardian ad litem for Ms. Schiavo.
Michael Schiavo files a state-court lawsuit arguing that "Terri’s Law” is unconstitutional and seeking an injunction to stop the reinsertion of the PEG tube; the court requests briefs on the Constitutional arguments about "Terri’s Law.”
FED CT The federal court denies the motion for a temporary restraining order filed in the lawsuit of the Advocacy Center for Persons with Disabilities, Inc.
0CT/21/03 PEG REINSERTED Ms. Schiavo’s PEG tube is reinserted.
22-Oct-03
David Demers, Chief Judge for the Pinellas County Circuit Court, orders both the Schindlers and Michael Schiavo to agree within 5 days on an independent guardian ad litem as required under the Governor’s order.  ("Terri’s Law” directs: "Upon issuance of the stay, the chief judge of the circuit court shall appoint a guardian ad litem for the patient to make recommendations to the Governor and the court.”)
28-Oct-03
President George W. Bush praises the way his brother, Governor Jeb Bush, has handled the Schiavo matter.
29-Oct-03
Michael Schiavo files court papers in his state-court lawsuit, arguing that "Terri’s Law” is unconstitutional. The American Civil Liberties Union has joined Michael Schiavo.
31-Oct-03
Judge Demers appoints Dr. Jay Wolfson as Ms. Schiavo’s guardian ad litem. Dr. Wolfson holds both medical and legal degrees; he is also a public health professor at the University of South Florida.  He is supposed to represent Ms. Schiavo’s best interest in court, but he has no authority to make decisions for her.
4-Nov-03
Governor Jeb Bush asks Circuit Court Judge W. Douglas Baird to dismiss Michael Schiavo’s suit (filed October 21, 2003) that challenges "Terri’s Law.”
8-Nov-03
Judge Baird denies Governor Bush’s motion to dismiss the state-court suit.
10-Nov-03
Governor Bush appeals Judge Baird’s decision; the filing of the appeal has the effect of staying the removal of Ms. Schiavo’s PEG tube.
14-Nov-03
Judge Baird vacates the stay.
14-Nov-03
In response to Judge Baird’s lifting the stay, the 2nd DCA issues an indefinite stay.
19-Nov-03
Governor Bush files a petition to remove Judge Baird.
21-Nov-03
Florida Sens. Stephen Wise and Jim Sebesta introduce legislation (S692) that would require persons in persistent vegetative states to be administered medically supplied nutrition and hydration in the absence of a living will, regardless of family beliefs about what those patients would have wanted. The measure is withdrawn from consideration on April 16, 2004.
1-Dec-03
University of South Florida Prof. Jay Wolfson, guardian ad litem, concludes in his report that Ms. Schiavo is in a persistent vegetative state with no chance of improvement.
10-Dec-03
The 2nd DCA refuses to remove Judge Baird, who is the presiding judge in the state-court lawsuit filed October 21, 2003. 
5-Jan-04
The Schindler family petitions the Pinellas County Circuit Court to reappoint Jay Wolfson, the guardian ad litem.
8-Jan-04
Judge Demers rejects the request to reappoint the guardian ad litem, citing the pending court decisions over the constitutionality of “Terri’s Law” as reason to wait on any action.
13-Feb-04
The 2nd DCA reverses Judge Baird’s ruling (in the case filed October 21, 2003) that denied the Schindlers permission to intervene in Michael Schiavo’s Constitutional challenge to “Terri’s Law.”  The 2nd DCA explains that Judge Baird did not follow proper procedure.  The court also gives permission to Governor Bush to question several witnesses who Judge Baird previously had ruled could not offer any relevant testimony.
12-Mar-04
Judge Baird again rejects the Schindlers’ request to intervene in Michael Schiavo’s suit that questions the constitutionality of “Terri’s Law.”
20-Mar-04
POPE JPII Pope John Paul II addresses World Federation of Catholic Medical Associations and Pontifical Academy for Life Congress on "Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas." His remarks spark widespread interest and controversy.
29-Mar-04
Nursing home workers discover 4 “fresh puncture wounds” on one arm and a fifth wound on the other arm; the workers state that a hypodermic needle appears to have caused the wounds.  Attendants discovered the wounds shortly after the Schindlers visited Ms. Schiavo for 45 minutes.  Toxicology reports indicate that no substance was injected into Ms. Schiavo. Clearwater police later conclude that the marks might have been made by a device used to move Ms. Schiavo and, in any case, that no evidence of abuse or other wrongdoing could be found.
29-Mar-04
Judge Greer denies a motion filed by the Schindlers seeking to have Michael Schiavo defend himself in a hearing; they allege that he is violating a 1996 court order that requires him to share a sufficient amount of Ms. Schiavo’s medical information. Michael Schiavo claims that he has shared an adequate amount of information through attorneys.
16-Apr-04
S692 is withdrawn from consideration in the Florida Legislature.
23-Apr-04
The 2nd DCA rules that the Pinellas County trial court has jurisdiction to hear and is the proper venue for the case Michael Schiavo has filed against Governor Bush asserting that "Terri's Law" is unconstitutional.
5-May-04
Pinellas Circuit Judge W. Douglas Baird rules that "Terri's Law," sought and signed by Gov. Bush and approved by the Legislature on October 21, 2003, is unconstitutional. The governor appeals the ruling.
1-Jun-04
The 2nd DCA grants a motion from attorneys for Michael Schiavo to send the case directly to the Florida Supreme Court and bypass a lower-court review. Meanwhile, attorneys for Gov. Bush file a motion asking that all appeals be halted until the issue of whether Michael Schiavo has the authority to fight the governor on his wife's behalf is resolved.
16-Jun-04
Florida's Supreme Court, pointing to "a question of great public importance requiring immediate resolution by this Court," accepts jurisdiction and sets oral arguments for August 31, 2004.
30-Jun-04
2nd DCA affirms Judge Baird's March 12 ruling denying the Schindlers the ability to intervene in the lawsuit over the constitutionality of "Terri's Law."
19-Jul-04
The Schindlers file a motion in the Circuit Court for Pinellas County seeking relief from judgment in Schindler v. Schiavo. Based in part upon the recent statement by Pope John Paul II, they argue that the orders mandating withdrawal of the PEG tube from Ms. Schiavo and authorizing Michael to challenge the constitutionality of "Terri's Law" violate her "free exercise of her religious beliefs [and] her right to enjoy and defend her own life and, in fact, imperil her immortal soul."
27-Jul-04
National group of bioethicists files amicus brief "in support of Michael Schiavo as guardian of the person."
31-Aug-04
The Florida Supreme Court hears oral arguments in the lawsuit over the constitutionality of "Terri's Law."
31-Aug-0

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