486 A.2d 1209 (N.J. 1985)
Claire Conroy was an eighty-four-year-old woman who had lived a cloistered life, never married, and worked until retirement at age sixty-two or sixty-three before being placed in the Parkview Nursing Home.1 In 1979 she was adjudicated incompetent due to organic brain syndrome and her nephew Thomas C. Whittemore was appointed her guardian; he arranged her admission to the thirty-bed facility where she initially could converse, follow directions, and walk but later became increasingly confused, disoriented, and physically dependent.2
Conroy was hospitalized twice at Clara Maas Hospital, first in 1979 for dehydration and urinary tract infection and again from July 21 to November 17, 1982, for elevated temperature and dehydration; during the second stay surgeons recommended amputation of her gangrenous left leg but the nephew refused consent, and she survived.3
On July 23, 1982, a nasogastric tube was inserted for medicines and nutrition after inadequate oral intake; it was removed briefly in October but reinserted on November 3 and remained in place after her discharge to the nursing home on November 17, 1982, with a failed attempt at oral feeding in January 1983.
At the time of trial Conroy was bedridden in a semi-fetal position, suffered from arteriosclerotic heart disease, hypertension, diabetes, gangrenous ulcers, necrotic decubitus ulcers, a urinary catheter, and limited swallowing; she could move her head, neck, hands, and arms slightly, scratched herself, pulled at her tube and catheter, moaned when moved or fed, followed people with her eyes, and smiled occasionally, but could not speak and had very limited intellectual functioning.4 Two physicians testified she was not brain dead, comatose, or in a chronic vegetative state, though one described her as severely demented with no higher functioning and the other said she responded somehow; medical evidence on her capacity to experience pain was inconclusive.5
The nephew testified that Conroy had feared and avoided doctors throughout her life, had never visited one until 1979, had wanted to die in her own house, and would not have consented to the nasogastric tube; a Roman Catholic priest testified that removal would be consistent with church teaching on extraordinary treatment. The trial court permitted removal of the tube, the Appellate Division reversed while the appeal was pending, Conroy died with the tube in place, and the Supreme Court granted certification because the issues were capable of repetition yet evading review.6
Whether life-sustaining treatment may be withheld or withdrawn from an incompetent, institutionalized, elderly patient with severe and permanent mental and physical impairments and a limited life expectancy?7
Life-sustaining treatment may be withheld or withdrawn from such a patient if the subjective test is met by clear evidence that the patient would have refused the treatment under the circumstances.8 Alternatively, the limited-objective test is met by some trustworthy evidence that the patient would have refused treatment and the burdens of continued life with treatment markedly outweigh the benefits.9 Or the pure-objective test is met by a showing that the net burdens markedly outweigh the benefits and the patient experiences recurring severe pain that cannot be alleviated.10
Yes. The nephew's testimony about Conroy's avoidance of doctors and desire to die at home provided some trustworthy evidence of her wishes under the limited-objective test. However, the inconclusive medical testimony on whether she experienced pain or could experience pleasure meant that neither the limited-objective nor the pure-objective test could be satisfied.11
The evidence in this case was insufficient to authorize withdrawal of the nasogastric tube under any of the three tests.12
Related opinions on this issue
Handler concurred in the result but dissented from the majority's formulation of the limited-objective and pure-objective tests.13 Handler argued that the tests improperly focus on pain as the dominant criterion and thereby exclude other significant values such as personal dignity, privacy, independence, and the presence of progressive irreversible physical deterioration including ulcers, lesions, gangrene, and incontinence.14 Handler would have adopted a broader standard that weighs relief of suffering, preservation of functioning, and quality as well as extent of life sustained, allowing withdrawal when pervasive bodily intrusions become inhumane even in the absence of demonstrable pain.15
Handler emphasized that the pain standard can dictate prolongation of life despite other factors that militate in favor of termination, such as abhorrence of dependence and valuation of personal privacy and dignity.
Whether substantive guidelines exist for surrogate decision-makers to determine when to withhold or withdraw life-sustaining treatment from such a patient?16
Substantive guidelines exist in the form of three tests.17 The subjective test requires clear evidence of the patient's own wishes.18 The limited-objective test requires some trustworthy evidence of the patient's wishes plus a showing that burdens markedly outweigh benefits.19 The pure-objective test requires a showing that burdens markedly outweigh benefits and that the patient suffers recurring severe pain.20
Yes. The court supplied these three tests as the governing standards for surrogate decision-makers.21 The nephew's testimony about Conroy's aversion to doctors and desire to die at home constituted some trustworthy evidence under the limited-objective test.22 Yet the inconclusive medical testimony on pain and capacity for enjoyment prevented satisfaction of any test.23 The record did not establish that the burdens of continued tube feeding markedly outweighed its benefits or that Conroy experienced recurring severe pain.24
The three tests supply the required substantive guidelines, but the evidence here did not meet any of them.25
Related opinions on this issue
Handler agreed that guidelines are necessary but maintained that the majority's tests are too narrow.26 Handler contended that a surrogate should be permitted to consider the full array of factors including the patient's general physical condition, progressive deterioration, and the indignity of constant bodily manipulation, rather than being limited to a pain-centered calculus that would often bar withdrawal even when other humane considerations support allowing natural death.27 Handler stressed that the pain criterion denies relief to those who at the end of life might disapprove of an artificially extended existence despite the absence of pain.28
Handler would have the court adopt a test that weighs relief of suffering, preservation of functioning, and quality as well as extent of life sustained.29
Whether specific procedures, including judicial appointment of a guardian and review by the Ombudsman for the Institutionalized Elderly, must be followed before life-sustaining treatment may be withheld or withdrawn from a nursing-home resident?30
Specific procedures must be followed. A judicial determination of incompetence and appointment of a guardian if none exists is required.31 Notification to the Ombudsman for the Institutionalized Elderly who must investigate is required.32 Confirmation of the medical condition by two unaffiliated physicians is required.33 Concurrence of the guardian, attending physician, ombudsman, and family members when the limited-objective or pure-objective test is used is required.34
Yes. The court required these procedural safeguards because of the vulnerability of nursing-home residents.35 Conroy already had a guardian appointed in 1979, but the record contained no evidence that the ombudsman was notified or that two independent physicians confirmed the prognosis.36 The medical evidence on pain remained inconclusive, so the procedural requirements were not satisfied and withdrawal could not be authorized.37
The outlined procedures, including ombudsman involvement and independent medical confirmation, are mandatory for nursing-home residents.38