108 N.J. 394, 529 A.2d 434 (1987)
Nancy Ellen Jobes, age thirty-one, was admitted to Riverside Hospital on March 11, 1980, following an automobile accident that killed her four-and-one-half-month-old fetus.1 During surgery to remove the fetus, she suffered severe loss of oxygen and blood flow to her brain, resulting in massive and irreversible damage.2 She has remained unconscious since that time.3
On July 28, 1980, she was transferred to the Lincoln Park Nursing Home, where she has resided continuously.4 Her condition includes a tracheostomy, catheter, chronic infections, atrophied and contracted limbs, and inability to swallow; since June 1985 she has received nutrition and hydration through a jejunostomy tube inserted into her small intestine.5
In May 1985, her husband John H. Jobes, III, and her parents requested that the nursing home withdraw the j-tube.6 The nursing home refused on moral grounds.7 Mr. Jobes then filed suit in the Chancery Division seeking authorization to withdraw the tube, asserting that his wife was in a persistent vegetative state and would choose to terminate artificial feeding if competent.8 The court appointed Richard Kahn as guardian ad litem, who after investigation supported the request.9 The nursing home moved for appointment of a life advocate, which was denied.10 The Public Advocate intervened in opposition.11
Prior to trial, the judge visited Mrs. Jobes at the nursing home.12 After a seven-day trial in 1986, the trial court found by clear and convincing evidence that Mrs. Jobes was in an irreversible persistent vegetative state and that she would not want to be sustained by the j-tube.13 The court authorized withdrawal under physician supervision but permitted the nursing home to maintain the tube until Mrs. Jobes could be transferred.14 The judgment was stayed pending appeal.15 Both Mr. Jobes and the nursing home petitioned for direct certification, which the Supreme Court granted.16
Medical evidence presented at trial included examinations and tests at Cornell Medical Center by Dr. Fred Plum and Dr. David Levy, who concluded Mrs. Jobes was in a persistent vegetative state, along with supporting testimony from other neurologists.17 Conflicting testimony came from Dr. Allan Ropper and Dr. Maurice Victor, who examined her briefly at the nursing home and concluded she had some cognitive responses.18 Family members and friends testified about prior statements Mrs. Jobes had made indicating she would not want to live in a condition like Karen Quinlan's.19
Whether the family of an incompetent patient in a persistent vegetative state who has not clearly expressed her wishes may exercise substituted judgment to authorize withdrawal of life-sustaining treatment?20
The right of a patient in an irreversibly vegetative state to determine whether to refuse life-sustaining medical treatment may be exercised by the patient's family or close friend.21 The surrogate decisionmaker must use substituted judgment to effectuate as much as possible the decision that the incompetent patient would make if competent, considering the patient's personal value system, prior statements, and all facets of the patient's personality with particular reference to philosophical, theological, and ethical values.22
Yes. Mrs. Jobes had not clearly expressed her wishes because her prior statements were remote, general, spontaneous, and made in casual circumstances, and her religious affiliation offered little guidance.23 Nevertheless, her husband and parents had an intimate understanding of her medical attitudes and general world view from their close relationship, placing them in the best position to know the motives and considerations that would control her medical decisions.24 There was some trustworthy evidence supporting their judgment that she would not want to be sustained by the j-tube under her present circumstances.25
The family may exercise substituted judgment to authorize withdrawal of the jejunostomy tube.26
Related opinions on this issue
Justice Handler joined fully in the reasoning and the result of the majority.27 He noted that the substituted judgment standard fits well the facts of this case.28 He observed that this standard may not be workable when the patient has always been incompetent or when there is no one sufficiently familiar with the patient to know how the patient would have decided.29
He emphasized that doubt is inherent in self-determination for incompetent patients and that objective best-interests factors may become intertwined with subjective approaches in extreme cases.30
Justice Pollock concurred subject to the thoughts expressed in his opinion.31 He joined in the opinion of the Court and in the concurring opinion of Justice Handler.32 He endorsed the Court's reliance on a competent patient's right of autonomy to determine the course of his or her medical treatment.33
He agreed with the recognition of the family as the appropriate social unit to speak for the patient when the patient cannot speak for himself or herself.34 He observed that a substituted-judgment analysis for a patient in a persistent vegetative state may take into account the patient's present condition.35 He noted that when evidence of the patient's wishes is less persuasive, considerations other than the patient's preference may manifest themselves.36
He stated that the focus for such patients remains on the likelihood of the patient's return to a cognitive and sapient life.37 He suggested that recourse to an ethics committee could provide guidance and support to the ultimate decisionmaker.38
Whether independent neurological confirmations are required before life-sustaining treatment may be withdrawn from a non-elderly nursing home patient in a persistent vegetative state?39
For non-elderly non-hospitalized patients in a persistent vegetative state who have a caring family or close friend, the surrogate decisionmaker must secure statements from at least two independent physicians knowledgeable in neurology.40 The statements must confirm that the patient is in a persistent vegetative state and that there is no reasonable possibility that the patient will ever recover to a cognitive, sapient state.41 If the patient has an attending physician, that physician likewise must submit such a statement.42 These independent neurological confirmations substitute for the concurrence of a hospital prognosis committee.43
Yes. Mrs. Jobes was a non-elderly nursing home patient in a persistent vegetative state.44 The court required independent neurological confirmations from at least two physicians.45 These confirmations substitute for the concurrence of a hospital prognosis committee and thereby prevent inappropriate withdrawal of treatment.46 The trial court had already found by clear and convincing evidence based on extensive examinations by Doctors Plum and Levy that she was in an irreversible persistent vegetative state with no prospect of improvement.47
Independent neurological confirmations are required before the jejunostomy tube may be withdrawn.48
Whether a nursing home may refuse to participate in the withdrawal of a jejunostomy tube from a long-term resident whose family has decided to terminate artificial feeding?49
A nursing home may not refuse to participate in the withdrawal of a jejunostomy tube from a long-term resident whose family has decided to terminate artificial feeding.50 This applies when the family had no notice of any contrary policy at the time of admission and transfer to another facility would be extremely difficult or impossible.51 Allowing refusal would frustrate the patient's right of self-determination.52 The nursing home must continue to provide care for the patient's comfort and dignity.53
No. Mrs. Jobes' family had no reason to believe they were surrendering the right to choose among medical alternatives when they placed her in the nursing home in 1980.54 The nursing home did not inform the family about its policy toward artificial feeding until May 1985.55 The evidence indicated it would be extremely difficult to find another facility that would accept her as a patient.56 Allowing the nursing home to discharge her would essentially frustrate her right of self-determination.57
The nursing home may not refuse to participate in the withdrawal.58
Related opinions on this issue
While I dissent from the disposition in this case primarily for the reasons stated in the companion case of In re Peter, 108 N.J. 365 (1987), I reiterate my respect for the aggrieved family and their conscientious decision. I find it difficult to understand how we can order nursing professionals with an abiding respect for their patients to cease to furnish the most basic of human needs to a patient in their care.59 I believe a proper balance could be obtained by adhering to the procedure adopted in In re Quinlan, 70 N.J. 10, cert.
denied sub nom. Garger v. New Jersey, 429 U.S. 922, 97 S.Ct. 319, 50 L.Ed. 2d 289 (1976), that would have allowed the nonconsenting physician not to participate in the life-terminating process.