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In re Quinlan

Decided: November 10, 1975.


Muir, J.s.c.


In his initial pleading Joseph Quinlan, father of 21-year-old Karen Ann Quinlan, seeks, on grounds of mental incompetency, to be appointed the guardian of the person and property of his daughter. He alleges her "vital processes are artificially sustained via the extraordinary means of a mechanical MA-1 Respirator." He imprecates the court grant "the express power of authorizing the discontinuance of all extraordinary means of sustaining the vital processes of his daughter."

By a pleading amendment he also seeks to restrain the Morris County Prosecutor, Karen Quinlan's attending and treating physicians and St. Clare's Hospital from interfering with the exercise of the authorization sought, and to enjoin the prosecutor from prosecuting for homicide when the authorization sought is effected.

The court, pursuant to R. 4:26-2, appointed Daniel Coburn, Esq., guardian ad litem.

At the pretrial conference held on the return date of an order to show cause issued with the amended pleading, the State of New Jersey through the Attorney General intervened.

Plaintiff initially asserted that Karen Quinlan is legally and medically dead but altered this position prior to trial by admitting she is not dead "according to any legal standard recognized by the State of New Jersey."

It is stipulated by all parties that Karen Ann Quinlan is unfit and unable to manage her own affairs.

The court's findings of fact are as hereinafter set forth:

Karen Ann Quinlan, one of three children of Joseph and Julia Quinlan, was born April 24, 1954. She was baptized and raised a Roman Catholic. She attended Roman Catholic Church-affiliated elementary and secondary schools. She is a member of her parents' local Roman Catholic Church in

Mount Arlington, New Jersey. The parish priest is Father Thomas A. Trapasso.

Sometime in late 1974 or early 1975 Karen Quinlan moved from her parents' home. Thereafter she had at least two subsequent residences, with the last being a lake cottage in Sussex County, New Jersey.

On the night of April 15, 1975 friends of Karen summoned the local police and emergency rescue squad, and she was taken to Newton Memorial Hospital. The precise events leading up to her admission to Newton Memorial Hospital are unclear. She apparently ceased breathing for at least two 15-minute periods. Mouth-to-mouth resuscitation was applied by her friends the first time and by a police respirator the second time. The exact amount of time she was without spontaneous respiration is unknown.

Upon her admission to Newton Memorial urine and blood tests were administered which indicated the presence of quinine, aspirin, barbiturates in normal range and traces of valium and librium. The drugs found present were indicated by Dr. Robert Morse, the neurologist in charge of her care at St. Clare's, to be in the therapeutic range, and the quinine consistent with mixing in drinks like soda water.

The cause of the unconsciousness and periodic cessations of respiration is undetermined. The interruption in respiration apparently caused anoxia -- insufficient supply of oxygen in the blood -- resulting in her present condition.

Hospital records at the time of admission reflected Karen's vital signs to be normal, a temperature of 100, pupils unreactive, unresponsivity to deep pain, legs rigid and curled up, with decorticate brain activity. Her blood oxygen level was low at the time. She was placed upon a respirator at Newton Hospital.

At 10 P.M. on April 16, 1975 Dr. Morse examined Karen at the request of her then attending physician. He found her in a state of coma, with evidence of decortication indicating altered level of consciousness. She required the respirator

for assistance. She did not trigger the respirator, which means that she did not breathe spontaneously nor independently of it at any time during the examination. Due to her decorticate posturing, no reflexes could be elicited.

In the decorticate posturing the upper arms are drawn into the side of the body. The forearms are drawn in against the chest with the hands generally at right angles to the forearms, pointing towards the waist. The legs are drawn up against the body, knees are up, feet are in near the buttocks and extended in a ballet-type pose.

He found her oculocephalic and oculovestibular reflexes normal. The oculocephalic reflex test consists of turning the head from side to side with the eyes open. In a positive response, when the head is rotated to the right, the eyes deviate to the left. As part of this test the head is also moved front and back, the neck is flexed in the back movement, causing the eyelids to open. This phenomenon is called "doll's -- eyelid response". (Dr. Morse found that reflex intact on April 26, according to hospital records.) The oculovestibular reflex ascertained by a caloric stimulation test consists of the slow introduction of ice water into the ear canal. The eyes drift or move toward the irrigated ear. It is a lateral eye movement test.

He also found pupillary reaction to light in both eyes.

Her weight at the time was 115 pounds.

Dr. Morse could not obtain any initial history (i.e. , the circumstances and events occurring prior to Karen's becoming unconscious). There was no information available from her friends. He speculated at the outset on the possibility of an overdose of drugs, past history of lead poisoning, foul play, or head injury due to a fall. He indicated that the lack of an initial history seriously inhibits a diagnosis.

Karen was transferred to the Intensive Care Unit (I.C.U.) of St. Clare's Hospital, under the care of Dr. Morse. At the time of her transfer she was still unconscious, still on a respirator; a catheter was inserted into her bladder and a tracheostomy had been performed.

Upon entry to the St. Clare's I.C.U. she was placed on a MA-1 respirator, which provides air to her lungs on a controlled volume basis. It also has a "sigh volume," which is a periodic increase in the volume of air to purge the lungs of any accumulation of fluids or excretions. The machine takes over completely the breathing function when the patient does not breathe spontaneously.*fn1

Subsequently, the serial blood gas or arterial blood gas examinations were made. The tests indicate the degree of acidity (pH) in the blood, the level of oxygen (p02) in the blood and the level of carbon dioxide (pC02) in the blood. The latter is indicia of the extent carbon dioxide is discharged from the lungs. The pH reflects whether there is an excess of acid (acidosis) or an insufficiency of acid (alkalosis) in the blood. I note, parenthetically, that the blood gas tests have been conducted continuously from the time of Karen's admission to St. Clare's up to the present. There are constant references through the hospital records of pH, p02 and pC02 measurements. Dr. Javed, the attending physician internist, indicated some 300 tests were conducted.

Dr. Javed testified the blood tests were all normal while Karen was on the respirator.

In an effort to ascertain the cause of the coma, Dr. Morse conducted a brain scan, an angiogram, an electroencephalogram (EEG), a lumbar tap and several other tests. The first three are related to the brain and are conducted, according to the testimony, with the object of finding an injury or insult to the brain, such as a subdural hematoma or the like, or for ascertaining any abnormality in the brain activity patterns. The latter is particularly true of the EEG where electrodes are placed on the skull. The measurement

is made of cortical neurons. The neuron is basically a conducting cell of nervous energy. The recordings are made on awake and sleep cycles. The awake recorded data, referred to in the testimony as alpha rhythm or activity, indicates a frequency of pattern which can be compared against normal frequencies or patterns to determine whether any abnormality exists. The EEG establishes the existence or non existence of normal patterns. It does not precisely locate the insult or lesion causing, in this case, the unconsciousness. Dr. Morse indicated that the EEG performed at the outset established nothing abnormal for a comatose person and did not establish the offending agent to her central nervous system which caused her unconsciousness. Subsequent EEGs provided no further information. All indicated brain rhythm or activity.*fn2

Subsequent tests and examinations did not further the establishment of the precise location and cause of Karen's comatose condition.

Dr. Morse testified concerning the treatment of Karen at St. Clare's. He averred she receives oral feedings since intravenous feeding is insufficient to sustain her. She is fed a high caloric nutrient called "Vivenex," which she receives through a small nasal gastro tube inserted in her gastro-intestinal system. He asserts this is necessary to keep her "viable". She has apparently lost considerable weight, being described as emaciated by most of the examining experts, who also indicate her weight condition to be good under the circumstances.

There is constant threat of infection, according to Dr. Morse. Antibiotics are administered to thwart potential infection, with tests constantly being made to keep a check

on this threat. The hospital records indicate specialists consulted with respect to the cleaning, utilization and operation of the urethral catheter and with respect to the treatment and care of decubiti (lesions commonly known as bed sores) generated by her continuous repose.

The day-by-day charts, entitled "Vital Signs," kept by nurses who give her 24-hour care, indicate, in part, the following:

1. Her color was generally pale, her skin warm, she was almost constantly suffering from diaphoresis (sweating), many times profusely but occasionally moderately or not at all;

2. There was always a reaction to painful stimuli, she responded decerebrately to pain, she sometimes would grimace as if in pain, which would be followed by increased rigidity of her arms and legs;

3. There would be periodic contractions and spasms, periodic yawning, periodic movements of spastic nature;

4. Pupils were sometimes dilated, sometimes normal, but almost always sluggish to light;

5. Body waste disposal through the urethral catheter and the bowel was indicated to occur;

6. Feedings of Vivinex were given alternately with water on various nurses shifts;

7. The nurses were constantly moving, positioning, and bathing her;

8. Body rashes occurred at times; decubiti were treated with heat lamps on occasions;

9. Sometimes she would trigger and assist the respirator; other times she would go for periods without triggering it at all;

10. Her extremities remained rigid with contraction of them being described as severe at times;

11. On May 7, nurses indicated she blinked her eyes two times when asked to and appeared responsive by moving her eyes when talked to, but there is no further evidence of this type reaction thereafter.

Dr. Javed indicated that efforts were made to wean or remove Karen from the respirator. The hospital records support this. Dr. Javed testified that for weaning to be successful, the patient must have a stable respiratory pattern. Karen was taken off the respirator for short periods of time. Each time, her respiratory rate, rate of breathing, went up and

the volume of air intake would decrease. He indicated her breathing rate would more than double in intensity while her "tidal volume" or air intake would drop 50%. The longest period of time she was off the respirator was one-half hour. He further indicated that during removal from the respirator her p02 dropped. He stated that the respiratory problem is secondary to the neurological problem, and without improvement in the latter she cannot be removed from the respirator since she would be unable to maintain her vital processes without its assistance.

Dr. Morse's hospital notes indicate there is no neurological improvement from the time of her admission to St. Clare's to date. He testified that Karen changed from a sleeping comatose condition to a sleep-awake type comatose condition but described this as normal in comatose patients and not any indication of improvement. During the awake cycle she is still unconscious.

In Dr. Morse's opinion the cause of Karen's condition is a lesion on the cerebral hemispheres and a lesion in the brain stem. In response to various questions from respective counsel he described the cortex of the brain as being affected, with involvement of the brain stem. He indicated that the lesion involves the central hemisphere as far down as the thalamus, with patchy areas of the diencephalon and the respiratory centers located in the pons and medulla areas, and also noted there is evidence of possible cerebral hemorrhage, subcortical white matter involvement, and possible involvement of the diencephalon and certain portions of the brain stem. In Dorland's Illustrated Medical Dictionary (25 ed. 1965), 365, the cortex is defined as the outer layer or thin layer of gray matter on the surface of the cerebral hemisphere, and that it reaches its highest development in man, where it is responsible for the higher mental functions, for general movement, for visceral functions, perception, and behavioral reaction, and for the association and integration of these functions. The testimony

indicated that white matter is located under the cortex. It also reflected a system of nerves commencing with the spine, leading through the brain stem and spreading out in network fashion through the cerebral hemispheres, encompassing the white matter and cortex.

The brain stem is described as consisting of essentially three parts: the pons, the medulla oblongata, and the midbrain, with some authorities including the diencephalon. It is the stemlike portion of the brain that connects the cerebral hemispheres with the spinal cord. The brain stem, apparently, including the diencephalon, is the control for the respiratory functioning of the body.

In the absence of a clear history, Dr. Morse relied basically upon the decorticate posturing of Karen Quinlan and the respiratory difficulty for reaching his conclusion as to the brain lesion locations. He contrasted the decorticate posture to decerebrate posture of a patient for drawing his conclusions.

He asserted with medical certainty that Karen Quinlan is not brain-dead. He identified the Ad Hoc Committee of Harvard Medical School Criteria as the ordinary medical standard for determining brain death, and that Karen satisfied none of the criteria. These criteria are set forth in a 1968 report entitled, "Report of the Ad Hoc Committee of Harvard Medical School to Examine the Definition of Brain Death: A Definition of Irreversible Coma," 205 J.A.M.A. 85 (1968).

The report reflects that it is concerned "only with those comatose individuals who have discernible central nervous system activity" and the problem of determining the characteristics of a permanently nonfunctioning brain. The criteria as established are:

1. Unreceptivity and Unresponsitivity -- There is a total unawareness to externally applied stimuli and inner need and complete unresponsiveness * * *. Even the most intensely painful stimuli evoke no vocal or other response, not even a groan, withdrawal of a limb, or quickening of respiration.

2. No Movements or Breathing -- Observations covering a period of at least one hour by physicians is adequate to satisfy the criteria of no spontaneous muscular movement or spontaneous respiration or response to stimuli such as a pain, touch, sound or light. After the patient is on a mechanical respirator, the total absence of spontaneous breathing may be established by turning off the respirator for three minutes and observing whether there is any effort on the part of the subject to breathe spontaneously * * *

3. No Reflexes -- Irreversible coma with abolition of central nervous system activity is evidenced in part by the absence of elicitable reflexes. The pupil will be fixed and dilated and will not respond to a direct source of bright light. Since the establishment of a fixed, dilated pupil is clear-cut in clinical practice, there would be no uncertainty as to its presence. Ocular movement (to head turning and to irrigation of ears with ice water) and blinking are absent. There is no evidence of postural activity (deliberate or other). Swallowing, yawning, vocalization are in abeyance. Corneal and pharyngeal reflexes are absent.

As a rule the stretch of tendon reflexes cannot be elicited; i.e., tapping the tendons of the biceps, triceps, and pronator muscles, quadriceps and gastrocnemius muscles with reflex hammer elicits no contraction of the respective muscles. Plantar or noxious stimulation gives no response.

4. Flat -- Electroencephalogram -- of great confirmatory value is the flat or isoelectric EEG * * *.

All tests must be repeated at least 24 hours later with no change.

The validity of such data as indications of irreversible cerebral damage depends on the exclusion of two conditions: hypothermia (temperature below 90 degrees F.) or central nervous system depressants, such as barbiturates.

Dr. Morse reflected carefully in his testimony on Karen's prognosis. He described her condition as a chronic or "persistent vegetative state." Dr. Fred Plum, a creator of the phrase, describes its significance by indicating the brain as working in two ways:

We have an internal vegetative regulation which controls body temperature, which controls breathing, which controls to a considerable degree blood pressure, which controls to some degree heart rate, which controls chewing, swallowing and which controls sleeping and waking. We have a more highly developed brain, which is uniquely human, which controls our relation to the outside world, our capacity to talk, to see, to feel, to sing, to think. [ See Dorland's definition set forth heretofore.] Brain death necessarily must mean the ...

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