How Will Terri Schiavo Die? (ABC says death by starvation is peaceful)

Though the legal wrangling in the Terri Schiavo case has been loud and contentious, the brain-damaged woman's physical response to having her feeding tube removed is likely to be very serene.

"The process of starving to death seems very barbaric but in actuality is very peaceful," said Dr. Fred Mirarchi, assistant clinical professor of emergency medicine at Drexel University College of Medicine in Philadelphia.

"The patient's experience is really pretty benign," said Dr. Joanne Lynn, a hospice physician associated with Americans for Better Care of the Dying, a group working for improved end-of-life care. "Overwhelmingly, what will happen is nothing."

Lynn, who has worked with numerous families facing end-of-life situations, said most patients who are removed from life support will die within a matter of a few days or weeks.

"Some people can last four or five days — some people can last 20 days," she said.

Schiavo's feeding tube was removed on Friday afternoon following a contentious battle between her husband, who said his wife would not want to live in a vegetative state, and her parents, who wanted her kept on live support.

Schiavo's feeding tube was removed twice before, in 2001 and 2003. The second time, the tube was replaced after six days when Florida Gov. Jeb Bush signed a hastily passed law allowing him to intervene in the case. "Terri's Law" was later ruled unconstitutional.

The physical process of dying after life support is removed follows a pattern familiar to hospice workers. And the fact that Schiavo is in a vegetative state will likely make her death faster and less painful, Lynn said.

"It depends on whether she has the ability to swallow anything — and if that anything is offered," she said. "If she's unable to swallow anything, the course toward dying, so far as anyone can tell, is fairly comfortable."

Most patients who cannot eat or drink will enter a physical state known as ketosis. During ketosis the body begins to use fat and muscle as a fuel source.

In advanced cases of ketosis, the nervous system response is dulled, and patients rarely feel pain, hunger or thirst. There is also some evidence that ketosis can produce a state of well-being or mild euphoria.

Family members and friends are often surprised to find that a terminal patient's eyes will open and they will appear to glance around the room. "It's very confusing on an emotional level," said Lynn.

But Lynn explained that the part of the brain-controlling eye movement is actually very primitive and can remain active even after other parts of the brain appear to have stopped functioning.

"Cyclical breathing is very typical," Lynn said, adding that in some cases the patient will breathe very rapidly, then take just one or two breaths per minute.

Over time, the patient will become more and more dehydrated and will eventually develop kidney failure, Mirarchi explained.

"Patients at this point are uremic — filled with bodily toxins — and are unaware of their surroundings," Mirarchi said. "They develop electrolyte imbalances that eventually cause an abnormal beating of the heart."

In the final moments of life, the abnormalities in the patient's heart rate known as arrhythmia are common.

The efforts of caregivers may in some cases complicate the death of the patient. Giving a patient water, for example, may prolong the process. "Going without water makes it more gentle," Lynn said. "Allowing chemicals [in the blood] to cause arrhythmia is more merciful."

THE FINAL DAYS

Death from dehydration common, placid, doctors say

Removing a feeding tube from a patient who has no hope of recovery is a common practice that leads to a peaceful death, doctors say.

BY JACOB GOLDSTEIN

jgoldstein@herald.com

Unless an order is given to reinsert her feeding tube, Terri Schiavo will soon begin a peaceful decline that will lead to death in about two weeks, experts said Saturday.

She won't be aware of thirst, hunger or suffering, because the parts of her brain that create awareness were destroyed 15 years ago, according to the doctors who have examined her.

Schiavo will die of dehydration -- a common end for patients with no reasonable hope of recovery, and one widely believed to be essentially painless.

Patients who, unlike Schiavo, are conscious to begin with, lose consciousness about a week after the tube is removed. The body's systems fail in the following days, leading to ''a sort of peaceful slipping away,'' said Dr. John Kuluz, a University of Miami expert in pediatric critical care and brain injury.

Removing feeding tubes ''happens all the time,'' said Dr. Douglas Katz, a Boston University neurologist. ``It's a common procedure in people who have hopeless medical conditions, among them people in vegetative states.''

According to doctors, Schiavo is in a persistent vegetative state -- a condition of unconsciousness that persists endlessly, even though basic brain functions continue to cycle the body through periods of sleep and waking.

NO 'SENSE' OF PAIN

Vegetative patients can feel pain in a primitive sense -- reflexes might make them flinch when poked, for example. But they are not conscious of feeling pain or discomfort.

''Even though some of the pathways for sensation are intact up to a point, the part of the brain that processes information about sensation and feeling is not working,'' Katz said. ``A person who is unconscious or in a vegetative state cannot have any sense of discomfort or suffering.''

Even for patients who are conscious to begin with, death by dehydration appears peaceful, according to a study published in 2003 in the New England Journal of Medicine.

A survey of 107 hospice nurses who cared for terminally ill patients who chose to die by refusing food and water found that ``most deaths . . . were peaceful, with little suffering.''

The study asked nurses to rate the patients' deaths on a zero-to-nine scale, with nine being the best possible death; the median rating was eight.

Christine Exposito, a registered nurse at HospiceCare of Southeast Florida, said in about half of the cases in which one of her terminal patients loses the ability to survive without a feeding tube, the patient's family will allow the patient to die of dehydration.

ORGAN FAILURE

Dehydration is a gradual process. The body loses water through urination, perspiration and breath. After several days, the volume of blood in the body begins to decline because of the lack of water.

The concentration of toxins and carbon dioxide in the blood increases. All of the body's systems gradually become weaker.

After about 10 days, organ systems begin to fail. The kidneys and liver may stop filtering toxins from the blood. The muscles that drive breathing begin to fail.

Barring an intervention, Terri Schiavo will die in about two weeks when her heart, deprived of oxygen, stops beating.

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