A Question of Life

Doctors told Mark and Karla Miller their unborn daughter would face a life of pain and illness. Then, against the Millers' wishes, Woman's Hospital did everything it could to keep the newborn alive. Last month, after an extraordinary trial in a Houston co

And what a reimbursement. Hospital delivery charges for full-term newborns increased 40 percent over the study's five-year period. Meanwhile, the delivery charges for sick babies and "preemies" increased an incredible 214 percent.

Doctors, of course, aren't thinking of a hospital's bottom line when a patient's life is at stake, but they're always aware that their decisions may be second-guessed in a courtroom. Plavidal was certainly aware of that possibility. A decade earlier, he had given parents a poor prognosis for their 23-week-old fetus. Doctors recommended that the newborn's life not be artificially prolonged. The parents agreed, and the infant died two hours after birth. Four years later, Plavidal and the hospital were sued by the parents.

At about 4:30 p.m., a couple of hours after the Millers made their heartbreaking decision, Jacobs examined Karla in her room. As he left her bedside, he summoned Mark into the hallway.

"The hospital wants you to sit down and talk to some people," Jacobs said. "It would be a favor to me."

He took Mark down the hall to an unoccupied hospital room, where four people, including Plavidal and Anna Summerfield, the director of neonatal intensive care for Woman's Hospital, were waiting. Though the tone of this meeting has been disputed, the gist of the discussion and the ultimate outcome have not. Jacobs introduced everyone, and, according to Mark Miller, stepped back against a wall.

Summerfield took charge, saying she was aware of the Millers' decision to withhold neonatal treatment from their baby. However, she said, the hospital's policy required resuscitation and care of any live-born child weighing at least 500 grams. Mark explained that he and Karla had talked it over with Kelley and Jacobs, and that the physicians agreed with their decision not to prolong the infant's life artificially.

Summerfield repeated the hospital's policy, adding that if the Millers could not abide by it, she would help arrange Karla's transfer to another hospital. Mark asked to see a copy of the hospital's written policy.

"Are you a lawyer?" asked Plavidal.
"No," Mark replied, "but I can have one here in ten minutes."
Plavidal assured Mark that he didn't need an attorney and then offered to share two personal anecdotes. The first was the story about the parents who sued for the nontreatment of their premature infant. The other, also involving the birth of a 23-weeker, had a happier ending. The child weighed 705 grams at birth, Plavidal said, and showed vigorous signs of life. It was immediately put on life-support by a neonatologist. Four months later, this extremely premature infant left the hospital and grew to be a healthy boy.

The point, Plavidal stressed, is that no one knows whether a child will live or die; therefore, physicians are duty-bound to pursue life. Dr. Charleta Guillory, the resident neonatologist at Woman's, agreed. Guillory explained that the state-of-the-art capabilities of the hospital's neonatal intensive-care unit, coupled with recent advances in the practice, would ensure the Millers' child the best care available anywhere.

Mark was stunned. He and Karla were intelligent people, making what they considered to be an informed decision. Yet no one was listening. Meanwhile, he was being subjected to a sales job. Mark looked sadly around the room, sized up his smaller adversaries and flippantly said:

"What if I stand in the delivery room door and don't let anyone in?"
In court many years later, he recounted Summerfield's reply: "If you do anything to interfere with hospital procedure, you will be removed from your wife's bedside by security."

Nonetheless, Mark refused to give his consent to resuscitate the child. Shortly before 11 p.m., Karla was wheeled into the delivery room. Green sheets had been hung in front of the overhead mirrors that allow mothers to watch their babies being born. Another sheet was placed before Karla's face. Sidney came so quickly that delivering physician Robert Anding, Jacobs's partner, was still scrubbing in an adjacent room. The nurse actually took Sidney from Karla's womb.

She was blue, limp and silent. Her heart rate was a sluggish 80 beats per minute. The nurse handed the infant to the neonatologist on call, who attached her to a mechanical ventilator. Two hours later, Sidney was in the neonatal intensive-care unit, where she would remain on life support until early December. In her first 24 hours of life, she underwent a spinal tap and multiple blood transfusions. She received experimental therapies such as intramuscular shots of Vitamin E and doses of surfactant, which expands undeveloped lungs to make breathing easier. Then there was something called a "TPN protocol" -- an injection of liquefied saturated fats. That treatment, also considered experimental, provided the nutrition that Sidney's stomach and bowels were too undeveloped to handle.

Two days after her birth, Sidney's brain began to bleed. It was too early to gauge how much damage would result, but her medical chart reported several alternative prognoses: Grade II hemorrhage, 40 percent chance of cerebral palsy; Grade III, 75 percent chance; Grade IV, 95 percent chance.

On August 19, Karla Miller was well enough to visit the neonatal intensive-care unit for her first look at Sidney. There wasn't much to see, really, just an impossibly small human being about the size of a man's hand. Sidney's face did not have the cherubic folds of flesh of a healthy newborn, but was swallowed up by an oxygen mask connected to a mechanical ventilator. Her eyes, which were fused shut for almost a month after birth, were covered by bandages. Tubes and catheters sprouted from her gelatinous skin. Her pain, which must have been intense, was dulled by doses of phenobarbital and morphine.

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