Doctors vs. Parents: Who Decides Right to Life?
Darrin Murray was racing around the recovery room at Children's Memorial Hermann Hospital in a blind panic. His teenage stepdaughter was in agony and no one was doing anything to help her.
Two days before, 14-year-old Sabrina had come out of surgery for a sinus infection that had developed into a brain abscess. Doctors assured her parents that she would fully recover in a matter of weeks from what appeared to be a successful and relatively simple surgery.
But by the next day, Sabrina began feeling nauseous and complained of incredible pain. Nurses dosed her with morphine, but the drug didn't seem to help. Begging, "Help me," and "Please, do something," Sabrina began vomiting. She tore away at the dressing on her head and began pulling at her central line I.V.
In response, nurses doled out another round of morphine and strapped Sabrina's arms down with restraints.
On this day, Murray had already dashed out to the nurses station pleading for assistance four times in the last 20 minutes, but each time all the nurses told him was that they were paging the doctor and couldn't do anything without a physician's consent.
Suddenly, Sabrina's body seized. Her back arched, she rose up and gasped, then collapsed back into the bed. Murray says everything went quiet, everything except the terrifying dead-hum of her heart monitor. She had flat-lined.
"I almost had a heart attack because I thought she'd died," says Murray. "Everyone came in there and pushed me out of the room and ran a tube down her throat. I was panicking and crying, it was so awful."
The medical staff were able to revive Sabrina, and a doctor performed emergency brain surgery to reduce the swelling pressure in her head.
Sabrina's mother, Beatrice Lopez, who had to be at work, sped over to the hospital and arrived while her daughter was still in the operating room.
"Right after the second surgery," she says, "we went to see Sabrina and her head was so enlarged it just didn't look like her. A lady doctor appeared who we had never seen before, and she gave us the worst news that we could hear. The doctor told us that Sabrina'd had two strokes and because of them, she was in a coma that they didn't think she was going to come out of. And if she did, she would be a vegetable."
As shocking as the devastating news of their daughter's condition was, Lopez and Murray say it would not compare to what happened next.
Within about three days of the second surgery, Lopez says, doctors "started talking about our options. And we started getting scared, because the options were not good."
Lopez and Murray say that doctors and hospital staff began pressuring them to withhold treatment and feeding, which would ultimately starve Sabrina to death. To the parents, this was unacceptable. They wanted their daughter to live.
"I was very disappointed with the way Memorial Hermann handled things," Lopez says. "They put it out on the table that we were being selfish."
Murray and Lopez accuse the hospital staff, doctors and nurses of doing everything they could to try to end Sabrina's life during the ensuing six weeks, including:
• Refusing to implement simple procedures such as giving Sabrina feeding and breathing tubes that would have enabled the parents to take their daughter home and care for her themselves,
• Attempting to turn relatives and friends against Lopez and Murray by encouraging them to persuade the parents to withhold treatment, all the while violating federal privacy laws by discussing Sabrina's healthcare information,
• Entering two separate do-not-resuscitate orders against her parents' wishes, and
• Threatening the family with convening the hospital's ethics committee, which under Texas law can overrule the family's wishes and withhold life-support treatment from a patient.
"It was like we were caught in a bad dream," says Murray. "We couldn't believe this was happening."
Lopez and Murray allege that the hospital staff did not properly monitor Sabrina's sodium levels after the first surgery and did not give her the fluids she needed that they say would have prevented the strokes. Instead, doctors and nurses kept giving Sabrina morphine, a drug known to deplete sodium.
As Lopez and Murray saw it, the hospital and physicians that caused their daughter's condition were now trying to end her life. And it seemed like there was nothing they could do to stop it.
Terrified, Sabrina's parents called the nonprofit organization Texas Right to Life, which referred Lopez and Murray to an attorney. The parents were able to transfer Sabrina to Texas Children's Hospital, where Lopez says Martin received treatment that doctors at Memorial Hermann had refused to give, treatment that saved her life.
Now, two years later, Lopez and Murray are suing Memorial Hermann and Martin's doctors and nurses for allegedly failing to properly treat the teen. The family's lawyer, Robert Painter, says that in his opinion Memorial Hermann and the doctors and nurses working on the case wanted Sabrina to die to bury the evidence of malpractice and limit the potential damages in court. So far, Memorial Hermann and the others have denied any wrongdoing.
The family is seeking tens of millions of dollars to help pay for what will now be a lifetime of rehabilitation and care for their daughter. For, while Sabrina Martin's life was saved, she will never be exactly right again.
For more than three weeks during the early spring of 2006, Sabrina had been complaining of crushing headaches. At first her parents thought they might be related to stress.
Sabrina, a star athlete, was finishing up with basketball and was getting ready for track season. Plus, she was involved in a number of other after-school activities including the honor society and the yearbook. The teen was also starting to date, and was gearing up to take the TAKS standardized testing for eighth graders at Klein Intermediate School.
The family's pediatrician said the problem might be nutritional, so the doctor put her on a special diet and was supposed to see her again two weeks later. But Sabrina could not wait that long. She was desperate for relief.
One night while Lopez, a systems manager with AT&T, was in Beaumont working, Murray took Sabrina to the Houston Northwest Medical Center's emergency room. There, says Murray, doctors performed a brain scan and said they thought Sabrina had a tumor. In a hurry, the hospital loaded Martin into an ambulance and rushed her to Children's Memorial Hermann Hospital, located in Houston's Medical Center. As soon as Lopez heard the news, she raced back to Houston.
At Memorial Hermann, Lopez says, doctors determined Sabrina did not have a tumor but rather severe sinusitis and that the infection had leaked into the brain, causing an abscess. Doctors wanted to perform a craniotomy, drilling a small hole in Sabrina's head to drain the abscess.
"We never had any experience with anything like this," says Lopez. "Memorial Hermann, that's just where they drove her from the clinic. I always just thought that a hospital was a hospital and that all of the ones down there in the Medical Center were the same and quite reputable."
Memorial Hermann Healthcare System is a nonprofit organization comprised of 14 hospitals and dozens of specialty and outpatient centers. According to its Web site, the group has more than 19,000 employees and more than 4,000 medical staff members, with an annual payroll of more than $1 billion. Nearly 340,000 people visit its emergency rooms every year.
The Memorial Hermann system routinely wins numerous awards, including one in 2006 for its children's hospital, which was named the only healthcare facility in Houston and one of only six in the country to receive the Excellence In Life Support Award from the Extra-Corporeal Life Support Organization in Ann Arbor, Michigan, which backs the development of new therapies for the support of failing organ systems.
When asked for comment about Sabrina's case, Memorial Hermann spokeswoman Beth Sartori issued a statement saying, "Sabrina Martin's story is a sad one, and everyone associated with her care at Children's Memorial Hermann Hospital is deeply sympathetic to her and her family. However, because of the lawsuit against the hospital and the physicians that cared for her, we are not at liberty to comment further."
Memorial Hermann was one of a host of hospitals across the state that along with doctors and right-to-life groups endorsed the Texas Advance Directives Act, which the Legislature passed in 1999 and which was signed into law by then-Governor George W. Bush. (The right-to-life groups have now backed off their support of the Advance Directives Act and say the law is unfair and gives too much power to doctors.)
In essence, the law gives doctors the ability to either continue or withhold life-sustaining treatment against the wishes of the patient or the patient's legal guardian. To do so, the doctor presents his case before the family and an ethics committee, and if the committee agrees with the doctor's decision, the family is given ten days to find another facility that will comply with their wishes before treatment is either continued or withdrawn. Families are given a list of lawyers and organizations to help facilitate a transfer.
Texas and Virginia are the only two states in the country that have a time limit as part of such laws, Virginia's being 14 days for the family to find a transfer.
In Texas, the law has come under fire over the past several years. Families, their lawyers and right-to-life groups have battled doctors and health care facilities in the media and in court to try to prevent them from employing the act. In 2007, an attempt to lengthen the ten-day time period died in the Texas House of Representatives.
In general, opponents — ranging from rightwing, right-to-life groups all the way to the American Civil Liberties Union — say the law gives too much power to the hospitals and doctors and takes away individuals' civil rights to determine their own fate.
Proponents, mostly those in the health field, argue that it creates a necessary safe harbor for physicians when further medical treatment is deemed inappropriate and emotionally invested family members can't be objective. They say the law is only invoked when patients are terminally or irreversibly ill and when physicians believe that their treatment is merely prolonging the dying.
Even though the ethics committee never formally convened in Sabrina's case, activist organizations say Memorial Hermann and the doctors who work there have a quicker trigger finger than others when it comes to invoking the law.
Elizabeth Graham is the Director of Texas Right to Life, the only organization in the state on the call list provided to families in Texas who are notified that an ethics review is forthcoming. She says that while no formal statistical database exists, her group has received calls from 30 families throughout the state facing the ten-day law over the last three years, with nearly 17 percent coming from relatives with patients at Memorial Hermann in Houston.
"Memorial Hermann is the place from whom we receive the most frequent calls," Graham says. "They tend to rush towards running the ten-day clock."
Graham does concede that because of Memorial Hermann's size and because the system serves such a large number of people, her statistics could be skewed.
Dr. Robert Fine of Baylor Healthcare Systems in Dallas, speaking on behalf of the Texas Medical Association, an organization representing 43,000 doctors and medical students, says it's not fair to label one hospital or another as having a quicker trigger.
"I just think that's absurd," he simply says, "and I think that's wrong."
Graham says another disturbing pattern she sees at Memorial Hermann is doctors entering orders not to resuscitate patients without first checking with or gaining consent from the families.
"It's a totally separate mechanism that accomplishes the same goal," says Graham, "but much quicker."
In Sabrina's case, doctors entered two orders not to resuscitate the teen, according to Sabrina's medical records.
"Hospitals routinely do that," Graham says. "In another case at Memorial Hermann, we were participating in an ethics committee process and the neurologist who had done brain surgery... he said that he put a DNR in the file. We asked, 'Did you consult with the patient's mother? Did you have any indication this is what the patient wanted?' And he said, "No, we do it all the time.' The doctor just decided to put a DNR on this patient. And I can think of two others right off the top of my head. And mind you, for all of this, these are only the ones who call us for help. There could be countless others."
Fine says that orders not to attempt resuscitation are almost always done in collaboration and with consent of the patient's family.
"I'd say it's that way 99.999 percent of the time," he says. However, "A doctor can write a [DNR] order on a patient if they feel that it is appropriate for the patient. No law prohibits that."
Fine concedes that because there is no database on the number of orders not to resuscitate that are entered or the number of times any one hospital convenes its ethics committee to decide whether to withdraw treatment, it's difficult to know which hospitals, if any, employ the laws more often than others.
"In most cases," he says, "because of the (privacy laws), we can't discuss them."
Graham says there is very little Texas residents can do to protect themselves if something goes wrong and they find their loved one's case in front of an ethics committee.
"The standard mantra has been to get the patient's wishes laid out in writing beforehand," she says. "But in Texas this means nothing because they can override it. It can be somewhat helpful, though, because if your wishes are spelled out, you have a stronger case if you have to go to court. What I would recommend is to call hospitals and ask what the hospital policies are."
About a day after being told her daughter was in a coma, Lopez was sitting in the waiting room outside the intensive care unit when suddenly Lopez's stepmother came rushing over.
She told Lopez that she had been hanging around the hallway when a nurse came up and asked when Sabrina's funeral was going to be.
It took all the strength Lopez could muster not to break down and cry.
"I was so devastated and confused," says Lopez. "I didn't know if it was the truth or what. At this point, I didn't feel in good hands and I was starting to distrust the whole system completely."
This was only the beginning, Lopez and Murray say, of what became a horrifying pattern of hospital workers going behind their backs, talking to family members and trying to get them to yank the plug on Sabrina.
They claim that for days following Sabrina's second surgery, nurses and doctors were pulling extended family members aside, trying to encourage them to persuade Lopez and Murray to stop treatment, that it was the right thing to do.
"We ended up quarreling with family members who took the hospital's side," says Lopez. "It was chaos. Even now, it's still really hard and I don't talk to some of them anymore."
At one point, Lopez says, she called everyone who knew her daughter to tell them what was going on, including Lopez's former boyfriend living in Illinois. Daniel Martin, who showed up at the hospital, may be Sabrina's biological father, but Lopez and Painter say he has no legal rights and has had minimal involvement in Sabrina's life.
Painter says that doctors spoke with Daniel Martin, who sided with the physicians, but there was one glaring problem. As with all the other extended family members who agreed to withhold treatment, Daniel Martin had no say over the matter, and in fact, says Painter, it was a violation of federal privacy laws for anybody at Memorial Hermann to discuss the teen's medical condition with anyone other than Lopez and Murray, the legal guardians.
"I ended up writing a letter that I faxed to the hospital administration about the privacy law violations," says Painter. "And 20 minutes later, I got a call back and Daniel Martin was out of the picture. The hospital tried to split the family, and they do that quite frequently."
As Lopez and Murray would discover, however, that was just the start of the hospital's behind-the-curtain tactics.
Three days after Sabrina's second surgery, one of her doctors entered an order not to resuscitate her, says Painter. Lopez and Murray had no idea he had done so. They say they did not want the order put in. According to hospital records, the same day that the instruction was entered, a social worker documented that it "appeared (Lopez and Murray) did not agree with the recommendations for DNR as of yet."
Then, two days later, a different doctor issued a second order not to resuscitate Sabrina, the very day that hospital records show Lopez had requested a second opinion from another neurologist.
"I felt so violated," says Lopez. "I couldn't believe they would do this. I mean, we're talking about a hospital; they're supposed to have the patient's best interest, and this was way too soon to be giving up."
Lopez was further dumbfounded when doctors refused to insert a feeding pipe, called a G-Tube, or perform a simple tracheotomy, placing a breathing tube into Sabrina's neck, allowing her to leave the hospital so that Lopez could care for her daughter at home.
"They never proposed the G-Tube and trach," says Lopez. "I researched the options and said we wanted that. But Memorial Hermann wouldn't do it, saying she wouldn't have a high quality of life. And I was very disappointed because I was like, 'How do you define quality of life?' She doesn't need to play basketball as long as she can understand what we're saying."
Painter says he was appalled to learn how the hospital's ethics committee conducted itself. He alleges that the hospital's then-chief ethicist, who is no longer with Memorial Hermann, took an informal poll of committee members before convening the panel. However, the votes were not there, so the group never officially met.
"It's shocking how they did this," says Painter. "Instead of being neutral, the ethicist was acting like a floor whip in Congress. The one saving grace was that one doctor said he saw brain activity and that Sabrina may survive."
Painter and his clients believe that all these alleged attempts to end Sabrina's life were an effort to cover up the mistakes that led to her condition.
"You have a patient who comes out of surgery and is doing fine," says Painter. "But as time quickly moves on, she becomes combative, her speech changes, her motor skills go weird, her sodium levels are diving, she's in pain, pulling her turban and her central line, and they have her tied down and just keep giving her morphine to mask the symptoms and just ignore the real problem until she goes into arrest. It's absolutely incredible."
In Texas, if doctors follow the Advance Directives Act, successfully withdrawing treatment, and the patient dies, they are immune to being sued for the death, says Painter. If medical error caused the condition leading to the withdrawal of treatment, the doctors and hospital can still be liable, but the amount of money potentially owed is substantially less because the patient is dead and will not require large sums to pay for extended medical care.
"There's a conflict of interest here because there's an economic incentive to misuse the law," says Painter. "In my opinion, what they were trying to do was literally bury the malpractice."
Sabrina Martin's case illustrates a growing debate over whether doctors accused of medical error should still be able to unilaterally enter orders not to resuscitate patients or to invoke the Advance Directives Act.
"The assumption, I think, has always been that you have to assume doctors are acting in good faith," says Burke Balch, director of the National Right to Life's Robert Powell Center for Medical Ethics in Washington, D.C. "Yet, human nature is such that people do engage in cover-ups and people do make mistakes. There can be simple bad actors and flat-out malpractice that this (law) provides an opportunity to cover up. And human nature being what it is, that's what tends to happen."
Dr. Robert Fine points out that hospitals cannot initiate the Advance Directive law, only doctors can. And the physician who does invoke the law cannot sit on the ethics committee. In addition, Fine does not believe doctors and hospitals are in cahoots, because in most facilities throughout Texas, hospitals do not employ doctors, rather physicians work as independent agents.
"In my judgment," Fine says, "there's no way for a doctor to use this, to, let's say, hide a mistake. As a matter of fact, if a doctor wants to 'hide a mistake,' the last thing they're going to do is call in an independent committee."
State Representative Garnet Coleman, (D-Houston), who helped author the 1999 act, tends to agree with Fine. When asked if he thinks the law is sometimes used to bury malpractice, he says, "I would hope not, and that's why we have autopsies. I don't think that the law either encourages it and I don't think that it discourages it. As long as you've had an autopsy, then you would find out what was the cause of death and whether there was a medical error."
Texas ethicist William Winslade has a slightly more humanistic take.
"I'm sympathetic to doctors who don't want to provide life-support or treatment to people with incurable diseases," he says. But "in a case where the person's condition was the result of alleged medical error, I think that the hospital would be prudent and it would be morally appropriate for the hospital to prolong the process and not simply invoke the process because they can."
Imagine being conscious and aware, fully able to understand what people are saying, yet virtually unable to walk, talk, eat or go to the bathroom on the toilet.
This is the world of Sabrina Martin.
Her short-term memory is not what it used to be, say her parents, but Sabrina can remember practically everything up until her second surgery two years ago. For a while she was able to speak, but recently she has regressed and has difficulty finding her voice.
"Because she is in this locked-in syndrome," Sabrina's physician, Dr. Sharon Kawai, says during a taped interview with Painter, "she knows what she was able to do before and that she's not able to do now."
Lopez and Murray say they must be careful around their daughter not to talk about the hospital and their efforts to save Sabrina because she gets visibly upset and it can take an entire day to calm her down. And then there's the nightmares.
"She would wake up screaming, 'I don't want to die,'" says Lopez. "And we would sit up with her and rock her back to sleep. It was like she was stuck in that traumatic moment when all that craziness was happening at the hospital."
Shortly after transferring to Texas Children's Hospital, Sabrina began to improve so dramatically that doctors recommended she not go home but rather be moved to a rehabilitation facility in San Antonio. There, at Kindred Hospital, Sabrina emerged from her coma. Doctors were able to remove her breathing tube and Sabrina began getting better, even advancing to the point where she was able to help her younger sister do math homework by counting on her fingers. Doctors now say Sabrina should have a full life expectancy.
"The people at Memorial Hermann said this would never happen," says Lopez.
Today, Sabrina must wear a diaper and primarily eats through her feeding tube, but she can swallow some soft foods like mashed potatoes and drinks from a bottle. She is wheelchair-bound, but can partially stand when lifted out of her seat. Occasionally she'll whisper, but mostly she nods her head and makes noises to express herself.
Still, it's a long way from being a "vegetable," say Lopez and Murray. And to them it's a blessing.
"It's all small improvements," says Lopez, "but to us they're major."
Starting this summer, Sabrina will begin attending Special Education classes at Klein Intermediate in hopes of doing well and continuing on with school in the fall.
While Lopez continues to work full-time, Murray quit his job as a salesman two years ago and takes care of Sabrina at home. But he has help.
Davida Veal was a former classmate and basketball teammate of Sabrina's before the surgeries, but now she calls Martin her best friend in the world. Two years ago, Veal decided to help care for Martin. She moved out of her own home and is living with Lopez and Murray, sharing a bedroom with Martin.
Every day after classes, Veal says she comes home and hangs out with her friend, telling Sabrina about the latest gossip at school, watching TV, combing her hair or just holding Sabrina's hand while she sleeps. Nothing brings Veal more joy, she says, than when she cracks a joke that makes Sabrina laugh.
Veal becomes sad and cries, however, when remembering life before the surgeries.
"We can't do the same things we used to do together," she says. "And it all happened so fast. I mean we were in eighth grade taking our TAKS together and she was fine except for her headaches, and then a couple days later she was in the hospital. When I first found out what happened, I didn't think it was going to hurt me as much as it did. And then I just felt that I needed to do more than I normally would."
For Veal, that meant going to her parents and asking if she could move in with Martin.
"At first my parents were like, 'We don't want you to be away from home,' but then I begged and begged and told them that I promised myself that I would not leave her side," says Veal. "I mean, I miss my family, but for me it's worth it. I don't have a problem doing it because it's my choice and it's what I want to do."
Lopez and Murray feel the same way.
Sabrina's mother calls her daughter "My Sleeping Beauty" because Sabrina dozes off much of the time. Caring for her is not easy, but her parents says it's far better than the alternative presented to them by the folks at Memorial Hermann.
"I'm so glad we did what we did," says Murray. "It's a lot of work. But it's better now than it was at first. Some days I just want to go up to those doctors and say, "See, look at her now."