On 14 December 1989, Helga Wanglie, eight-six, broke her hip when she slipped on a rug in her Minneapolis home. After the hip fracture was successfully treated at the Hennepin County Medical Center (HCMC) she was discharged to a nursing home. She was re admitted to HCMC on 1 January 1990 when she developed respiratory failure and was placed on a respirator. Over the next five months repeated attempts to wean Mrs. Wanglie from the respirator were unsuccessful. During this initial admission, Mrs. Wanglie was conscious, aware of her surroundings, could acknowledge pain and suffering, and could recognize her family.
The hospital was unable to wean Mrs. Wanglie from the respirator, and on 7 May 1990 she was transferred to another facility that specializes in the care of respirator-dependent patients. When further attempts were made to wean her from the respirator at t he new facility, she experienced a cardiopulmonary arrest on 23 May. She was resuscitated and then transferred to another acute care hospital in St. Paul. She was now felt to have extremely severe and irreversible brain damage. Because of this dismal p rognosis, a hospital ethics committee reviewed her case and doctors discussed with the family the possibility of limiting further life-sustaining treatment. However, the family resisted this idea and requested that Mrs. Wanglie be transferred back to HCM C, where they felt she had received excellent care.
Since readmission to HCMC on 31 May 1990 the patient has been vigorously treated with continued respirator support, antibiotics for recurrent pneumonia, artificial feeding, and treatment for electrolyte and fluid imbalance. Initial diagnosis on readmissio n to HCMC was persistent vegetative state secondary to severe hypoxic-ischemic encephalopathy. Over the next several months repeated evaluations by the neurology and pulomnary medicine services confirmed the diagnosis of permanent unconsciousness (persi stent vegetative state), and permanent respirator dependy becuase of chronic lung disease.
Because of her age, previously prolonged hospital stays at HCMC in early 1990, multiple medical complications, ultimately unsuccessful weaning from the respirator, and neurologic condition, the medical staff caring for Mrs. Wanglie viewed her prognosis as extraordinarily poor. They did not believe that the respirator could benefit her. However, the immediate family--her husband, daughter, and son--insisted that all forms of treatment be continued. In view of the fact that recovery from cardiac arrest w ould be extraordinarily unlikely, the family did reluctantly agree to a DNR order.
Oliver Wanglie understands that his wife is unaware of herself, her sourroundings, and his visits. When asked if he understood the medical diagnosis and that the patient would not recover consciousness or improve in any significant way, he replied, "That may be true, but we hope for the best." The family's reluctance to discontinue treatment is based on religious and personal grounds. Mr. Wanglie has said that only God can take life and that doctors should not play God. Prior to December he told hospi tal staff that his wife had not discussed these issues, and that her views were a "black box."
Because of the conflict between the medical staff's view of Mrs. Wanglie's dismal prognosis and the family's insistence on intensive treatment, the HCMC ethics committee became involved in the case shortly after the second admission. The initial advisory opinion from the ethics committee was that hospital staff should err initially on the side of continuing treatment and following the wishes of the family, and make every reasonable attempt to resolve conflicts between the family's wishes and the views of the hospital staff. In late 1990 it became apparent that the conflict between the family's insistence on continued medical treatment and the hospital staff's strong feeling that further treatment was not indicated could not be resolved.
Several family conferences were held in November and December. The family was told that the attending physicians caring for Mrs. Wanglie had concluded that continued use of the respirator could not serve the patient's interests. On 3 December a conferen ce was held with hospital staff, the Wanglie family, and Dr. Steven Miles, representative of the hospital ethics committee and petitioner in this case. After this conference, in a letter dated 3 December, Oliver Wanglie wrote, "My wife always stated to m e that if anything happened to her so that she could not take care of herself, she did not want anything done to shorten or prematurely take her life."
In a letter to Mr. Wanglie the hospital's medical director responded:
All medical consultants agree with [the attending physician's] conclusion that continued use of mechanical ventilation and other forms of life-sustaining treatment are no longer serving the patient's personal medical interest. We do not believe that the hospital is obliged to provide inappropriate medical treatment that cannot advance a patient's personal interest. We would continue life-sustaining treatment on the order of a court mandating such treatment. In view of the extraordinary nature of your r equest [to continue treatment], we ask that you file petition to obtain such an order by December 14.
When it was obvious that the family refused to file a petition on its own, the hospital filed papers with the Fourth Judicial District Court, Hennepin County, on 8 February 1991.
The costs of Mrs. Wanglie's care are reimbursed by Medicare and Physicians' Health Plan, a private supplementary insurance plan. By the time this case was first heard in court on 28 May the costs for both hospitalizations (at HCMC) were approximately $80 0,000.
The principal parties do not dispute most of the medical facts. The family accepts the diagnosis of persistent vegetative state and respirator dependence.
The hospital is willing to let Mrs. Wanglie's family transfer her to another facility where she would continue to receive vigorous treatment, including respirator support. Both the hospital and the Wanglie family have made determined efforts to find anot her physician or health care facility in Minnesota willing to take Mrs. Wanglie in transfer. These efforts have, thus far, been unsuccessful, though other providers would be willing to care for her were she not respirator dependent.
The hospital is seeking appointment of a conversator to represent the patient to decide whether continued treatment is appropriate. It is not directly requesting the court to discontinue treatment immediately over the objections of the family. In seekin g court involvement, the hospital and its ethics committee are aware that there has never before been a case in the United States of a hospital seeking a conservator to consider nontreatment when the immediate family has strongly and unanimously objected. The major point of the hospital's current position is that the family cannot demand that physicians continue to give treatment that is not in the patient's best personal medical interest.
Ronald E. Cranford,
Department of Neurology
Hennepin County Medical Center