Decision Making in End-of-life Circumstances

Decision Making in End-of-life Circumstances

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Decision Making in End-of-life Circumstances

Traveling home on a cold January evening in 1983, a car loses control going around a slippery corner. The car spins, then flips, and the woman inside is thrown into a ditch thirty feet from where the car eventually comes to rest. She sustained numerous injuries and eventually stopped breathing. By the time paramedics arrived, she had not taken a breath for at least 15 minutes, her blood pressure was 0 over 0 and her pulse was 0 beats per minute: This is what is known as a “Code Blue” (PBS Frontline). Twenty minutes had passed before adequate amounts of oxygen had reached her brain. (Permanent brain damage generally results after six minutes without oxygen.) The woman’s name is Nancy Cruzan and her story is considered one of the most important milestones in the development of “right to die” policies in the United States because it is the first right to die case the Supreme Court ever heard.

After extensive evaluation following her accident, Nancy was diagnosed with “probable brain damage compounded by significant oxygen deprivation” (Sisters of Leavenworth). Nancy remained in a coma for approximately three weeks and then progressed to an unconscious state in which she was able to ingest some nutrients orally. However, it soon became too difficult for Nancy to orally ingest the proper amount of nutrition, and it was necessary to implant a feeding and hydration tube. The tube was placed under consent from her father. Nancy’s eyes were open and she could move her mouth, but she did not have an understanding of what she heard or saw and could not speak. Nancy was described as being in a “permanent vegetative state” (American Medical Association).

Ten months after her tragic accident, Nancy was moved to a state hospital, where various treatments and rehabilitative efforts were shown to be unsuccessful. After the realization that Nancy would most probably never regain her mental faculties, her parents Joe and Joyce Cruzan asked for the cessation of the administration of medically assisted nutrition and hydration via the gastronomy tube. The hospital did not feel they were authorized to honor the family’s request without court approval (Sisters of Leavenworth). The family was now faced with the emotional difficulties of requesting the removal of the same tube of which they had authorized the placement just a short time before.

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The Cruzan family asked a Missouri trial court for a declaratory judgment in which they requested that the court order the hospital to remove the feeding tube. The court then appointed a guardian ad litem for Nancy. The trial court directed the hospital to honor the family’s wishes to remove the feeding tube based on the following:

(1) the permanent and irreversible damage that she had suffered as a result of prolonged oxygen deprivation; (2) its belief that a person in Cruzan's condition had a fundamental right under the Missouri and Federal Constitutions to refuse or direct the withdrawal of "death prolonging procedures"; and (3) her expressed thoughts at age twenty-five, in somewhat serious conversation with her housemate, that if sick or injured, she would not wish to continue her life unless she could live at least halfway normally, suggested that she would not wish to continue on with her nutrition and hydration given her present condition.

(Sisters of Leavenworth)

The state and guardian ad litem appealed the decision to the Supreme Court of Missouri, where the ruling of the lower court was reversed. The Cruzan family appealed to the United States Supreme Court, but lost because the court found that “due process was not violated by the Missouri requirement that an incompetent person's wishes in regard to the withdrawal of life-sustaining treatment be proved by clear and convincing evidence” (Sisters of Leavenworth). The Cruzan family continued working with the courts in Missouri and eventually was able to provide enough proof through further witnesses to show sufficient evidence of Nancy’s wishes to discontinue the artificial nutrition and hydration, and her feeding tube was removed. Two weeks later Nancy Cruzan died. Her head stone reads:

“Born July 20, 1957 / Departed January 11, 1983

At Peace December 26, 1990.”

(American Medical Association)

The family and friends of Nancy Cruzan have established The Cruzan Foundation to honor the life of Nancy, as well as help others in similar situations. Through the resources of the foundation, members of the Cruzan family are able to share their experiences and speak with other families about end-of-life decision making. For more information on The Cruzan Foundation visit their website at Following Nancy’s death, William H. Colby, the Cruzan family’s attorney, wrote a book depicting the story of Nancy Cruzan and her family’s legal battle to peacefully allow her life to end. In the book, Long Goodbye: The Deaths of Nancy Cruzan, Colby portrays a family’s suffering from the loss of their daughter, while also describing the ways in which the Cruzan case was instrumental in leading to new policies that are specific to decision making in end-of-life circumstances.
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