Guardianship of Hamlin, Matter of
| Decision Date | 01 November 1984 |
| Docket Number | No. 49101-1,49101-1 |
| Citation | 102 Wn.2d 810,689 P.2d 1372 |
| Parties | , 53 USLW 2250 In the Matter of the GUARDIANSHIP OF Joseph HAMLIN, An Incompetent Person. |
| Court | Washington Supreme Court |
Bogle & Gates, Robert A. Stewart, Seattle, for appellant.
Ken Eikenberry, Atty. Gen., James B. Wilson, Steven Milam, Asst. Attys. Gen., Seattle, for Harborview Medical Center.
Norman K. Maleng, King County Prosecutor, Fred A. Kaseburg, Stephen Sewell, Deputy Pros. Attys., Seattle, for King County.
The main issue is a determination of who, if anyone, has authority to authorize the withdrawal of life support systems when (1) the patient has only minimal brainstem activity and (2) the patient has been severely mentally retarded since birth, therefore never expressing his wishes about termination of life support.
While this case was on appeal, Joseph Hamlin, the patient/ward, died. Because the issues presented clearly met our criteria for deciding moot cases, we retained the matter for decision. Sorenson v. Bellingham, 80 Wash.2d 547, 558, 496 P.2d 512 (1972).
While Joseph Hamlin is now deceased, we mention the facts of his condition to give perspective to the problems facing doctors, hospitals, courts, families and guardians as they attempt to resolve the issues in cases of this nature.
Hamlin, blind and severely retarded since birth, was 42 years old when admitted to Harborview Medical Center (hereinafter Hospital) on June 15, 1982, for treatment of severe pneumonia and hypoxemia. On June 25, 1982, the Hospital filed a petition in superior court seeking appointment of a guardian for Hamlin because "[the patient was] critically ill and ... [was] incapable of understanding his illness or intelligently consenting to care." The court appointed attorney Sally Pasette as guardian ad litem. After her investigation, the Foundation for the Handicapped (hereinafter Foundation) agreed to accept guardianship of Hamlin. The Foundation was appointed guardian; the guardian ad litem was discharged.
Hamlin's mental age had been assessed at approximately one year. His self-help age was assessed at 1.2 years and his I.Q. was estimated to be between 6 and 13. He was able to feed himself with a spoon and drink from a glass; he could indicate his general wants and demonstrate pleasure and displeasure.
After admission to the hospital, Hamlin was placed in intensive care, given antibiotics and placed on a mechanical ventilator. This treatment proved effective and on July 15, 1982, the antibiotics were discontinued and he was removed from the ventilator. During this period Hamlin appeared to be awake, he opened his eyes and mouth and moved his extremities spontaneously.
On July 19, 1982, Hamlin suffered cardiorespiratory arrest from which he was resuscitated. The lack of oxygen, however, had completely destroyed cerebral cortical activity. Afterward, his neurological function consisted of only brainstem function (function of the primitive control area which controls breathing, heart rate and other automatic functions located in the region where the spinal cord enters the brain). Technically, Hamlin's neurological status was: he maintained cardiac activity; he maintained attempts at breathing; he had slight withdrawal of the extremities to deep pain; and he had corneal reflexes. He did not have any spontaneous muscle movements and showed no evidence of any neurological activity above the brainstem.
The attending physicians testified that recovery of any neurological function by Hamlin beyond his then level of brainstem activity would be unprecedented. Furthermore, removal of life support systems would be expected to cause his respiration to cease in a short time and his body would die naturally. They also asserted that in such cases it was medically and ethically wrong to continue life support systems. Therefore, the medical staff recommended that Hamlin not be resuscitated in the event of cardiopulmonary arrest or respiratory failure, withdrawal of mechanical ventilation and no further treatment with antibiotics.
Hamlin had no family, relatives or close friends with which the medical staff could consult concerning his treatment. The treating physicians asked Hamlin's guardian, the Foundation, to consent to termination of the mechanical ventilator. The Foundation refused to consent because it believed it lacked authority to so consent and that consent was prohibited by RCW 11.92.040(3). After this refusal the Hospital petitioned the superior court for an order authorizing termination.
The trial court reappointed attorney Pasette as Hamlin's guardian ad litem. The guardian ad litem's position was that (1) no invasive measures should be taken in the event of a cardiopulmonary arrest, and (2) removal from mechanical ventilation should not be done until brain death occurred. The Foundation argued the same points as outlined earlier.
The trial court heard testimony from Hamlin's two attending physicians, testimony from a physician who examined Hamlin at the request of the Foundation, and also received Hamlin's medical records. Those records show that at least 20 physicians examined Hamlin. All physicians reached the same conclusion, to wit: Hamlin was in a vegetative state, completely unresponsive to his surroundings, unable to breathe without a respirator and with virtually no prospect of recovery to his preadmission condition.
Based on the foregoing, the trial court concluded that it was in Hamlin's best interests to authorize the withholding and withdrawal of life sustaining treatment. The court entered an order holding:
1. In the event of cardiopulmonary arrest or respiratory failure, Hamlin should not be resuscitated;
2. Hamlin should not be provided antibiotics in the future;
3. The mechanical ventilator should be withdrawn from Hamlin and not reapplied;
4. The foregoing order should not be implemented until the time for appeal has expired.
It was stipulated by the parties that the order should not be implemented until the case had been decided on appeal.
The first issue is whether the guardian, as part of its duty to care for and maintain the ward, may terminate life support systems. RCW 11.92.040(3) provides in part:
It shall be the duty of the guardian ...
(3) Consistent with the powers granted by the court, if he is a guardian or limited guardian of the person, to care for and maintain the incompetent or disabled person, assert his or her rights and best interests, and provide timely, informed consent to necessary medical procedures The guardian argues that the statutory words "care for and maintain", absent definition by statute or judicial decision, must be given their usual and customary meaning. Admittedly, a literal dictionary definition would seem to exclude authority to consent to termination. A decision to terminate life support systems, however, transcends dictionary definitions. Absent an applicable constitutionally valid statutory procedure to resolve this most fundamental question, we must fashion procedures to provide guidance to those who must directly face termination decisions.
The duties of the guardian are defined in RCW 11.92.010 et seq. The statute provides that the guardian is to assert the ward's rights and best interests and provide timely, informed consent to necessary medical procedures. RCW 11.92.040(3). Thus, the guardian has the duty and, therefore, the power to act in the best interests of the ward, to assert the ward's rights, and participate in medical decisions. Just as medical intervention is, in the majority of cases, clearly in the best interests of the ward, nonintervention in some cases may be appropriate and, therefore, in the ward's best interest. We emphasize that these decisions must be made on a case-by-case basis with particularized consideration of the best interests and rights of the specific individual. We also stress the distinction between treatment which is expected to result in some measure of recovery and that which merely postpones death. See, e.g., Superintendent of Belchertown State Sch. v. Saikewicz, 373 Mass. 728, 370 N.E.2d 417 (1977); In re Storar, 52 N.Y.2d 363, 420 N.E.2d 64, 438 N.Y.S.2d 266 (1981).
All physicians who examined Hamlin agreed with the diagnosis that he was in a persistent vegetative state with no prospect of regaining his cognitive functions, maintained by life support systems, and that withdrawal of those systems would lead to his natural death in a short time. Under these circumstances the guardian could conclude that it was in Hamlin's best interests to terminate the life support systems. We hold, therefore, that the guardian did have authority to consent to withdrawal of life support systems. In re Colyer, 99 Wash.2d 114, 660 P.2d 738 (1983); Custody of a Minor, 385 Mass. 697, 434 N.E.2d 601 (1982); In re P.V.W., 424 So.2d 1015 (La.1982).
The guardian also argues that RCW 70.122, the Natural Death Act (NDA), prescribes the exclusive method for withholding or withdrawing life sustaining procedures. While that act evidences a public policy recognition of that right, it is not exclusive. Colyer illustrates our conclusion that the act is not the only source for determination of these issues. Moreover, by its terms, the NDA is limited to persons of sound mind. RCW 70.122.010 and .030(1)(d). Thus, Hamlin could never have executed a valid directive under the act. An incompetent patient does not lose his right to consent to termination of life supporting care by virtue of his incompetency. Colyer, 99 Wash.2d at 124, 660 P.2d 738. Accord, In re Quinlan, 70 N.J. 10, 355 A.2d 647, cert. denied, 429 U.S. 922, 97 S.Ct. 319, 50 L.Ed.2d 289 (1976); Superintendent of Belchertown State Sch. v. Saikewicz, supra; Leach v. Akron Gen. Med. Ctr., 68 Ohio Misc. 1, 426 N.E.2d 809 (1980); Severns v. Wilmington Med. Ctr., Inc., 421 A.2d 1334 (Del.1980), decision on remand, 425 A.2d 156 (Del.Ch.1980); John F. Kennedy Mem....
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