http://www.cnsnews.com//ViewSpecialReports.asp?Page=\SpecialReports\archive\200504\SPE20050412a.html
Schiavo's 'Dr. Humane Death' Got 1980 Diagnosis Wrong
By Jeff Johnson
CNSNews.com Senior Staff Writer
April 12, 2005
(CNSNews.com) - A neurologist hired by Michael Schiavo to confirm that his wife Terri was in a persistent vegetative state said he was "105 percent sure" of that diagnosis, but Dr. Ronald Cranford expressed similar certainty about a patient he examined in 1980 who later regained both consciousness and the ability to communicate.
Three days before Terri Schiavo's death, Cranford appeared on the MSNBC talk program, "Scarborough Country," to discuss her condition. Cranford was interviewed by reporter Lisa Daniels.
DANIELS: Are you 100 percent correct in your opinion that Terri Schiavo is in a persistent vegetative state? Do you agree with that?
CRANFORD: I am 105 percent sure she is in a vegetative state. And the autopsy will show severe irreversible brain damage to the higher centers, yes.
DANIELS: Why are you so sure, doctor?
CRANFORD: Because I examined her ...
Cranford - who is assistant chief in neurology at the Hennepin County Medical Center in Minneapolis, Minn., professor of neurology at the University of Minnesota Medical School and a faculty associate at the university's Center for Bioethics - went on to call another neurologist who disagreed with his diagnosis "a charlatan" and accused Daniels of being "stupid."
Host and former U.S. Rep. Joe Scarborough interrupted to defend Daniels, touching off a clash with Cranford, which included the doctor admonishing Scarborough with: "You've got to get your facts straight."
Cranford also certain, but wrong about 1980 diagnosis
Cranford expressed similar certainty about another patient he declared to be in a persistent vegetative state (PVS) in 1980, former Minneapolis Police Sgt. David Mack.
''Sergeant Mack will never regain cognitive, sapient functioning,'' Cranford said six months after Mack was shot while serving a search warrant on Dec. 13, 1979. ''He will never be aware of his condition nor resume any degree of meaningful voluntary conscious interaction with his family or friends.''
Based on Cranford's unequivocal diagnosis of Mack, the officer's relatives removed him from a respirator in August 1980 "because his family felt he should be allowed to die rather than exist in such a state," according to published reports.
But Mack did not die.
On Oct. 22, 1981, 18 months after Cranford declared Mack's case hopeless, doctors at the advanced care facility where Mack was being treated noticed that he was awake. The Associated Press described Mack's recovery.
"A policeman considered 'vegetative' after being shot in the head in 1979 has come out of his coma and, although doctors caution he may never recover fully, he is spelling out some of his desires: 'TALK. WALK. SKI. DOG,'" the news report stated, explaining that someone would point to letters displayed in alphabetical order on a board while Mack nodded "yes" or "no" until the correct letter was reached.
Asked how he felt about his recovery, Mack smiled and spelled out "SPEECHLESS!"
"Doctors say Mack has recovered about 95 percent of his intellectual capabilities," the news account continued, "and can understand everything said to him."
Mack's wife, Marlies, said her husband could initially respond only by taking a deep breath in response to a doctor's request.
"Then his eyes started following hand movements," she continued. "He got better and better, but it was slow."
Cranford insisted at the time that his initial diagnosis was correct.
"There is no doubt in the world that he was in the persistent vegetative state," Cranford said of Mack in a 1981 interview. "He had no interaction with the environment."
In an interview last week with Cybercast News Service, Cranford acknowledged a "mistake," but maintained that his original assessment of Mack was accurate.
"At the time I said that, he was in a vegetative state," Cranford said. "But, I did make that misstatement about Sgt. Mack and I was wrong and I did make a mistake in that case."
Cranford argued that Mack's case is different from Terri Schiavo's because a CAT scan of Mack's brain showed no atrophy, while Schiavo's CAT scan showed severe deterioration.
"We learned something very valuable," Cranford said. "If you have a CAT scan on a patient that you think is in a vegetative state and it does not show progressive atrophy within six to 12 months, then you might want to reconsider the diagnosis."
Making absolute diagnosis 'not totally responsible'
Dr. David Stevens is a physician and medical ethicist who serves as executive director of the Christian Medical Association. He believes there is a different and more important lesson to be learned -- that "being an absolutist" when making a medical diagnosis based only on observation and opinion "is not totally responsible.
"Unfortunately, oftentimes, medical opinions can be 'flavored' with the individual's own worldview and preconceptions," Stevens said. "And, in Dr. Cranford's situation, I think, though he accuses others of that, he is guilty of the same thing.
"He is a 'right-to-die' proponent. He believes there are people who have lives not worthy to be lived, and those lives should be ended," Stevens continued, "and that colors him and his medical opinions. And examples of that are overstating the case to assure that people's feeding tubes are removed."
Cranford said that he has "never been a member of any organization that's primary purpose was to advocate active euthanasia because I'm not that supportive of active euthanasia."
However, he joined the board of directors of the Choice in Dying Society, an organization created when the Society for the Right to Die and Concern for Dying merged in 1991. Research by Cybercast News Service shows that both of those groups had previously changed their names to remove the word "euthanasia" in response to negative publicity.
Cranford also told reporters in 1991 that he wanted to be known as "Doctor Humane Death." He has since publicly claimed to have facilitated the deaths of between 25 and 50 disabled patients by removing the feeding tubes that provided their nutrition and hydration.
PVS diagnosis 'based on probabilities, not absolutes'
The American Academy of Neurology (AAN) defines a "persistent vegetative state" as a condition that appears within one month after a brain injury and in which the patient shows:
-No evidence of awareness of self or environment and an inability to interact with others;
-No evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile, or noxious stimuli;
-No evidence of language comprehension or _expression;
-Intermittent wakefulness manifested by the presence of sleep-wake cycles;
-Sufficiently preserved hypothalamic and brainstem autonomic functions to permit survival with medical and nursing care;
-Bowel and bladder incontinence; and
-Variably preserved cranial nerve (pupillary, oculocephalic, corneal, vestibulo-ocular, gag) and spinal reflexes.
The academy also states that "recovery of consciousness from post-traumatic PVS after 12 months in adults and children is unlikely. Recovery from non-traumatic PVS after 3 months is exceedingly rare." AAN guidelines finally explain that the diagnosis of a "permanent vegetative state" is, "as with all clinical diagnoses in medicine, based on probabilities, not absolutes."
Stevens said that last criterion is the main problem with the types of absolute statements made by doctors like Cranford when giving a PVS diagnosis.
"With persistent vegetative state, that diagnosis is based upon an observation and an opinion," Stevens said. "The diagnosis itself carries with it a prognosis -- in other words, that people are not going to recover, that this is permanent and that, therefore, you can do things like were done with Terri Schiavo, where her feeding tube was removed.
"A number of cases have shown this not to be the case," Stevens said. "The one that [Cranford] was involved in is a good example of that, but there are other cases as well, where patients thought to be in a persistent vegetative state have then recovered, some of them quite significantly."
Cybercast News Service found more than two dozen cases where published news reports document patients diagnosed as being in a persistent or permanent vegetative state, or coma "waking up," including:
Recovery after three years - Marcello Manunza suffered a brain injury during a car crash in November 1987. In July 1990, relatives noticed that he was following them around the room with his eyes and appeared to be trying to read encouraging signs that had been placed in his nursing home room. Within days he was able to eat, control the movement of his limbs and speak;
Recovery after seven years - Hawaii resident Peter Sana lapsed into a coma after contracting meningitis, an inflammation of the membrane that encloses the brain and spinal cord. He was in a Honolulu nursing home in September 2001 when he began responding to commands from nurses. Sana's father visited him every day during the seven years. His caregivers credit visits by family members with giving Sana the will to wake up;
Recovery after eight years - The first thing Conley Holbrook said after rousing from a PVS in 1991 was "Momma." He then identified the two men who had beaten him unconscious with a log on Nov. 27, 1982. Holbrook awoke while he was hospitalized for pneumonia; and
Recovery after 18 years - In 1983, Patti White Bull of South Dakota was diagnosed as being in a coma or PVS due to complications from a Caesarean section. Two months later, her husband and other family members removed her from life support. On Christmas Day 1999, White Bull woke up and asked to see her children. A day later, she was walking around her nursing home room with assistance.
A 1996 study published in the British Medical Journal found that 43 percent of patients in the United Kingdom thought to be in a PVS had been misdiagnosed. Of the 40 patients whose cases were reviewed, 17 were later found to be "alert, aware and often able to express a simple wish."
A 1993 study of 49 patients found that 18 of them, or 37 percent, "were diagnosed inaccurately.
"Errors in diagnosis may result from confusion in terminology, lack of\super \nosupersub extended observation of patients, and lack of skill or training in the assessment of neurologically devastated patients," according to the study, published in "Neurology," the journal of the American Academy of Neurology.
Stevens said this is all the evidence that should be needed to call for a higher standard when it comes to diagnosing a patient as being in a persistent or permanent vegetative state.
"Unfortunately, right now, it's a circular diagnosis," Stevens explained. "Doctors who are advocates for it are willing to state absolutely that a patient is in PVS and then, when the patient comes out of PVS, then they use circular reasoning and say, 'Well, then they weren't in it at all.'"
Cranford admitted that a positron emission tomography, or PET scan, could have been conducted to confirm or disprove the diagnosis in the Schiavo case. The test measures the metabolism of the cerebral cortex and patients in a verifiable PVS typically have less than 50 percent of the PET scan activity of a healthy brain.
"The only reliable PET scan in the country that could do this would be in New York City. And had I known this case would have gone to this point, I would have advocated that (PET scan) three years ago during the evidentiary hearing," Cranford said. "But we never knew Congress would get involved."
Cranford said he also did not recommend the test because he believed that neither Terri's husband, nor her parents would want her moved to New York City. That explanation troubled Stevens.
"If you cannot make a firm and absolute diagnosis, you shouldn't make a firm and absolute decision about what you're going to do with those patients based on that diagnosis," Stevens said.
The Christian bio-ethicist also believes that the circumstances under which a patient, like Terri Schiavo, can be denied nutrition and hydration should be much more limited.
"We must have clear, compelling and written evidence that that is the patient's desire before that is removed," Stevens argued, adding that allowing such decisions to be made based on hearsay testimony creates the potential for conflicts of interest, especially when those testifying stand to gain financially from the death of the disabled individual.
Even when such a written directive not to use a feeding tube to keep a patient alive exists, Stevens argued that the physician's ethical responsibility continues.
"The critical issue is that, if you do not put a feeding tube in, you must, you must offer food and water by mouth," Stevens said. "If you don't do that, it's not the disease that kills the patient. It's you that kills the patient.
"That was the big ethical issue, the most foundational issue in the Terri Schiavo case," Stevens said. "That is like not only taking someone off a respirator because it's futile, but also, at the same time, removing all of the oxygen from the room.
"Your intent is not to remove a burdensome therapy," Stevens concluded. "Your intent is to remove a burdensome patient."
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