Matter of Lawrance

continuity including others and stabili ty, adjudicating custody modification re LAWRANCE, In the Matter of Sue Ann quests. statutory requirement Incompetent An Adult. changed so cireumstances be substan No. 29S04-9106-CV-00460. continuing existing tial and as to "make the Supreme Court of Indiana. restrict the order unreasonable" should not review to the circumstances Sept. requirement custodial environment. The by finding that equivalent to and satisfied change "necessary for the welfare be Poret,

of the child." 434 N.E.2d at 888. case, sup present the trial court

ported custody its find modification with father,

ings noting that as custodial

parent, had relocated from Wabash to Val Indiana,

paraiso, of the children one adjusting poorly

was to her new school and Valparaiso,

home in and that the father had appropriately

failed to deal with the chil physical

dren's and emotional needs since custody It also last determination. ob

served that the noncustodial mother had

remarried, Wabash, maintained a home in college degree,

earned a full- and obtained employment.

time It found that due to her

employment special training, ap she

peared equipped to be better than the fa special problems

ther deal ex custody the children. The modi

hibited supported by

fication also the testimo

ny psychologist specializing

treatment of children. Because the record support evidence and inferences to

contains judgment,

the trial court's it should not be Poret, appeal.

reversed on 434 N.E.2d 885. granting clarifying

I favor transfer and

whether relocation and noncustodial life-

style may custody considered in modifi- proceedings.

cation

KRAHULIK, J., concurs. Union, Liberties Indiana Civ.

napolis, curiae. amicus Black, Indianapolis, Paul R. Ass'n, curiae. amicus Health Care Weber, M. Walter Monaghan, P. Thomas Ky., Advocates, Hope, New Speech Free Law, Valparaiso, Potts, School J. John Ill., Indiana Lansing, for Appel, A. Thomas League Inc., Life, The Catholic Rights to curiae. Rights, amici and Civil Religious for Dinn, Ullrich, J. Constance C. William Health, Indianapolis, Bd. of Indiana State Watson, Pearson, Harry John Linley E. for The Gen., Indianapolis, Atty. Office Health, curiae. amicus Bd. of State Indiana Medical State Dyer, Indiana L. Ronald Medi- Ass'n, Indiana State Indianapolis, for Ass'n, amicus curiae. cal Elvidge, Gooch, D. Sharon V. Michael Moberly, Buechlein, & Harrison M. Grace at Riv- House The Manor Indianapolis, for curige. erview, amicus Waters, Indianap- Miller, Miller & Eric I. Villal- Jesse Nelson and olis, T. for Donald ami- Representatives, Indiana State pando, curiae. ci Nimz, Thomas Jr., M. Mary Bopp, James Stroud, Indianapolis, M. Kenneth For Legal Center Marzen, National J. Law, Stroud, Professor M. Kenneth Inc., Disabled, & Dependent Medically Law-India- University School appellant. Indianapolis, curiae. napolis, amicus Jr., Bennett, H. Bryce Egloff, L. John Over- Dutton & Bays-Beinart, Donna Indianapolis, for Egloff, & Riley Bennett Kern, Indianapolis, man, C. Kenneth appellees. For So- Fellowship Universalist Unitarian for Asso- Lafayette, Funk, West Alan C. Justice, curiae. amicus cial U.S., Citizens For Retarded ciation Task Force Advocacy Ethics SHEPARD, Justice. Chief Medical Group, and Action Nursing Home parents is whether question Handi the United Force Task Issues may state vegetative Federation, curiae. amici capped pro- artificially the withdrawal authorize Macey, In- Kreuscher, Segal & their E. Janice nutrition vided Rouse, holdWe Fenella daughter. Rose Gasner dianapolis, M. never-compagent Dying, For ~~ City, for Concern York New they may. Inc., Die, To Right For and Soc. Inc. curiae. amici History Case Kornblum, A. Lockyear, James Theodore Ann began, Sue litigation When Evansville, Joseph Kornblum, Lockyear & year old woman forty-two awas Lawrance D.C., for The nonverbal, Washington, nonambu- L. "completely who was Bianculli curiae. Corp., amicus Hillhaven and ... total requir[ing] latory, artificially delivered A. sustained Terri Whaley, Alan Selby, L. Myra C. Peti- Order Amended hydration." India- Ryan, & Donadio Miller Czajka, Ice Authority during tion for at 8. She died (HCCA) Indiana Health Care Consent Act appeal. the course of this Sue Ann had includes in its definition of "health care" nine, healthy age been until the when the administration of artificially provided displayed symptoms she of intracranial hydration; nutrition and that Sue Ann's pressure craniotomy. and underwent a mother and father have the authority to permanent damage She suffered brain and withdraw consent for unwanted health care special camps attended schools and for the 16-8-12-4; under Indiana Code mentally handicapped. From at least 1966 can order the withdrawal of balancing prob- suffered artificially delivered hydra- nutrition and lems and seizures which became more fre- daughter tion objective for their under an quent over time. she fell while standard; (6) interests" "best that attending camp and underwent a second United and States constitutions 24, 1987, craniotomy. July On she was guarantee Ann right Sue to un- refuse nursing admitted to the Manor House home treatment, including wanted nutrition and in Noblesville. persist She remained in a hydration; and that parents Sue Ann's can vegetative approximately ent state from make this refusal on her behalf. March 15 that time until her death. Amended Petition. 1991, 4, March On Sue Ann Lawrance's The trial hearing court held a on March parents petitioned the Superior Hamilton 26, testimony 1991. The demonstrated that authority Court to their withdraw parents siblings Sue Ann's and four all daughter's artificially provided nutrition agreed with the decision to artifi withdraw hydration. and petition, their amended hydration. cial nutrition and Sue Ann's asked that the court make ten Miller, treating physician, Dr. Thomas tes findings, (1) which we condense as follows: hearing, tified at the and the court received per- that Sue Lawrance has been a into a letter from evidence Sue Ann's neu 1987, vegetative sistent state since June rologist Wesley Wong. Dr. Both doctors recover, that she expected is never and persist confirmed that the was in a futile; that continued treatment Sue Ann cannot state, make her own health care vegetative recovery ent was not expected, supported and that the doctors appointed decisions and that she has no family's decision.1 representative; below, explained verbally, get 1. As respond we have elected to ad- her tried and I have legal hand, pass dress three squeeze my issues and thus do not on never seen her move. The adequate support whether the evidence was only thing I can ever obtain from her is move- Judge finding Barr's that Sue Ann Lawrance pain." ment to Id. at 255-56. He then testified vegetative persistent a was in state as that term Ann, opinion, persist- that Sue in his was "in a commonly understood in the medical com- state," vegetative my opinion ent and that "[iJn munity. The medical evidence before the court Turner, talking Wong, Dr. from Dr. the stud- was as follows: performed, say ies that have been I'd there is no Wong's my Dr. letter stated: "Based on neuro- hope regaining "her likelihood of ever [of con- Anp evaluation, is, logical I believe that Sue human sciousness, consciousness, a conscious- residing unfortunately, vegetative in a chronic state.")" persistent vegetative ness above a Id. supported by picture state. This is her clinical at 256. improvement and her lack over the last 3% part Dr. Miller relied in in his evaluation on his years. vegeta- has She remained in a chronic Turner, consultation with Dr. Michael Sue Ann's injury consisting acute tive state since her brain 15, 1991, neurosurgeon. A March letter from believe, aof subdural hematoma.... I that Sue that, Dr. Turner admitted into evidence stated prognosis recovery, Ann's for a full return of although he had not examined Sue Ann in over neurologically, to a full functional state is essen- years, three he could conclude he would tially Unfortunately, any nil. she has not made "strongly favor withdrawal of all treatment improvement neurologically, and I do not ex- persistent vegetative from Ann if she is in a Sue pect improve her to in the future." Record at years state and has remained so for the 3%/% 272. since acute subdural her hematoma. I would 1987,] July Dr. Miller testified that I "[since improvement expect no further from her head have never seen her make a communicative effort, Therefore, injury after 24 months. the state she speaking. such as I have never seen her surely purposeless, purposeful is in could be considered and make I a movement. permanent hope recovery." have her make a movement in re- without for further see[n] in, sponse pain. gone I have talked to her Id. at 239. Superior the Marion probate division partic- House, party, a though not Manor 16, 1991, Judge J. Charles May On for the Court. hearing. Counsel ipated at Fellow- hearing at which each of held Deiter nursing cross-examined home House, St. Manor parents, her presented Ann's ship, also Sue family's witnesses Judge present. Vincent's, were and others Huestis, the home's Diane witnesses. own litem to ad guardian appointed House Deiter that Manor administrator, testified peti- parents' of that purposes on the Ann for taking position no represent Sue was comply with Fellow- home would tion, granted and that The court hearing. Throughout attorney court. its appointed the decision ship's petition made however, House Manor limit- temporary proceeding, Ann's Mullins Patti remained the home concern limit- authority clear its Mullins' guardian. ed regulation federal subject to state from relief stay or other seeking a ed to of Sue the decision regardless Superior sanction Hamilton judgment doctors. family and Ann's review seeking appellate Superior Court. Hamilton judgment on his order Jerry Barr entered Judge amendments minor and made May requested Mullins May On held He May May 8 County order Hamilton stay of the in a was (1) Ann that Sue part: relevant 18, 1991, May hearing on At a Judge Barr. state; (2) that vegetative persistent of stay withdrawal agreed to parents the authority under the had Ann's twenty-one hydration and nutrition consent, surrogate decision- as "to HCCA the court agreement, this light In days. artificially makers, the withdrawal to days. twenty-one stayed its order from hydration and nutrition delivered 1991, resigned as 23, Mullins May On otherwise would daughter ... who their Judge Deiter guardian. limited vegeta- temporary indefinitely in a remain tempo- as successor Avila appointed Daniel liberty interest state"; (8) "the that tive attorney an I, Avila is guardian. rary See. limited in Article individual, set forth as for the Legal Center National Constitution, include Indiana 1 of the Dependent. On free to be and Medically Ann Lawrance Disabled right of Sue that as an joined and 30, treatment to be medical Avila moved May unwanted to the State case. requires the Hamilton party in further Article additional said Ann's of Sue same the decision the motion denied give Judge effect Barr Judge 3, Barr makers"; moved Avila June day. On decision surrogate no fur- has Judge Health Board of appeal; pending Indiana State his order stay nutri- 5. Ann's regarding Sue on June this motion jurisdiction Barr denied ther they should hydration, tion and in a motion next filed appellant Avila of Sue the decisions interfere asking for on June Appeals the Court and doe- surrogate decisionmakers Ann's Ap- The Court appeal. pending stay any succes- "or House tors; Manor concerning that re- argument heard peals hospital, or any facility, nursing home sor stay provid- granted June 7 quest on not inter- should provider" any health filed was proceedings of the ing a record surro- plans the treatment fere with record p.m. The 14, 1991, at 4:30 by June they should decisionmakers, gate This Court timely filed on June any part of "all or withdrawal permit "Veri parent-appellees' granted then of Sue artificial Supreme Transfer fied Petition and surro- physicians as her Lawrance Ann on June 5. filed they had Court," which direct." shall makers gate issues on a number raise Both sides 1991, 2, May after time Some touch generally issues These appeal. in nursing home Ann from moved Sue temporary whether questions: three Hospice Vincent's County to St. Hamilton bring this standing to has guardian The called limited group A County. Marion in deny- in erred Judge Barr appeal; whether the Disabled Fellowship with Christian party; as a joined motion to be ing Avila's guardianship for her petitioned then (1909), holding Judge Barr erred 172 Ind. 87 N.E. 140. and whether Cases Act autho- public the Health Care Consent found to fall interest ex within surrogate Lawrances as decision- ception typically likely rized the contain issues Sue Ann's nutrition See, makers to withdraw recur.2 eg., Mill Creek Teachers hydration. Ass'n, 712; Smitherman, 456 N.E.2d at 238 Ind. at 151 N.E.2d at 497. The July Sue Ann Lawrance died On exception instant case falls within this litiga- Both of natural causes. sides to this general public our rule. The at interest expressed proceed their desire to tion have part by great stake is demonstrated in despite case with the her death. high quality number of amicus briefs sub Question suggest mitted to this Court. These briefs Mootness that, irrespective pa of the death of the long-standing courts rule litigation, tient in many this Indiana citi has that a case is deemed moot when been zens, professionals, and health effective relief no can be rendered expect care institutions to face the same parties before the court. When the con- legal questions in the future. We are also controversy crete at issue in a case "has persuaded proceed high because of the settled, manner been ended or some findings analysis caliber of, disposed unnecessary so as to render it Judge light Barr's orders. Ann of Sue involved," question the case to decide death, however, Lawrance's this no (1904), will be dismissed. Dunn v. State longer need address all of the issues in the 317, 321, 163 Ind. 71 N.E. 894. The presented by parties. City case as Cf. means death of Sue Lawrance v. Louisville & longer requested Jeffersonville provide Court can no Jefferson (1908), 645, 656, Bridge ville 169 Ind. Co. parties. relief to the We therefore address (when public questions 83 N.E. 340 this case should dismissed first whether be disposed in remain at issue case otherwise as moot. of, may ques select "the essential Court While Article III of the United case, may tions in the so far as the record jurisdiction States Constitution limits the of them"). present be said to to actual and contro federal courts cases versies, the Indiana Constitution does not Issues Thus, any contain similar restraint. al following We have elected address the dismissed, though usually moot cases are issues in this case: long recognized that a Indiana courts have I. the Model Health Care Con- Whether under an may case be decided on its merits (HCCA),Ind. 16-8-12- sent Act Code §§ exception general rule when the case (West Supp.1990), applies 1 to -12 when questions "great public inter involves of never-competent See, Employ e.g., est." Indiana Educ. persistent vegetative state seeks to Relations Bd. v. Mill Class ment Creek patient's artificially provid- withdraw the (1983), Ind., room Teachers Ass'n 456 hydration. ed nutrition and 709, 711-12; N.E.2d State ex rel. Smither (1958), proceedings are re- Davis 238 Ind. 151 II. court man v. Whether 495; quired effectuate the will of decision- Gregory Boyd N.E.2d State ex rel. v. Appeals courts decide live cases and 2. The Court of has declared that an Article III See, required eg., additional element is to resolve a moot United States Parole controversies. likely 395-401, case on its that the must be merits: case Geraghty, v. 445 U.S. 100 Comm'n County Hosp. to evade review. Bartholomew v. 1202, 1208-1211, L.Ed.2d S.Ct. 63 479 (cit (1982), Ryan Ind.App., 440 N.E.2d 759 III); (describing De mootness' basis Article (1978), ing Ind.App., Krochta v. State 372 N.E.2d 312, 316, Odegaard, 416 S.Ct. Funis v. U.S. 94 475). holding misreading premised on a This is 1704, 1705-06, (1974) (per cu- 40 L.Ed.2d 164 Krochta, "evading which nowhere includes riam) (case "great under decided state court deciding requirement as otherwise review" exception public mootness rule still interest" "Capable repetition, yet evading moot cases. subject analysis federal mootness to threshold doctrine, stricter review" is a federal mootness court). appealed to federal when own, requirement than our rooted in the uni comments Act The statute. Consent dural Care Health if the makers is based HCCA which hydra- act on form nutrition such apply to does See purpose. its this is indicate Unif. decisions. tion Health-Care Model Commissioners' Law Superior the Marion Whether III. 1, 458 part Act, 9 U.L.A. Consent limited temporary appointing erred note) (prefatory Model Act] [hereinafter Lawrance. Sue guardian is in nature procedural ("'This Act at scope.") id. narrow purposefully Care Health Does I. Act ("Nothing in this (comment) 11, 472 Apply? Act Consent termi [regarding existing law changes Ann's Sue found Judge Barr J v. J & treatment]"); Eads nation nutri- Ann's authority to withdraw had 485, 491, N.E.2d (1971), Ind. Sales Code Indiana under hydration tion does the HCCA that contends Appellant laws substantive the examine led to are He decision. Lawrances' the apply to landscape in is, legal state, which 16-8-12-11 Code Indiana § relies HCCA written. act was which chapter "This provides: affect typi- families in culture which in a written au- individual's concerning an law Indiana pa- when care decisions health cally make decision care a health make to thorization law common cannot. tients individual, or or another individual for the an environment describe statutory law both medical withdraw, or withhold provide, making is a cen- patient in which life." sustain prolong or necessary to tenet. tral added). 16-8-12-11(a) (emphasis Ind.Code § in doctrine law common Indiana's statutory con objective Our right of the recognizes consent formed and effect to determine struction accept reject or intelligently "to patient v. Thompson legislature. intent (1980), Ind. Russell v. Revord treatment." 266, 286 N.E.2d (1972), 259 Ind. Thompson Perhaps 763, 767. App., 401 N.E.2d whole, a statute examine We 657. the basis explanation strongest meaning to ordinary common giving Gen Payne v. Marion rule is contained Ins. v. Foremost used. words Life N.E.2d Ind.App., 549 (1990), Hospital eral 181, Ind. (1980), 274 Ins. Department patient's "The 1046, denied: trams. 1092. N.E.2d gua is the sine self-determination right of in duty to obtain physician's non "af the word use of takeWe (then Judge) As Justice consent. leg formed 16-8-12-11(a) indicate fect" § being of adult human 'Every said: Cardozo proce- HCCA be that the intent islature's years right and sound mind has a to deter members are generally most con- mine what shall be done with his own cerned with the patient. welfare of a It is body ....' Society v. New they provide who patient's comfort, for the Schloendorff (1914), care, Hospital 125, 129, York 211 N.Y. interests, and best they who treat 105 N.E. 93." patient person, as a sym- rather than a Jobes, bol a cause." In re 108 N.J. This common legal law has evolved in a (1987) (citations 529 A.2d governed by culture the Indiana Constitu omitted). Even they when have not left tion, begins by declaring which formal advance expressed par- directives or liberty of our citizens is inalienable. Ind. opinions ticular about life-sustaining medi- I, Const. art. The debates of our § suggest treatment, constitutional convention cal most Americans want care, decisions upon those about their who wrote constitution believed their inca- pacity, liberty opportunity included the to be made for by family them manage physician, except one's own life those ar rather by strangers than yielded up body politics3 government. eas to the preference This is reflected in the HCCA's provision, default which Like the common law and our constitu- says patient's family may close make tion, Indiana's statutes reflect a commit- health care decisions when no other health patient ment self-determination. The representative guardian has been Act, Living though inapplicable Will to the designated patient. for the Ind.Code 16- § bar, case at declares "[clompetent right 8-12-4. This to consent pa- right adults have the to control the deci- tient's course of treatment necessarily in- relating care, sions to their medical own right cludes the to refuse a course of treat- including the decision to have medical or ment. surgical procedures means or calculated to prolong provided, withheld, their lives Determining the existence of a substan- (West withdrawn." Ind.Code § right tive representative or her Supp.1990). The Attorney new Powers of life-sustaining to refuse medical treatment Act, by allowing patients designate indi- dispose does not of the issue at hand. Only viduals consent to or refuse their own artificially provided if hydra- nutrition and care, also respect demonstrates tion falls within the definition of such treat- patient autonomy. Ind.Code 30-5-5- procedures ment do the prop- HCCA 16(b)(2) (Burns Supp.1991). policy This erly apply to the petition. Lawrances' HCCA, also evident which allows We conclude that the administration of patients to select individuals to consent to (most artificial nutrition peo- 16-8-12-6;

their health care. Ind.Code § ple "tube-feeding") call it is medical treat- U.L.A,. 16-8-12-8; Act, Ind.Code Model ment which can be refused. Three sources 6, part (comment) ("'The 1 465 decision to § inform understanding: our the view of the the authority allow transfer of rests on the community; Indiana medical Indiana statu- principle of the basic human need of self tory law, HCCA; including per- the and autonomy."). determination and individual authority suasive from numerous courts Respect patient autonomy for does not across country. the incompetent. end when the becomes society, In our health care making rely community We often on the medical patients typically upon for transfers incom- accepted concepts definitions com- petence patient's family. to the "Our com- monly applied discipline. in that On this experience mon human subject, informs us that the Indiana State Medical Associa- I, Delegate (1850). Delegate Thomas 3. Smith declared that article Convention 968 John B. Howe 1, recognition section a constituted that God people governments, asserted that when create given persons equally complete had all sover- they do not create restrictions on their natural affairs, eignty including simplest over their merely delegate rights portion but of them to pursuit happiness right such as the and "the government long they expedi- for so as deem it upon brightness to walk abroad and look Id. at 960. ent. noon-day[.]" at sun 1 Debates in Indiana 40 would treatment" "medical limitation Medi- American

tion, affiliate a state hydration decisions. and nutrition include explains: (AMA), Association cal and nutrition artificial that conclude We opinion rec- medical weight of clear The 16-8-12-1 within § is hydration nutri- artificially provided ognizes (2)."5 medical constitute hydration and tion ap with AMA's example, consistent is This conclusion For treatment. expressly de- courts widespread view 2.20 ... Opinion parently Ethical nutrition provision between the artificial distinction objective fines is no "'there medical treatment as artificial hydration withholding of and withdrawal in a person treatment." may be withdrawn medical any other feeding and 382, A.2d 365, 529 The AMA's Peter, N.J. vegetative 108 state. In re promi- other See, consistent omitted). position (footnote 419, 428 372-73, 321, commissions, 486 in- N.J. Conroy, 98 re and e.g., organizations nent ("Onee Commission one enters cluding the President's 1236 A.2d Medi- Ethical Problems Study of high-technology complex, realm Research, Has- 'emo care, to shed Behavioral it is hard and cine medical However, Academy artifi American Center, of food. symbolism' and tings tional tubes, nasogastric as feedings such Neurology. cial infusions intravenous gastrostomies, Medi- Indiana State Curiae of Amicus Brief from bottle-feed different significantly are AMA Council 9; also see Ass'n at cal (citation omit spoonfeeding....") ing or Affairs, Current Judicial Ethical 580, 587 Romeo, F.Supp. 697 ted); Gray v. (1989). 18 Opinions Drabick, 200 Cal. v. (D.R.I.1988); Drabick legisla scope which very broad The 840, 846 n. 9 Cal.Rptr. 185, 195, 245 App.3d us persuades also the HCCA gave ture denied, 488 U.S. cert. (Cal.Ct.App.1988), to decisions applied may be procedures its (citing L.Ed.2d 387 102 958, 109 S.Ct. hydra nutrition artificial concerning agreement). courts numerous affect did not itself (even if the act tion categorizing artificial recognize that authority)4 We substantive existing treat as medical hydration care, nutrition "any care health defines HCCA many necessarily mean ment does Ind. service, procedure...." treatment, procedures such consider would did citizens legislature 16-8-12-1(2). The Code § surgery. as, say, invasive to same "treatment" term limit the even refuse would who through the family members Read Some treatment." "medical surgery extraordinary view, even community's permission medical lens of by both the supported interpretation existing 5. This substan- affect does not as the act 4. Just attorney statutes. living powers of will decisions, de- it also health law on tive definition in its Attorney includes Act Powers "may be construed nothing act clares that providing of "the of health 16-8-12- § Ind.Code euthanasia." authorize endotracheal through intravenous, termination be "the euthanasia We take 30-5-2- [sic], nasogastric Ind.Code tubes." omission, with the by act or life of another's incorpo- is then (Burns Supp.1991). act This so, eliminate in order to do specific intention extent HCCA into the reference rated Hosp., England Sinai suffering." Brophy v. New HCCA, Ind. not conflict that it does (1986); N.E.2d Mass. in- (Burns Supp.1991). The Code Brame, Syn- A Quinlan: In re Hyland & accord notion that supports corporation care, Technology, Rut.- 8 Medical and Law thesis HCCA, includes broadly of as defined (euthanasia deliber- (1976) "the 52 Cam.L.J. and nutrition artificial of administration the suffering from contrast, Living easing ActWill into death 1985 ate hydration. In disease"). eutha- as Insofar and fatal painful a appropriate provision of "the expressly excludes suffering of a to relieve defi- internal is intended from its hydration" nasia nutrition applicable to concept Ind.Code procedures. not a dying patient, it is life-prolonging of nition two vegetative (West state. The Enacted Supp.1990). patients 16-8-11-4 § not patients who are such exclu- no meaning this section contained of the HCCA later, years legislature never in- sion, light suggesting of to assess is difficult a state in such hydra- nutrition artificial Attorney exclude of tended Power to our amendments recent care. of health definition HCCA's tion Act.

41 might compelled designed feel to continue tube-feed to resolve health care decisions Still, ing. hydration artificial nutrition and without a proceedings. need for court successfully provided only by Thus, can be 16-8-12-4, legislature estab- § professionals working trained in a controlled priority lishes the desired for substitute envir onment.6 Act, decisionmakers.7 Model See U.L.A. part (comment). In the case at § sum, In we conclude that artificial nutri- bar, Sue Ann incapable Lawrance was hydration tion and is treatment that a com- care, consenting to her own health Ind. refuse, petent patient accept can that- 16-8-12-4(a); (2) appointed Code had not § incompetent patient of an can representative a health care herself under accept or patient, refuse it on behalf of the 16-8-12-6, 16-8-12-4(a); (8) Ind.Code § § procedures apply and that the of the HCCA guardian appointed had no to such decisions. 16-8-12-7, representative under Ind. § Proceeding Necessary? IL Is a Court 16-8-12-4(a)(2)(A); Code had not § disqualified her as decision makers Having determined that the withdrawal 16-8-12-8, under Ind.Code 16-8-12- § § hydration of artificial is a 4(a)(2). short, In all of the conditions scope health care decision within 16-8-12-4(a)(2) Indiana Code were met § HCCA, Judge turn Barr's find- we now child, "spouse, parent, for a adult or adult ings. We read the Lawrances' amended sibling" to make a health care decisionfor petition request declaratory as a relief provisions Sue Lawrance under the only. family sought assurance that Indiana Code 16-8-12-4. The HCCA § the decision to withdraw artificial nutrition mandates that such authorized decision- scope fell within the good makers "shall act in faith and in the HCCA, they and that could order such incapable best interest of the individual withdrawal, parents, Ann's Sue under 16-8-12-4(d). consenting." Ind.Code § ruling Indiana Code 16-8-12-4. § proceedings required Court were petition, however, the trial court issued the Lawrances to make health care deci declaratory injunctive both relief. The daughter. sions for their Health, enjoined court Board State House, homes, nursing Manor successor legislature's design Given hospitals, providers, and health care none operate that the HCCA without court inter parties were which action. vention in none of in instances where HCCA, society participants disagree, written for a in terested we think any declaratory proceedings future routinely which health decisions are by physicians, made inappropriate.8 families on advice of is under 16-8-12-4 would be § (A) suggests feeding guardian representa- 6. The record that such is not there is no or other (1); layman for the to administer. tive described in subdivision Ann's feed- (B) guardian representative ing described or other her doctor in the Hamilton proceedings strength, court as "three-fourths act; available or declines reasonably (C) guardian or other the existence of the per cce.'s hour." Record at 286. representative the health care is unknown to provider.... provides part: Indiana Code (a) incapable consenting If an individual un- during 8. Counsel for the Lawrances said oral appointed chapter der section 3 of this has not litigation argument part that this commenced in representative under section 6 of because his clients were uncertain about representative chapter or the health care authority. state of the law and about their own appointed chapter under section 6 of this is not might Even be some if there unusual circum- act, reasonably available or declines to consent warranting declaratory proceed- j stance a future may given: to health care ing, issuing injunctive litigation, relief in such (1) by judicially appointed guardian did, Superior as the Hamilton would be person representative appointed or a under sec- Moreover, improper. Indiana Code 16-8-12- chapter; tion 7 of this merely recognizes very 4 traditional and the child, (2) by spouse, parent, private play a adult or adult role which American families sibling disqualified unless under section 8 of health care decisions. The existence of the stat- chapter, if: ute does not convert decisions into state 42 as practice realm of in the lies of treat concerning "[Elthics withdrawal

Decisions established That's well theory. to by opposed decided necessarily better not are ment I think And Aristotle. of time from the to think hubris be It would the courts. here. talking about we're what that's otherwise. good medi- practice to it mean does What care health future to leave desire Our Dr. (testimony of at 315 Record cine?" families, and their patients, to decisions ethicist). medical Gramelspacher, Greg the not with comports physicians their of eth- decisions respect for history of Assembly, but also with General will of treat- withdrawal ics committees have courts who other of decisions the court deci- on field, reliance where ment See, In eg., conclusion. same the reached burdensome, has its unduly would sions A.2d at 451 529 at Jobes, N.J. 108 re known first well the early as origins place to resolve proper the not ("Courts are Quinlan, 70 re area. See in this case problems that un- personal agonizing (1976). A.2d 647 355 N.J. can- legal system Our cases. these derlie struggle in with- involved intimate more providers care replace Health not caring those patient, by the like- are also must be borne decisions of treatment drawal care about who those patient, for light of conservatively very ly to act Drabick, 200 professional v. on their Drabick constraints patient."); external at 847 Cal.Rptr. at Cal.App.3d curi- along amici with Appellant, conduct. commis- general a Riverview, not have do Indiana ("[Clourts at House Manor ae deci- treatment medical supervise sion to Association, Indiana and the Care Health own treatment their make Patients sions. out nu- Health, ably point of Board State physi- their of gov- the advice regulations decisions federal state merous ex- members, For sometimes profession. Family health erning the cians. pa- when participate -27 persons, to 16-10-4-1 other Code Indiana ample, §§ hand, Courts, the other licens- for the 1991) tients cannot. rules establishes (West one is avail- no only when facilities; Code involved Indiana become health ing decisions re- (West Supp.1990) make ~4 able 16-10-4.1-1 §§ disagreements."). are medicaid there federal compliance when quires Administrative regulations; to be decisions medical Permitting most (1988 Supp. 16.2 article title Code not does court intervention without made operational licensing and 1991) establishes in a patients helpless place irresponsibly Additional- facilities. health standards called Families risk. unusual position 1986) (West 35-46-1-4 Code ly, Indiana § court do coming to without to act upon dependent as neglect of establishes Neither restraint. operate without to -18 4-28-5-1 Code felony; Indiana §§ are patients families nor providers ser- protective adult 1991) an (West creates de- in treatment discretion unbridled given unit; Indiana Code vices safeguards serve other Numerous cisions. child a local establishes (West Supp.1990) making. constrain county. service protection line of defense first expect We hardly hypotheti are constraints These treatment in withdrawal against abuses abuses sort out attempt to cal, they do but medical guidelines ethical to be v. Hall See from reasonable ethics by medical Advances profession. behavior. (affirm Ind., by State 493 N.E.2d (1986), issued opinions and ethics committees conviction homicide ing reckless rapid keep pace with AMA like the groups son); treatment technology; who medical medical withheld the field progress Court, App.3d 147 Cal. Superior v. Barber committees ethics medical perceive we (dismissing Cal.Rptr. that ethics year and every stronger grow Altman, physician)} against indictment sophisticated. increasingly grow opinions 16-8- equitable under relief proceeding A meaning the fourteenth within action Constitution, the court call does and thus course, 12-7, upon U.S. amendment authority state. exercise apply them. process clause due Act, of this section. Model part to Indict Doctor Who Said U.L.A. Jury Declines Times, Suicide, July {comment) p. N.Y. (suggesting objec Aided in a He § 1991, 1, at col. 2. tions to decisions be considered under seetion § 7) .. variety great of this The existence patients or their safeguards does not leave Because the Lawrances were au treatment in- representatives who refuse apparently willing thorized act and to do cluding nutrition and artificial physicians family so and because the consequences. unprotected from collateral decision, agreed with their there was no immunity contains extensive HCCA proceeding basis for a under 16-8-12-7.9 § providers relying provisions for health care Indeed, cireumstances, under these sorts of in they "believe on decisionmakers whom there should be no withdrawal of treatment good faith" are authorized to consent cases before an Indiana court under 16- § care. Ind.Code § 8-12-4 either. protect This same code section seems to 16-8- decisionmakers as Ind.Code well. § IIL. Did Err Court Probate 12-9(c). to this Numerous briefs submitted Appointing in a Guardian? however, Court, great num- highlight Superior ap The Marion operating on ber of other constraints pointed temporary guardian limited providers. expect health care We Lawrance under Indiana Code prevent these constraints serve to will (West Supp.1990), emergen an § hasty inappropriate treatment decisions. cy appointment provision of the code's arti in expect, example, We guardianship. ap cle on The Lawrances bar, in cases like the one at which error, peal this in as a cross accordance patient's physicians family members 59(G). with Ind. Trial Rule action, unanimously agree to a course of statutory requirements At least four HCCOA, good requirement faith of the must met a court can make such before 16-8-12-9, met, will be Ind.Code § appointment. an The trial court must find complete immunity keeping will follow. In that: design usually of an HCCA (1) guardian appointed has not been courts, independently works this re minor; person incapacitated for an sult, appropriate, despite where will attach exists; emergency an proceeding. the lack of a court incapacitated per- the welfare of the patient's provider When a action; requires or minor immediate son family disagrees some member with the patient's preferred by course of action {4) person appears to have au- no other decisionmaker, parents or other health care thority to act the circumstances.... provides a Indiana Code 16-8-12-7 mech § 20-8-8-4(a)(1) -4(a)(4). Ind.Code § challenges, regardless anism for of wheth temporary Patti Mullins as appointing er the initial decision involves court action. appropri guardian, Judge this section is Deiter found that Court action under limited authorized to con were met. At least with ate where an "individual all four conditions condition, finding reasonably to health care is not avail to the fourth respect sent Because the clearly erroneous. HCCA act, able, acting in declines to or is not decision about whether to applied interest of the individual need of best tube, 16-8-12-7(d)(8). gastric Ann's Sue Ann's health care." Ind.Code remove Sue § authori- commentary clearly "appear[ed] of the uniform act from to have Judge adapted circumstances" under ty the HCCA indicates which act 29-8-8-4(a)(4). resolving disputes very purpose is the Ind.Code Barr's order. particularly important appoint presume disputed We cases under it would be 16-8-12-7, guardian guardian pursue appointment litem who would the inter- ad ad necessary. the serious est alone and do so without ide- litem would be Given ological deeply personal proceedings, prediliction. nature of such A44 petition un Second, challenging a requirement of Furthermore, fourth the to "the would der made statute must be guardianship 16-8-12-7 emergency

the § 29-3-2 under IC jurisdiction having without court case even in this failed have individual Acting with- county where in the proceedings. court Hamilton receiving 16- HCCA purposes under present § intervention for court out family 16-8-12-7(a). as Sue The rele 8-12-4(a)(2), the Lawrance Ind.Code care." § child, or adult found at parent[s], can be "spouse, requirement Ann's venue vant had the have sibling[s]," still would (West Supp.1990). adult 29-38-2-2 Indiana Code § purposes authority to act had requisite that assume if we Even expect we 29-3-83-4(a)(4). Because of the County at the time to Marion § moved deci- HCCA of an attack a collateral dic that the code proceeding, County Marion guardianship emergency commenced proceedings are under sion that tates "[i]f meet 29-3- always fail § should statute be (1) county, they shall than one in more to consider no occasion 3-4(a)(4), have we first county where in the except stayed conditions three the other any of whether of the until final determination commenced at bar. case in the satisfied were county in the court by the proper venue temporary Mullins as Patti appointment 29- Ind.Code first commenced." § where by replacement her guardian, limited already had 3-2-2(b). proceedings Because Avila, invalid. were Daniel proceed County, any in Hamilton begun been guardianship County have emergency should Although the in Marion ings wheth Barr determined Judge challenge an stayed until used cannot be statute Indiana Code collaterally, County Marion the case to HCCA er transfer 29-8-2- Code a mechanism provide under Indiana proper § does 16-8-12-7 § That decisions. challenging 2(c). have been could 16-8-12-7 Indiana Code § decision, challenge Lawrances' used Conclusion Mr. Avila however, that not mean families to permits our state The law of Mar- successfully petitioned have could physi- their decide, in consultation used properly had he Superior ion one in a tube-feeding of a loved cians, that emergency guard- instead the HCCA be end- state should vegetative suggest factors Two ianship statute. to make these them permits law ed. Our Avila would Mullins or by petition such coming to court. When without decisions entertained. been not have those with unanimity amongst is not there petition requires such First, HCCA interest personal or tangible professional any inter or provider "a health be ers to re- available are the courts patient, 16-8-12- Ind.Code individual." ested need be. dispute if solve or Mullins 7(a). is no evidence There to Sue providing health were Avila KRAHULIK, GIVAN, DICKSON individu Lawrance, interested were JJ., concur. They her. knew they even als, generic her DeBRULER, J., "interested" dissents concurs and were ef makes the opinion. who any person separate sense If the interested. go to court fort Justice, concurring and dis- DeBRULER, permit Assembly intended General senting. decisions, it litigate strangers Ann Lawrance death of Because the may mount challenge be said a have could moot, appeal in this the issues has rendered The use individual." "any ed appeal An becomes dismissed. it should be strangers suggests "interested" word when be dismissed should moot and apply.10 need is, procedure would appellate process. That challenger like proper recourse petitioner were if the would be as it be the same under standing by trial court denied Avila requested relief his but to be interested grounds found Code refused. ordinary appellate interest would lack of controversy dispute originally existing defining proper their treatment can be ful- at time of the commencement of the ly appeal. appeals considered on Such will requiring action ceases to be a concrete one Furthermore, not evade review. I am not character, settlement, satisfied that this loses its essential is likely is a case to reoec- live, longer appeal no or the court on is who, many persons eur. There cannot be unable to render effective relief. ex State Lawrance, non-terminal, like Sue Ann are 196, (1909), Gregory Boyd rel. v. 172 Ind. being persistent vegetative maintained in a 140; County Hosp. 87 N.E. Bartholomew water, state on food and and have never (1982), Ryan Ind.App., v. 440 N.E.2d 754. competent during been their lifetimes to pointed majority opinion, As out in the a make medical treatment decisions. It is a appeal may moot nevertheless be main special and unusual case. Because this tained and decided if it falls within the appeal is moot does not fall within an exception questions great public of im exception it should be dismissed. portance. Hospital County Bartholomew majority The of the Court has ruled that 759; Ryan, v. 440 N.E.2d at In re Mar appeal exception this falls within an to the (1987), Ind.App., riage 509 Stariha of proceeds mootness rule and to address sev 1117, N.E.2d 1128. The case of v. State important eral issues. Because of this rul (1958), 568, 495, Davis 288 Ind. 151 N.E.2d ing majority opinion and the fact that the appeal. involved such an There the trial sets the course for the law in this class of court refused to order school children cases, myself obligated I deem to render transferred from one school to another for my own view on several issues. With re year appeal by the school 1955-1956. On spect proper construction of the parents this Court noted that the school Act, 16-8-12-1, Health Care Consent LC. year long passed 1955-1956 had since seq., single juris et I find a form of court moot, specific question but recognized in diction it and that form is decided the case on its merits under the probate jurisdiction. jurisdiction Probate is exception question because "the same reoe- be exercised courts accordance year year appellants curs after as to I read amended I.C. 16-8-12-7. parents through and the of other children petition parents of the Lawrance as one out the N.E.2d at 497. state...." Id. 151 seeking particular approval court supports exemplifies This statement decision, only which could be repeated holding Ap of the Court of appropriate under section 7. Because sec peals public exception that the interest re complied by giving tion 7 was not quires likely elements of reoceur- person alleged incapable notice to to be rence, and a context which will continue Lawrance, consenting, Ann an in County to evade review. Bartholomew pro competent person, required by due The Hosp. Ryan. v. need of cess, judgment reversed. should be reoccurring transfer their children was a Somers, 141, Covey v. Town 351 U.S. and the context of it would be a time so one (1956). 100 L.Ed. 1021 If the S.Ct. appellate unavail short as to render review requirement statute did not have this able. notice, 12 of the Indiana Article Section Ann who Persons like Sue Lawrance impose Constitution would it. Mueller See unconscious state while reach (1972), v. Mueller 259 Ind. 287 N.E.2d and fluid can being provided with food wrote, 886. As Justice Frankfurter "The expected long periods to live for of time. be liberty largely the his history of has been position This of the American Acade- tory procedural of observance of safe Neurology. Ameri- my of Position States, guards." McNabb v. United Academy Newrology on Certain can 332, 347, 608, 616, 87 L.Ed. U.S. 63 S.Ct. Management Aspects the Care and (1943). 827-28 Patient, Vegetative Persistent State purpose is to facilitate (1989). The of this Act Neurology 125-26 There- delivery by "health fore, such of "health care" there is no reason to believe that judgments provider[s]" to individuals who are persons court will die before question is requires consent. care" facili- consenting." Some "incapable questions is delivery of such valid, the answer because but needed tation care" is "Health law elsewhere. the civil found where impeded care is purposes. for such in this act consent not defined informed requires "incapa- patient is critical issues on the is silent delivery and The statute the health and because consenting," appeal. ble suit risk of civil runs provider parents of Sue co-petitioners, con- care" without "health providing when asked petition Lawrance, in their amended intended The Act is patient. sent of the particu- to a consent to sanction the Court routine customary and broadly to apply care," namely "the of "health lar form Thompson, See practice. medical nutri- artificially delivered of withdrawal Act: Consent Health Care New Indiana's daughter, Sue their hydration for and tion Pro- Health Care Guiding Light A granted trial court Ann Lawrance." 181, (1988). The 182 vider, 21 Ind.L.Rev. saying: petition part of that by providing purpose its serves Act Adjudges and now Orders [This terms definition possible broadest herein, William Co-petitioners that providers," care "health care" and "health Lawrance, the au- do have Bonita con- recognition to legal giving and then seq. et to thority under I.C. § makers, to consent, decision surrogate applicable itself Having declared artificially delivered the withdrawal realm, as- Act then care health entire from their sections the last two in the reader sures daughter.... a matter defining as it is not the extent policy public law and to restrain Indiana order went The amended 16-8-12- 1.C. Specifically, care realm. all health of Health Board State 16-8-12-12, (e)(2), I.C. (c), (e)(1), 11(a), execu- interfering with the providers provide: order was Clearly this plan. this tion of Indiana affect to pursuant not chapter does court probate

This by the not made authoriza- individual's concerning an 16-8-12-7, law but rests authority of 1.0. care a health can- to make which tion the Act the remainder upon individual, or to question next it. The or another support individual possibly withdraw, medical by other or withhold supported is provide, the order whether is life. sustain necessary prolong authority. lawful rights of natural the basic Recognition of indi- an not authorize chapter This liberty the start is life and person each care that any health to consent vidual cases of dealing with for courts ing point law. under Indiana prohibited is 1, Indiana Section Article class. and liber for life Protection Constitution. Indiana not affect chapter does This Arti constitution. by the guaranteed ty is concerning: law Constitu 1 and cle Sections a health care of The standard com vigilant in cases must be tion. Courts provision required provider basic natu these protect them to ing before care; recognizes the law common rights. ral required for health consent When refuse medical individual right of care; circumstances. appropriate treatment Hospital General v. Marion Payne See 1043; may be con- In re chapter N.E.2d in this 549 Nothing (1990), Ind.App., (1976); euthanasia. A.2d 647 855 Quinlan, to authorize N.J. 70 strued Dillon, 420 52 N.Y.2d it v. re Eichner the reader In instruct provisions These (1981); Super 64, 438 N.Y.S.2d provide statute N.E.2d of this purpose not the v. School State Belchertown intendent question answering a basis 728, 370 N.E.2d Saikewicz, "health Mass. proposed particular whether physicians decision. Her opin- were of the (1977). Supreme Judi The Massachusetts cial Court stated: regain ion that she would conscious- ness. person strong being damage

A interest in She had extensive brain has free from nonconsensual invasion of his portions brain; however, the frontal bodily integrity, and a constitutional healthy the brain stem was and her EEG right privacy may asserted to showed activity slow and erratic in the prevent infringements unwanted of bodi- regions. frontal She was not brain dead. ly integrity. competent person Thus Thus, spontaneously she breathed reg- general right has a to refuse medical ularly; her spontaneously heart beat circumstances, appropriate treatment regularly; signs and her other vital were by balancing indi- to be determined normal. profoundly important It is against counterveiling interest vidual she terminally was not ill and was not interests, in- particularly the State State suffering. preservation terest of life. At the time she body had an ideal striking that balance account is to be weight. Her skin good. condition was She magni- prognosis taken of the and of the had no bed sores. receiving She was some proposed tude of the invasion. The same minor medications and had had several sei- right incompetent is also extended to an lasting period zures a few minutes over a person, through exercised a 'substi- be which, opinion of months of the judgment' tuted on his behalf. The deci- neurologist, product were the of her uncon- sion should that which would be made scious, non-responsive existence. by incompetent person, if he were competent, taking into account his actual being She was in totally maintained this preferences interests and and also his helpless by liquids provided state food and present incompetency. and future through her a stomach tube. She was be- Spring, In re 380 Mass 405 ing by providers cared for who loved her (1980) (discussing N.E.2d Satkew- and took care of her. She was bathed and icz) axiomatic, requiring I it take no clean, kept propped up and often in a wheel authority, right citation of that this They chair and taken from her room. (1) suicide, (2) right include a to commit not thought withdrawing dreaded the her right body, a to mutilate one's own a process feeding If care. had been another, right by to have one's life taken stopped, eventually she would have died of right dying expedited by to have one's dehydration. starvation or participation of others. surgically The stomach tube had been petition sought The amended below in implanted long constant use for a posed form relief threat which hearing place. time in when court took life of Sue Lawrance. Because of body The invasion of her involved in those this, upon the trial court was called heightened vigilance. directly activities is not involved here. exercise a At the court, hearing in time of the the trial Sue Here it is the maintenance of the tube and early in Ann Lawrance was her forties and its continued use to deliver basic food and essentially had unconscious since been liquid which is at stake. The maintenance majority opinion describes her its use tube and continued are cer- youth: tainly person, judge invasive of the but I greatly healthy so. There are no chemicals or Ms. Lawrance had been until the nine, displayed symp- age of she when medicines involved which alter one's mental pressure toms of intracranial and under- physical processes. pro- The natural craniotomy per- went a ... She suffered cesses in the stomach and intestines are damage spe- manent brain attended simple, process It is a utilized. clean which camps mentally for the cial schools and liquid great does not involve a deal of handicapped. expenditure great deal of time Majority opinion at 35. had never been She providers. person per- health care A who personal support, in competent to make a sists life with such basic suffering, with pain and without disease, illness fight off strength to to react unable unconscious

though greatly beings, is human other cannot One support. by that burdened this burden compare help but hemodialysis, peritoneal

crushing ones of chemo- forms certain

dialysis, and

therapy. against which interest The state's may self-determination interest

patient's recently considered been has

be balanced manifestations, namely, the in four have life, the interest preserving terest in safe suicide, the interest preventing pro medical integrity guarding inno protecting

fession, the interest N.J. Conroy, 98 In re parties.

cent third (1985). 1209, 1223-25 348-53, A.2d food Indiana, contains 410 IAC 16.2-38-7 pur promulgated regulations regulations I.C. 16-10-4-5.

suant and man Facilities Health Care apply to needs of all basic nutritional that the

date balance, Here, met.

residents be un to refuse Ann Lawrance right of Sue artificially the form of treatment

wanted hydration, exercised food delivered knowledge of a without her

her Lawrance, by Sue choice personal inter counterveiling state way to the

gives facts her life. On preserving est the with record, approving the order life-sustaining of her

drawal legal justification find hydration does reversed.

and should T. of TINA the Matter R. of MICHAEL Matter

In the P. of RONNIE Matter

In the 49500-9008-JV-576,

Nos.

49500-9001-CV-11. of Indiana.

Supreme Court

Sept. notes consider "to (permissible Care Health Indiana's 16-8-12-4, part Laws of Uniform the Commissioners assessing step in first Act. Consent statute"); Brief uniform construing a when must order court's the trial validity of Liberties Civil Indiana Amicus Curiae determining whether therefore 28 n. 7. at Union to with- decisions applies to properly HCCA in a hardly enacted The HCCA hy- nutrition artificially provided draw existing recognition legal vacuum. dration. proce designed to law, establish act deci "health care" applies The HCCA making with dures " act, defined As sions. 'Thlealth pa rights of substantive altering the out service, treatment, care, any means care' sense, the In this families. and their tients or treat maintain, diagnose, procedure substantive "affect" not does HCCA mental condition. physical individual's an treatment. withdrawal law on to a admission includes term reading of accept appellant's We cannot 16-8-12-1(2). facility." Ind.Code § 16-8-12-ll1(@) Indiana Code § include expressly does definition This about to decisions apply HCCA nutrition artificial exclude hydration. HCCA.. decisions we procedural, the HCCA Regarding

Case Details

Case Name: Matter of Lawrance

Court Name: Indiana Supreme Court

Date Published: Sep 16, 1991

Citation: 579 N.E.2d 32

Docket Number: 29S04-9106-CV-00460

Court Abbreviation: Ind.