Who is this? SHORTSTORIES

IF A COLONOSCOPY IS PAINLESS, AS DOCTORS WILL OFTEN SAY, WHY DO THEY SUGGEST SEDATION? WHY DO THEY THINK A PAINLESS PROCEDURE NEEDS ANESTHESIA?

When the photograph above was taken, this woman would never have dreamed that she would become the center of a worldwide debate about medical, legal, theological, ethical, political, and social issues that would eventually include Congress, the White House, and even the pope. The ramifications of her case echo to this day, and include questions about the most fundamental aspects of life and death. As one small example, there was and still is debate about whether she died at age 26 or at age 41. Crazy, right?

Some things about her case are black & white facts: she was born Theresa Marie Schindler on December 3, 1963. Just a few weeks before her 21st birthday she married Michael Schiavo, and in 1986 they moved to Florida. There, in the early morning hours of Sunday, Feb. 25, 1990, Terri Schiavo collapsed in a hallway of their apartment in St. Petersburg. Her husband called 9-1-1, but did not perform CPR, a significant lapse since (whether he knew it at the time or not) she was in full cardiac arrest. As a result of oxygen deprivation from the time of her collapse until paramedics resuscitated her, she suffered massive, irreversible brain damage and was left comatose. About 10 weeks after her collapse, doctors determined she was in a persistent vegetative state (PVS), an important distinction since patients can and often do awaken from comas and recover completely, while PVS in nearly all cases is marked by total and permanent loss of cognitive ability.

Despite the PVS diagnosis just weeks after the initial event, the Schindlers contested that finding tirelessly, asserting that their daughter was in a minimal state of consciousness — even responding to visual and sound stimuli and trying to speak — and could be rehabilitated. They filed dozens of legal challenges in local, state, and federal courts to prevent actions that would be the norm in PVS cases.

For instance, at some point doctors and family members usually conclude that further treatment of any kind, including feeding tubes, is pointless in situations where there is virtually no hope of recovery. Terry Schiavo’s husband (also her legal guardian) came to that realization after four full years of treatment, both basic and experimental, but his inlaws were granted dozens of temporary stays to prevent the stoppage of Terri’s life sustaining treatments. They lobbied for the passage of “Terri’s Law,” a Florida statute that was designed to make it harder to withhold nutrition for people in situations like Schiavo’s. The law was quickly determined to be unconstitutional, but no fact or obstacle was too great for the Schindler family: after Terri’s death at age 41 in 2005 (although some contended she died in 1990 at age 26), her autopsy established that she was blind and severely brain damaged, her brain measuring only half the weight expected for a female of her age, height, and weight. Even so, that and every other medical finding was disputed by the Schindler family, which still maintains a website (terrischiavo.org) contesting everything determined by doctors.

A number of thoughtful analyses of the Schiavo case and the lessons it offers can be found online. Here is a link to one of the better ones: https://www.mayoclinicproceedings.org/ article/S0025-6196(11)61439-0/fulltext.

One general takeaway: very few of us have completed an advance medical directive document; that should change. +

I’ve been a nurse for almost 20 years, 17 of which have been in GI. I do colonoscopies and endoscopies all day, every day, and for the most part I can really say I love what I do. Since that’s been my home for so long I feel like I can help answer this question. I always tell my patients a few basic things. #1-the prep is the worst part. #2-the IV is the 2nd worst part. #3-the sedation is the best part. It works fast, you wake up fast, and generally you feel pretty good! We almost always use propofol and it is very safe and very comfortable for patients. Colonoscopies really aren’t terribly painful because you don’t have nerve endings in your colon like you have in, say, your fingertips. So you don’t usually feel sharp pain there. But what you DO feel is pressure. We fill the colon full of air and water and that allows us to expand it to see the wall. We need a good view because we need to look for polyps or other causes of concern, and when it’s collapsed in on itself we just can’t see. So it makes you feel a “fullness” like you need to go to the bathroom or pass gas. It isn’t particularly comfortable for most people, especially feeling that they’ll empty their bowels on the stretcher or all over your doctor. We see the entire large intestine and where the small bowel empties into the large intestine. Naturally, things go the opposite direction to flow out, not in, so it does feel pretty uncomfortable. Once we reach the extent of our scope and start moving the way your body naturally flows, it’s much easier and we can cut back on the sedation and start the wake up process. So while I’ve done several patients unsedated, most people want some light sedation just to make it all more comfortable. But we do not insist on sedation. If you feel you can manage we are willing to try with no sedation. It’s not very common but it sometimes happens when people don’t have a driver to get home since we absolutely will not perform the procedure with sedation if you don’t have someone to take you home. The medications generally wear off in 15–20 minutes and you can be on your way to lunch in half an hour (as long as you’re not the one driving!). We also try to remove some of that air when we are on our way out to make you more comfortable, but there will still be some to pass, and we encourage you to let that out for your own comfort and so we know things are moving as they should.