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In re D.L.H.

February 10, 2009


Appeal from the Order Entered January 24, 2008, Court of Common Pleas, Cumberland County, Orphan's Division, at No. 21-02-293.

The opinion of the court was delivered by: Allen, J.

Petition for Reargument Filed February 23, 2009



¶ 1 In a matter of first impression, this Court, inter alia, is asked to determine whether, under the facts of this case, the legal guardians of a lifelong incompetent person can refuse life sustaining medical treatment on behalf of the incompetent. Additionally, this Court must decide if the incompetent's common law right to refuse medical treatment, as vicariously asserted by the guardians, was infringed based upon the circumstances at bar.

¶ 2 Appellants, the parents and plenary guardians of D.L.H., appeal from the trial court's order denying their petition to decline life preserving medical treatment on behalf of D.L.H., an incapacitated person. Appellants essentially contend that although D.L.H. was neither permanently unconscious nor terminally ill, their status as the plenary guardians of D.L.H. vested them with the legal authority to make surrogate medical decisions for D.L.H., including the power to refuse potentially life sustaining medical procedures. The trial court, relying principally on the Health Care Agents and Representatives Act (the "Act"),*fn1 found that Appellants failed to meet the statutory requirements necessary to become D.L.H.'s "heath care agent," and thus, could not refuse life sustaining medical treatment on his behalf. We find no error in the trial court's ultimate disposition; accordingly, we affirm the trial court's order, albeit through different reasoning.

¶ 3 The underlying facts of this case are not in dispute and can be summarized as follows. D.L.H. is a fifty year old male who has suffered from profound mental retardation since birth. In his lifetime, D.L.H. never executed a legal instrument expressing his desires in regard to potential life sustaining medical treatment. On July 3, 2002, the trial court appointed Appellants as the plenary guardians of D.L.H., finding that D.L.H. was "so severely mentally impaired that he [was] unable to make, communicate or even participate in any decision relating to his estate or person[.]" Order, 7/03/02.

¶ 4 On December 21, 2007, D.L.H. became ill with aspiration pneumonia*fn2 after he swallowed a hairpin and vomited. D.L.H. was transferred from the Ebensburg Center, where he resided for forty-five years, to Memorial Hospital in Johnstown. The physicians at Memorial Hospital determined that D.L.H.'s medical condition required that he be placed on a mechanical ventilator to assist him in breathing. Appellants, as the plenary guardians of D.L.H., attempted to decline medical treatment on behalf of D.L.H., stating that mechanical ventilation was not in his best interest. The hospital, nonetheless, proceeded to place D.L.H. on a mechanical ventilator. Over Appellants' objection, D.L.H. remained on a mechanical ventilator for approximately three weeks, at which time his aspiration pneumonia subsided to the point where he no longer required ventilation treatment.

¶ 5 On January 4, 2008, Appellants filed a "Petition to Grant the Guardians Authority to Exercise the Powers of a Health Care Agent on Behalf of the Incapacitated" in the trial court. The Department of Public Welfare ("DPW") objected to Appellants' petition on the ground that D.L.H. was neither terminally ill nor permanently unconscious and never appointed a health care agent under the Act to refuse healthcare necessary to the preservation of his life. Although D.L.H. was still hospitalized at the time of the January 11, 2008 hearing, D.L.H.'s condition improved and he was removed from the mechanical ventilator. However, because D.L.H. or similarly situated individuals may at sometime in the future sustain a life threatening medical condition, the parties requested that the trial court rule on the merits of the petition. Despite the technical mootness of the issues raised in Appellants' petition, the trial court decided to hear the matter, ostensibly on the view that the issues were capable of repetition, yet likely to evade appellate review.

¶ 6 At the hearing, Appellants did not submit any evidence that tended to demonstrate that declining mechanical ventilation was, or would be, in D.L.H.'s best interest. Following hearing, the trial court, on January 24, 2008, entered an order denying Appellants' petition. The trial court perceived the issues raised in the petition as presenting pure questions of law, and concluded that since D.L.H. was not in a permanent vegetative state ("PVS"), the right of close family members to decline medical treatment of another, as enunciated in In re Fiori, 673 A.2d 905 (Pa. 1996), was inapplicable. Trial Court Opinion, 1/24/08, at 4-5. The trial court further concluded that the designation of a health care agent under the Act was the exclusive vehicle by which to refuse life sustaining medical treatment in situations where the patient was not suffering from an end-stage medical condition or in a PVS. Id. at 3, 6. Ultimately, the trial court concluded that under the Act, D.L.H. was not competent to refuse medical treatment and did not appoint a statutory health care agent. Id. at 7. On this basis, the trial court rejected Appellants' argument that their legal status as plenary guardians of D.L.H. encompassed the power to refuse life sustaining medical treatment on his behalf. Id. at 7.

¶ 7 Appellants now appeal to this Court, raising the following issues for review:

A. Whether a person who has been incapacitated since birth, nevertheless, retains the inherent right to make medical decisions, including the right to refuse potentially life sustaining procedures?

B. Whether a plenary guardian of the person has the power to make surrogate medical decisions, including the power to refuse potentially life sustaining procedures, when the incapacitated person is neither permanently unconscious nor terminally ill?

C. Whether the orphans' court has the power to authorize a plenary guardian of the person to make surrogate medical decisions, including the power to refuse potentially life sustaining procedures, when the incapacitated person is neither permanently unconscious nor terminally ill?

Brief for Appellants at 6.

¶ 8 Before addressing the merits of Appellants' issues, we first determine whether the issues are moot and incapable of appellate review. Regarding the mootness doctrine, this Court has previously stated:

Generally, an actual claim or controversy must be present at all stages of the judicial process for the case to be actionable or reviewable. If events occur to eliminate the claim or controversy at any stage in the process, the case becomes moot. Even if a claim becomes moot, we may still reach its merits if the issues raised in the case are capable of repetition, yet likely to continually evade appellate review. Therefore, if the issues raised by an appeal are 'substantial questions' or 'questions of public importance,' and are capable of repetition, yet likely to evade appellate review, then we will reach the merits of the appeal despite its technical mootness.

In re Duran, 769 A.2d 497, 502 (Pa. Super. 2001) (internal citations omitted).

¶ 9 Here, D.L.H.'s improving health and the medical physician's decision to remove the mechanical ventilator rendered the issues raised in this appeal technically moot. Appellants' issues on appeal, however, are capable of repetition due to D.L.H.'s uncertain future medical status and the class of persons in this Commonwealth who are incapacitated and under the care of a guardianship. It is reasonably likely that at least some of these similarly situated individuals will either develop a medical condition or be involved in an accident that requires life sustaining medical treatment and the guardian will assert the authority to make such a decision on behalf of the incapacitated person. Moreover, the issues raised in this case are capable of evading appellate review if the general rule of mootness is applied, because declining mechanical ventilation in a life-or-death situation, pursuant to a court order, will likely result in death before the appellate process can be completed. Finally, at the core of Appellants' issues lie an individual's time-honored common law right to bodily integrity and right to refuse medical treatment, which "does not cease upon the incapacitation of the individual." In re Fiori, 673 A.2d at 910. The Act apparently represents our legislature's attempt to delineate the circumstances in which a person may exercise these rights. Hence, the issues in the case concern matters that are of great public importance. For these reasons, we conclude that while the issues raised by Appellants are technically moot, they are nonetheless reviewable because they present questions of public importance that are capable of repetition and evading appellate review. See In re Fiori, 673 A.2d at 909 n. 4 (finding issue involving the decision to remove life sustaining treatment from an adult patient in a PVS technically moot as a result of the patient's death, but reaching the merits as the matter concerned a question of public importance and was capable of repetition and evading appellate review). Accordingly, we proceed to the merits of this appeal.

¶ 10 In their brief, Appellants raise three separate issues but present a conglomeration of interrelated arguments, reasoning and legal theories. For ease of disposition, we will address Appellants' contentions as one single issue.

¶ 11 Citing In re Fiori, 673 A.2d at 910, Appellants begin with the premise that although D.L.H. "lacked capacity from the day of his birth, he . . . retains the same fundamental right to decline medical procedures that is enjoyed by other citizens." Brief for Appellants at 12. Appellants contend that D.L.H.'s right to decline medical treatment extends to them by virtue of the trial court's July 3, 2002 order granting them the status of "plenary guardians" and 20 Pa.C.S. § 5521(a), the statute governing the powers and duties of a guardianship in this Commonwealth. Id. at 14-16. According to Appellants, "[t]he Act should not be read to restrict the power of the orphans' court to make an appointment of plenary guardians, nor to limit the authority of plenary guardians to assert the rights of the incapacitated." Id. Ultimately, Appellants propose that there is no substantive distinction between the authority of a plenary guardian under 20 Pa.C.S. § 5521(a) and the authority of a health care agent under the Act. Id. at 18-19. Appellants therefore deduce that their status as plenary guardians, in and of itself, vests them with sufficient authority to decline life sustaining medical treatment on D.L.H.'s behalf. Id. at 15-16.Alternatively, Appellants recommend that in order to preserve D.L.H.'s common law right to decline medical treatment, the trial court could have specially granted them the right to exercise the power to decline life preserving treatment under the facts of this case. Id. at 16-19. Upon review, we find no merit in Appellants' assignments of error.

¶ 12 In order to resolve Appellants' arguments on appeal, this Court is required to construe and interpret a variety of statues. "Issues involving statutory interpretation present questions of law for which our standard of review is de novo and our scope of review is plenary." In re Jacobs, 936 A.2d 1156, 1163 (Pa. Super. 2007). In resolving issues of statutory interpretation,

Our task is guided by the sound and settled principles set forth in the Statutory Construction Act, including the primary maxim that the object of statutory construction is to ascertain and effectuate legislative intent. In pursuing that end, we are mindful that 'when the words of a statute are clear and free from all ambiguity, the letter of it is not to be disregarded under the pretext of pursuing its spirit.' 1 Pa.C.S. § 1921(b). Indeed, as a general rule, the best indication of legislative intent is the plain language of a statute. In reading the plain language, 'words and phrases shall be construed according to rules of grammar and according to their common and approved usage,' while any words or phrases that have acquired a 'peculiar and appropriate meaning' must be construed according to that meaning. 1 Pa.C.S. § 1903(a). However, when interpreting non-explicit statutory text, legislative intent may be gleaned from a variety of factors, including, inter alia: the occasion and necessity for the statute; the mischief to be remedied; the object to be attained; the consequences of a particular interpretation; and the contemporaneous legislative history. 1 Pa.C.S. § 1921(c). . . Notwithstanding the primacy of the plain meaning doctrine as best representative of legislative intent, the rules of construction offer several important qualifying precepts. For instance, the Statutory Construction Act also states that, in ascertaining legislative intent, courts may apply, inter alia, the following presumptions: that the legislature does not intend a result that is absurd, impossible of execution, or unreasonable; and that the legislature intends the entire statute to be effective and certain. 1 Pa.C.S. § 1922(1), (2). Most importantly, the General Assembly has made clear that the rules of construction are not to be applied where they would result in a constructioninconsistent with the manifest intent of the General Assembly. 1 Pa.C.S. § 1901.

In the Interest of C.A., 2008 PA Super 263, at ¶ 5 (filed November 3, 2008).

¶ 13 By way of background, on November 29, 2006, our governor signed the Act into law. In 20 Pa.C.S. § 5423, our legislature stated its intent and findings in passing the Act. This provision provides, in relevant part:

§ 5423. Legislative findings and intent

(a) INTENT.-- This chapter provides a statutory means for competent adults to control their health care through instructions written in advance or by health care agents or health care representatives and ...

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