Vegetative state describes a body which is functioning entirely in terms of its internal controls. It maintains temperature. It maintains heart beat and pulmonary ventilation. It maintains digestive activity. It maintains reflex activity of muscles and nerves for low level conditioned responses. But there is no behavioral evidence of either self-awareness or awareness of the surroundings in a learned manner.

Approximately every thirty seconds to a minute she would lift her right shoulder up off the recliner. She would lift her head from the left armrest off the armrest to sort of a neutral position and move it to the right, taking about three to four seconds to do that, and that she did spontaneously every three to five minutes.
 [*406]  She would move her foot downward and her toes slowly about every ten to forty seconds. She would lift her leg, right leg stiffly off the chair about a half inch to an inch every five to ten minutes.

Generally vegetative patients . . . have a very narrow range of stereotyped movements that are repeated. [I]n general, moving a limb away from the body is not one of them. Certainly lifting an arm off a recliner or a bed wouldn't be one of them. So higher level movements of that sort or more complicated movements, lifting the head up, moving it to one side and then putting it back, to me, are against the vegetative state.

produce[s] in the mind of the trier of fact a firm belief or conviction as to the truth of the allegations sought to be established, evidence so clear, direct and weighty and convincing as to enable [the factfinder] to come to a clear conviction, without hesitancy, of the truth of the precise facts in issue.  [*408]  [State v. Hodge, 95 N.J. 369, 376 (1984) (citations omitted).]

She said that she wouldn't want those measures taken in her case and that she certainly wouldn't want to live that way.
I said, well, they wouldn't do that to me because I carried and still carry a form of identification that says that I do not wish to have any heroic measures taken in case of massive injury.
Subsequent to that she became interested in where I had gotten that and I told her that it was pretty common both at Baylor where I had taught prior to going up to Massachusetts and also at Harvard. I said that I would send her a card. My wife was there and I turned around to her and told her why didn't she send one. Then we moved on into discussion of other technical things.

An individual who is part of a closely knit family would doubtless take into account the impact his acceptance or refusal of treatment would likely have on his family. Such a factor is likewise to be considered in determining the probable wishes of one who is incapable of formulating or expressing them himself. In any choice between proposed treatments which entail grossly different expenditures of time or money by the incompetent's family, it would be appropriate to consider whether a factor in the incompetent's decision would have been the desire to minimize the burden on his family.
[In re Roe, 383 Mass. 415, 446, 421 N.E.2d 40, 58 (1981).]

[E]ven if no prior specific statements were made, in the context of the individual's entire prior mental life, including his or her philosophical, religious and moral views, life goals, values about the purpose of life and the way it should be lived, and attitudes toward sickness, medical procedures, suffering and death, that individual's likely treatment/nontreatment preferences can be discovered. Family members are most familiar with this entire life context. Articulating such knowledge is a formidable task, requiring a literary skill beyond the capacity of many, perhaps most, families. But the family's knowledge exists nevertheless, intuitively felt by them and available as an important decisionmaking  [***33]  tool.
 [*416]  [Newman, Treatment Refusals for the Critically Ill: Proposed Rules for the Family, the Physician and the State, III N.Y.L.Sch. Human Rights Annual 45-46 (1985).]

Our common human experience teaches us that family and close friends care most and best for a patient. They offer  [***34]  love and support and concern, and have the best interest of the patient at heart. The importance of the family in medical treatment decisions is axiomatic.

[F]amilies commonly exhibit the greatest degree of concern about the welfare of ailing family members. It is they who come to the hospital and involve themselves in the sick person's care and comfort. Competent patients usually actively solicit the advice and counsel of family members in decision-making. Family members routinely ask questions of the medical staff about the patient's condition and prognosis; one study found they frequently asked more questions than patients themselves did. Family members, in fact, commonly act as advocates for patients in the hospital, looking out for their comfort, care, and best interests. . . .
[Newman, Treatment Refusals for the Critically Ill: Proposed Rules for Family, the Physician and the State, III N.Y.L.Sch. Human Rights Annual 35 (1985).]

See generally Dyck, Self-determination and Moral Responsibility, 9 W.New Eng.L.Rev. 53, 55-60 (1987) (discussing family involvement in medical decisions in the context of the doctrine of self-determination).

The  [***35]  law has traditionally respected the private realm of family life which the state cannot enter. . . . We believe that this tradition of respect for and confidence in the family should ground our approach to the treatment of the sick.
 [*417]  [Farrell, supra, 108 N.J. at 355 (citation edited).]

The decisions of patients' families should determine what sort of medical care permanently unconscious patients [who have not left clear directives] receive. Other than requiring appropriate decisionmaking procedures for these patients, the law does not and should not require any particular therapies to be applied or continued, with the exception of basic nursing care that is needed to ensure dignified and respectful treatment of the patient.
[President's Commission Report, supra, at 4-5.]

No matter how expedited, judicial intervention in this complex and sensitive area may take too long. Thus, it could infringe the very rights that we want to protect. The mere prospect of a cumbersome, intrusive and expensive court proceeding, during such an emotional and upsetting period in the lives of a patient and his or her loved ones, would undoubtedly deter many persons from deciding to discontinue treatment. And even if the patient or the family were willing to submit to such a proceeding, it is likely that the patient's rights would nevertheless be  [***45]  frustrated by judicial deliberation. Too many patients have died before their right to reject treatment was vindicated in court. See, e.g., Conroy, supra, 98 N.J. at 342; Bartling [v. Superior Court for County of

Los Angeles,] supra, 163 Cal.App.3d [186] at 190, 209 Cal.Rptr. [220] at 221 (1984); John F. Kennedy Memorial Hosp. v. Bludworth, 452 So.2d 921, 923 (Fla.1984); Satz v. Perlmutter, supra, 379 So.2d 359;

Corbett v. D'Alessandro, 487 So.2d 368, 369 (Fla.Dist.Ct.App.) review denied, 492 So.2d 1331 (Fla.1986); In re L.H.R., 253 Ga. 439, 321 S.E.2d 716 (1984); In re Spring, 380 Mass. 629, [631] n. 1, 405 N.E.2d 115, 118 n. 1 (1980); Saikewicz, supra, 373 Mass. at [734], 370 N.E.2d at 422; In re Storar, 52 N.Y.2d 363, [369] n. 1, 420 N.E.2d 64, 66 n. 1, 438 N.Y.S.2d 266, [268] n. 1, cert. denied, 454 U.S. 858 [102 S.Ct. 309] [70] L.Ed. 2d [153] (1981); In re Hamlin, supra, 102 Wash.2d at [811], 689 P.2d at 1374.
[In re Farrell, supra, 108 N.J. at 357.]

We have not attempted to set forth guidelines for decisionmaking with respect to life-sustaining treatment in a variety of other situations that are not currently before us. Innumerable variations are possible. However, each case -- such as that  [***48]  of the severely deformed newborn, of the never-competent adult suffering from a painful and debilitating illness, and of the mentally alert quadriplegic who has given up on life -- poses its own unique difficulties. We do not deem it advisable to attempt to resolve all such human dilemmas in the context of this case. It is preferable, in our  [**450]  view, to move slowly and to gain experience in this highly sensitive field. As we noted previously, the Legislature is better equipped than we to develop and frame a comprehensive plan for resolving these problems.
[Id. at 387-88.]

The challenge for the courts will be to evolve innovative and flexible processes by which affected individuals can participate comfortably and confidently to secure the vindication of the interests we all seek to protect. [Chief Justice Joseph Weintraub Lecture by Justice Alan B. Handler at Rutgers Law School (March 11, 1987), 119 N.J.L.J. 482 (March 19, 1987).]

 [**455]  The right  [***65]  of an adult who . . . was once competent, to determine the course of her medical treatment remains intact even when she is no longer able to assert that right or to appreciate its effectuation.

. . . .

Since the condition of an incompetent patient makes it impossible to ascertain definitively his present desires, a third party acting on the patient's behalf often cannot say with confidence that his treatment decision for the patient will further rather than frustrate the patient's right to control his own body. Nevertheless, the goal of decision-making for incompetent patients should be to determine and effectuate, insofar as possible, the decision that the patient would have made if competent. [Conroy, supra, 98 N.J. at 359-60.] n6

[T]he decision in cases such as this should be that which would be made by the incompetent person, if that person were competent, but taking into account the present and future incompetency of the individual as one of the factors which would necessarily enter into the decision-making process of the competent person.

The aged, especially nursing home residents, are an extremely vulnerable population because of their physical and mental impairments and their dependence on others in their daily lives. Many elderly patients have few or no surviving relatives and are socially isolated. . . . Watching a relative die can be emotionally draining; families may want not to prolong the end but to begin to grieve and resign themselves to their loss. Even those with more altruistic intentions cannot help but project their suffering onto the incompetent. The family that suffers with a relative in a debilitated condition may assume that the patient must be similarly miserable. [Merritt, "Equality for the Elderly Incompetent: A Proposal for Dignified Death", 39

Stanford L.Rev. 689, 724-25 (1987) (footnotes omitted).]

We do not believe that it would be appropriate for a court to designate a person with the authority to determine that someone else's life is not worth living simply because, to that person, the patient's "quality of life" or value to society seems negligible. The mere fact that a patient's functioning is limited or his prognosis dim does not mean that he is not enjoying what remains of his life or that it is in his best interest to die. More wide-ranging powers to make decisions about other people's lives, in our view would create an intolerable risk for socially isolated and defenseless people suffering from physical or mental handicaps.

The medical and nursing treatment of individuals in extremis and suffering from those conditions entails the constant and extensive handling and manipulation of the body. At some point, such a course of treatment upon the insensate patient is bound to touch the sensibilities  [***79]  of even the most detached observer. Eventually, pervasive bodily intrusions, even for the best motives, will arouse feelings akin to humiliation and mortification for the helpless patient. When cherished values of human dignity and personal privacy, which belong to every person living or dying, are sufficiently transgressed by what is being done to the individual, we should be ready to say: enough. [Conroy, supra, 98 N.J. at 398-99 (concurring in part and dissenting in part).] n14

 [**460]  [I]t may be possible to gradually discern acceptable societal norms of humane treatment of moribund patients. Just as constitutional norms of personal privacy must be shaped by "the traditions and collective conscience of the people," so the common law of handling dying patients will be shaped by shared notions of how "we" citizens want to be treated at that critical juncture. That is, shared notions of human dignity will ultimately govern decisionmaking on behalf of incompetent moribund patients. [N. Cantor,  [***80]  Legal Frontiers of Death and Dying 76-77 (1987) (footnotes omitted)]

If no clear evidence of intent exists, a court must become involved in the decisionmaking. Life-sustaining treatment can be withheld or withdrawn if the court finds that such action would serve the patient's best interests and result in a dignified, humane death. At this stage, the court should appoint a guardian ad litem to present all reasonable arguments why the treatment should not be terminated. . . .

The court should first consider the probable duration of the patient's life with treatment and the quality of that life. Quality is not measured by social utility or degree of intelligence, but is instead determined by the patient's current level of conscious functioning as compared to the level of functioning that the individual has enjoyed during the majority of his life. The court can measure this by examining testimony about the patient's level of brain activity, self-awareness, and awareness of others. . . . The potential for abuse is circumscribed by the . . . requirement that the . . . court first find that death is imminent and irreversible. . . .

A court must weigh the duration and quality of life provided by treatment against the physical suffering, the extent of bodily intrusion required by treatment, and the resultant loss of patient dignity. (Id. at 734-35 (footnotes omitted).]