Case report The Eluana Englaro Case: Cause of death after the withdrawal of artiﬁcial nutrition and hydration in a subject in a permanent vegetative state and with quadriplegia Carlo Moreschi a , Ugo Da Broi a, *, Daniele Rodriguez b , Rino Froldi c , Andrea Porzionato d , Veronica Macchi d , Raffaele De Caro d a Department of Medical and Biological Sciences, Section of Forensic Medicine, University of Udine, Italy b Department of Molecular Medicine, Section of Forensic Medicine, University of Padova, Italy c Department of Jurisprudence, Section of Forensic Medicine, University of Macerata, Italy d Department of Molecular Medicine, Section of Human Anatomy, University of Padova, Italy 1. Introduction The withdrawal of artiﬁcial sustenance is a clinical intervention sometimes used in patients suffering from various irreversible pathologies in Europe and North American countries. Although bioethical implications and new legal directives involving the end of life are still under discussion in several countries, the level of perceived discomfort and the pathophysio- logical effects of a cessation of artiﬁcial nutrition and hydration continue to raise clinical and medico-legal concerns [1–10]. Current legislation and medical practice allow for the avoidance of therapeutic obstinacy in Italy without permitting active or passive euthanasic procedures [1–6]. Eluana Englaro was in a stable permanent vegetative state, though the treatment she required did not amount to therapeutic obstinacy. Depositions from witnesses, who reported Eluana Englaro’s expressed request, before her accident, not to be afforded medical treatment if she were ever in a vegetative condition, were considered legally admissible by the Judicial Authorities. Moreover, in the absence of speciﬁc Italian laws applicable to a request such as this, the Judicial Authorities admitted the inviolability of personal freedom (Article 13 Italian Constitution: personal freedom is inalienable) and the inapplicability of medical procedures without the informed consent and the respect of each person (Article 32 Italian Constitution: nobody can be forced to undergo medical treatment). The Italian Supreme Court of Cassation ascertained the irreversibility of her vegetative state and ﬁnally authorised the withdrawal of artiﬁcial sustenance in recognition of the woman’s expressed wish, and notwithstanding Article 5 of the Italian Civil Code which forbids the taking of any decisions which might damage one’s physical integrity. The decision of the Italian Supreme Court of Cassation created a precedent in Italy and led to an as yet unconcluded government debate on new legislation to cover the living will and to decide whether or not artiﬁcial nutrition and hydration should be considered as withholdable medical treatments [1–6]. Forensic Science International 231 (2013) e24–e29 A R T I C L E I N F O Article history: Received 12 October 2012 Received in revised form 13 March 2013 Accepted 18 May 2013 Available online 21 June 2013 Keywords: Permanent vegetative state Quadriplegia Withdrawal of artiﬁcial nutrition Withdrawal of artiﬁcial hydration A B S T R A C T A 38-year-old woman, who had been in a permanent vegetative state with quadriplegia for 17 years following a motor vehicle accident, died 87 h after the judicially authorised suspension of artiﬁcial nutrition and hydration. Medico-legal investigations, requested by the Judicial Authorities and focusing on the evaluation of clinical and necroscopic data, aimed to explain the cause of death, to exclude any lethal cause other than one deriving from the withdrawal of artiﬁcial nutrition and hydration and to verify the level of perceived discomfort and the correctness in the application of the supportive protocol during the end of life phase. The inability of quadriplegic patients to compensate critical hyperthermic and haemodynamic disturbances induced by dehydration was considered to be the cause of a rapid demise after the withdrawal of artiﬁcial sustenance. ß 2013 Elsevier Ireland Ltd. All rights reserved. * Corresponding author at: Sezione Dipartimentale di Medicina Legale, Universita ` degli Studi di Udine, Piazzale Santa Maria della Misericordia 11, 33100 Udine, Italy. Tel.: +39 0432 554363; fax: +39 0432 554364. E-mail address: ugo.dabroi@uniud.it (U. Da Broi). Contents lists available at SciVerse ScienceDirect Forensic Science International jou r nal h o mep age: w ww.els evier .co m/lo c ate/fo r sc iin t 0379-0738/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.forsciint.2013.05.021