was first litigated in 1976 in in re quinlan. the new jersey supreme court upheld the right of karen ann quinlan's parents to order her removal from artificial ventilation. in 1991 congress passed into law the patient self-determination act that mandated hospitals honor an person's decision in their healthcare. forty-nine states currently permit the next of kin to make medical decisions of incapacitated relatives, the exception being missouri. missouri has a living will statute that requires two witnesses to any signed advance directive that results in a dnr/dni code status in the hospital. in the united states, cardiopulmonary resuscitation (cpr) and advanced cardiac life support (acls) will not be performed if a valid written dnr order is present. many states do not recognize living wills or health care proxies in the prehospital setting and prehospital personnel in those areas may be required to initiate resuscitation measures unless a specific state-sponsored form is properly filled out and cosigned by a physician. legal precedent for the right to refuse medical interventions there are three notable cases which set the baseline for patient's rights to refuse medical intervention: karen quinlan, a 21-year-old woman, was in a persistent vegetative state after experiencing two 15-minute apneic periods secondary to drug use. after a year without improvement her father requested that life support be withdrawn. the hospital refused and this culminated in a court case. the trial court sided with the hospital, however the new jersey supreme court reversed the decision. this was the first of multiple state level decisions pre-empting the cruzan case which established the non-religious (there were other prior rulings regarding jehovah's witnesses) right to refuse care and extended that right to incapacitated patients via their guardians. it also established that court cases are not needed to terminate care when there is concordance between the stakeholders in the decision (guardian, clinician, ethics committees). it also shifted the focus from the right to seek care to the right to die. mrs. quinlan survived for 9 years after mechanical ventilation was discontinued. nancy cruzan was a 31-year-old woman who was in a persistent vegetative state after a motor vehicle accident that caused brain damage. her family asked that life support be stopped after 4 years without any improvement. the hospital refused without a court order, and the family sued to obtain one. the trial court sided with the family concluding that the state could not override her wishes. this ruling was appealed to and reversed by the mississippi supreme court. this case was ultimately heard by the united states supreme court, which affirmed the right of competent individuals to refuse medical treatment and established standards for refusal of treatment for an incompetent person. theresa "terri" schiavo was a 27-year-old woman who experienced cardiac arrest and was resuscitated successfully. she was in a persistent vegetative state thereafter. after 8 years in this state without recovery, her husband decided to have her feeding tube removed. schiavo's parents disagreed and the case that ensued ultimately was heard by the florida supreme court which ruled that remaining alive would not respect her wishes. the united states supreme court affirmed that decision and refused to hear the case. this case affirmed the right of a patient to refuse care that is not in their best interests even when incapacitated.