The Tinslee Lewis Case: A Landmark Legal Battle Over Life-Sustaining Treatment in Texas

The Tinslee Lewis case, involving a critically-ill infant and Cook Children’s Medical Center in Fort Worth, challenged elements of the Texas Advance Directives Act regarding life-sustaining medical treatment and the procedures and timeline to end that treatment. A major component that came under scrutiny was the “10-Day Rule” provision of the law that provided patients ten days to find an alternate medical facility to perform life-sustaining treatment in the scenario that an ethics committee, upon review of an attending physician’s decision to end treatment against the patient’s wishes, finds that continued treatment is medically inappropriate.

Tinslee Breaun Lewis was born prematurely to Trinity Lewis at Cook Children’s Medical Center in Fort Worth on February 1, 2019. While in utero, she was diagnosed with Ebstein’s Anomaly, a rare congenital heart defect that can manifest in a decrease in blood oxygen, heart rhythm irregularities, a reduction in cardiac function, and eventual heart failure. Tinslee suffered from troubled heart function, chronic lung disease, and pulmonary atresia and required continuous life-sustaining medical treatment from birth, with complications from her condition resulting in continuous hospitalization in the cardiac intensive care unit. Despite multiple surgeries, her health did not improve by any substantial metric. Physicians began expressing doubts about her ability to survive. Tinslee’s afflictions culminated in a respiratory arrest event on July 9, 2019. Despite an aggressive resuscitation attempt, she was placed on an Extracorporeal Membrane Oxygenation (ECMO) machine, which replaced the function of her heart and lungs, and a ventilator. On October 30, 2019, the hospital’s ethics committee met to discuss whether further lifesaving treatment for Tinslee Lewis, now nine months old, should be provided. All twenty-two members on the ethics committee voted against the continuation of such measures, a decision with which Tinslee’s mother, Trinity Lewis, vehemently disagreed. Trinity now had ten days to find a health care facility that would be willing to admit and treat Tinslee. This clash of conflicting perspectives on Tinslee’s chance of survival and the role of life saving medical treatment began a long legal battle that would redefine, both in the eyes of the public and Texas state law, the idea of what it means to save a life.

When Trinity Lewis was informed that the “10-Day Rule” was invoked in the case of her infant daughter, she immediately sought legal recourse. The case was filed as [T.L.], a Minor and Mother, [T.L.], on her behalf v. Cook Children’s Medical Center. On November 10, 2019, Judge Alex Kim, presiding over the 323rd Judicial District, Tarrant County, Texas, granted her request for a temporary restraining order against the hospital, filed by attorney Joe Nixon with legal and financial support from pro-life organization Texas Right to Life. The order prohibited the hospital from removing treatment and was set to expire on November 22. Cook Children’s released a statement saying that Tinslee’s health would “never improve” and that her condition was “irreversible” and “fatal.” The hospital added, “But more importantly, her physicians believe she is suffering.” They stated that they reached out to nearly twenty facilities across the country, all of whom had denied Tinslee as a patient on the basis that they agreed with Cook Children’s assessment and that they could not provide any additional care to “help improve this precious child’s life.” On November 19, Judge Kim extended the restraining order to December 10. However, the next day, Cook Children’s filed a motion asking for Judge Kim to be recused and questioning his impartiality and assignment to the case. The hospital argued that the fact that Kim spoke at a True Texas Project  presentation in North Richland Hills indicated partiality. True Texas Project was an organization that publicly supported Tinslee’s case. Under Texas law, evidence of partiality would require Kim to recuse himself. Furthermore, Cook Children’s stated that Texas Right to Life collaborated with State Representative Tony Tinderholt to contact a judge who would be likely to grant the restraining order, a claim that Texas Right to Life vehemently denied (instead claiming that it had been Nixon who had contacted Judge Kim). Finally, Cook Children’s claimed that Kim had asked the Tarrant County district clerk to assign the case to his court instead of performing a random assignment. Ultimately, the hospital was successful, and Judge Kim was removed from the case on December 4, 2019.

On December 12, 2019, newly-appointed Chief Justice Sandee B. Marion of the Texas Fourth District Court of Appeals heard arguments on the constitutionality of the Texas Advance Directives Act (TADA). Joe Nixon once again represented the Lewis family, and attorneys for Cook Children’s included Tom Walsh and Geoffrey Harper. Dr. Pam Foster, chair of the ethics committee at Cook Children’s, was cross-examined alongside other employees of the hospital. Hannah Mehta, the co-founder and executive director of Protect Texas’ Fragile Kids, took the witness stand to highlight the shortcomings of TADA. By this time, the case was receiving statewide attention to the degree that sixteen state legislators signed a letter pressuring Governor Greg Abbott into calling a special legislative session to repeal the 10-Day Rule. No session was called, however. On January 2, 2020, Judge Marion ruled that the hospital was allowed to take Tinslee off life support. The decision prompted a joint statement from Governor Abbott and Attorney General Ken Paxton, both of whom fully supported the Lewis family in their legal proceedings. Nixon proceeded to file an emergency motion to stay the ruling and argued that the hospital did not have the right to decide whether Tinslee lived or died.

On January 3, 2020, the Texas Second Court of Appeals granted an emergency motion, forcing Cook Children’s to continue treatment. Eventually, on July 24, 2020, the Texas Second Court of Appeals ruled to fully overturn the ruling made by Justice Marion on January 2. In a 148-page decision from the court, Justice Wade Birdwell stated that the lower court in its ruling must evaluate the TADA itself and that Cook Children’s, in invoking and following the “10-Day Rule,” failed to provide “adequate procedural due.” Birdwell argued that the hastening of death through the removal of treatment was inherently in violation of both the right to life and the right to due process outlined in the U.S. Constitution. Until the trial court rendered an order evaluating the TADA on its merits, the stay order issued by Birdwell remained in effect.

The next major period of legal developments, September 2020, began with attorneys from Cook Children’s filing an emergency motion to expedite the case on the basis that they judged that Tinslee was in agony while in her state of forced paralysis, a result of her painkillers, sedation, and paralytics intended to prevent her from removing her tubes. Her mother released a competing statement one week later and denied Cook Children’s claims about Tinslee’s condition while asserting that the hospital was limiting her ability to visit her daughter. After receiving amicus briefs in support of Tinslee from a coalition of religious leaders, activists, and political organizations, the Supreme Court of Texas ultimately declined the emergency motion on October 16, 2020. After this denial, the hospital made a preliminary plea to the Supreme Court of the United States to review the decision by the Second District Court of Appeals of Texas. The hospital questioned the role of the state in determining the private medical care provided and also raised the question of how personal protections afforded to physicians in relation to the decision of an ethics committee to withdraw life-saving treatment would be affected upon the reversal or repeal of TADA. On January 11, 2021, the U. S. Supreme Court declined to grant the appeal and referred the matter back to the lower court. The Forty-eighth District Court was charged with ruling on the continuation of Tinslee’s treatment and subsequently setting a precedent that could be used to challenge the foundation of the TADA.

The following months saw a series of appeals and arguments from both sides involving the cost of Tinslee’s treatment to the Texas Medicaid system, her chance of recovery, and when physicians have the right to refuse treatment. The state began a review on the appropriateness of the ongoing medical care on the basis of its $24 million financial cost to Texas STAR Kids, a special Texas Medicaid-managed program designed to provide medical coverage to underprivileged, low-income communities. A final trial date was set for January 25, 2022, however, the trial was delayed. In a status report on March 1, both parties reported that they were “working cooperatively to resolve the situation.”

On April 7, 2022, Tinslee Lewis was released from the Cook Children’s Medical Center and went home with her family, marking the end of a legal battle that had lasted Tinslee’s entire life. Her story highlighted the shortcomings of the existing TADA and renewed calls from a multitude of legal and medical professionals to reform what was regarded as flawed and outdated legislation. Sessions of the Eighty-eighth Texas Legislature saw heated discussion over how the TADA could be amended to better protect the rights of patients in determining their own medical care and quality of life. Eventually, House Bill 3162, a comprehensive revision to the TADA, was passed by the Eighty-eighth Texas Legislature and took effect on September 1, 2023. One of the most notable changes was an increase in the required notice period that hospitals must give to patient families prior to ending care from ten to twenty-five days. Additionally, H.B. 3162 resulted in changes to the procedure of an ethics committee meeting, the reporting requirements for health care facilities, the rules and regulations surrounding do-not-resuscitate orders, and the information statements provided to patients. In fighting for Tinslee’s life, the Lewis family illustrated to lawmakers, physicians, and the state of Texas the complexities and restrictions of the existing law regarding life-sustaining care.