Wednesday, March 30, 2005

Feeding Tubes and Heroic Life Support

In discussing the Schiavo case, I've heard many people make the argument that withdrawal of aggressive medical therapy such as a ventilator or hemodialysis is morally acceptable even without oral or written evidence that the patient would want it. In other words, people who hold this view feel that if physicians believe that a patient is not going to improve or that his anticipated quality of life will be poor then withdrawal of heroic life support is simply allowing God's will to be manifest. Apparently such a decision was even made on behalf of majority house leader, Tom DeLay's father.

On the other hand, many of these same people would be unwilling to withdraw nutritional support in the form of a feeding tube when facing the exact same clinical situation (as in the Schiavo case). The argument, of course, is that food and water is very different than "heroic" measures like a ventilator. Food and water is and water. It's not at all analogous to the extreme interventions that medical science has made possible.

This assumption is typically stated without proof. But is it a reasonable one? Actually, the answer will probably surprise most people: Modern enteral feedings as practiced today are extremely high tech and could never have been accomplished until very recently in the history of medicine. For a very good review of this see L Harkness's paper in the Journal of the American Dietetic Association, 2002.

The reliable surgical placement of a permanent feeding tube as opposed to the relatively temporary solution of a nasogastric tube was a major development and wasn't really possible until the 1940's. Modern nutritional formulas didn't come into being until the 1960's. Refinement of the technique of enteral nutrition as a whole didn't come together until the 1980's.

Terri Schiavo's longterm care, as managed for the past 15 years, was not reliably possible until mere decades before she went into a persistent vegetative state. To equate enteral feedings with merely eating is medically wrong.

You may still believe that witholding food from any patient is somehow morally wrong, but you can not say that tube feedings do not fall into the same high tech category as ventilators which after all only provide air. They are both aggressive, modern interventions that would never have been possible not so very long ago.

Had Terri Schiavo gone into a persistent vegetative state half a century ago, she would not have survived anymore than if someone in respiratory failure didn't have access to negative or positive pressure ventilation.

Administering enteral tube feedings is much more than just giving food and water.

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Anonymous Anonymous said...

I agree, it is a medical procedure. It falls under the other categories of treatments people have the right to refuse in their care.

I think it's a heinous way to die, but I don't confuse the subject.

I realize there are all sorts of conversations about "slipping into a coma" and "slipping away" and that a "PVS" person is probably not aware enough anyway, but really, what everyone seems to leave off is the part where the organs start shutting down, the body swells up (bloats), the lips are cracked (and please, that "vaseline" and "wet cloth" treatment stuff is a bunch of hooey; after 12 days, no amount of vaseline is going to keep your lips from cracking and bleeding; much less your tongue swelling up;) it's a race to see what kills you first: septic shock; stroke or choking to death on your tongue.

You might be unconscious when it happens, but it still happens. I just really find these docs on TV saying how "peaceful" it is very annoying.

March 30, 2005 4:52 PM  
Blogger Henry Stern, LUTCF, CBC said...

"Had Terri Schiavo gone into a persistent vegetative state half a century ago, she would not have survived anymore than if someone in respiratory failure didn't have access to negative or positive pressure ventilation."

This is where we part ways and -- IMHO -- your argument fails. Leaving aside for the moment that she may very likely *not* be in a PSV, the fact is that, if she was on a vent and/or [the gadget that keeps one's heart beating, which name escapes me right now, when I most need it], once *that* plug was pulled, she would die quickly and, one presumes, painlessly.

This is NOT the case with the feeding tube. As we have seen, she is dying VERY slowly, and apparently painfully (why else is she on morphine?). For me, this is the crux of the matter: if she were in a state such that she would die quickly, then at least there is mercy, if not justice. But to slowly starve a woman to death over a period of almost 2 weeks, there is neither justice nor mercy.

March 30, 2005 6:41 PM  
Anonymous Anonymous said...

As a Registered Nurse who, among other duties, has cared for patients requiring tube feedings, the procedure along with the enteral fluids are fairly low tech: 150cc syringe slipped into gastro feeding tube (last time I think it was q4h). Very different from maintaining a patient on a vent, or on hemodialysis (and I've done both). The gastrostomy required minimal care. Fifty years ago, a gastrostomy was feasible (don't know if they were done) ... but vents and dialysis were still developing technologies. So I don't agree with your equation of hydration/feeding per feeding tube and vents or dialysis. And in the care of dying patients, I was never ordered to deny hydration. Hydration was a comfort measure if nothing else. We typically give IV fluids, morphine, and sometimes atropine (for family more than anything else). But Teri Schiavo was killed as surely as someone put a .38 to her and pulled the trigger; but this death took thirteen days. This was a sad commentary on a materialist culture. Now, when will the insurance companies start demanding that your grandmother be killed because she's gone over her expected days of admission? And don't tell me it won't happen.

March 31, 2005 8:25 PM  
Blogger The Medicine Man said...

Anon, infusing enteral feeds into a G-tube, PEG or NGT is certainly technically easy and has the facade of simplicity. But the medical developments that led to that ease of use wasn't available until around 50 years ago.

Prior to that, patients like Terri Schiavo universally died very quickly because of malnutrition and its medical consequences.

Tube feedings ARE medical interventions and are no more analogous to eating than positive pressure ventilation is to breathing.

As an aside, I'm surprised that as an RN taking care of dying patients you were never asked to withdraw enteral feedings or hydration. This is a very common practice and one familiar to almost all hospice care providers.


March 31, 2005 10:07 PM  
Anonymous Anonymous said...

I disagree with your equation of tube feedings with vents ... it simply isn't the same. Giving an aspirin is a medical "intervention", but one so common that we no longer consider it "extraordinary". Yes, standards change with time and practice.
Hydration as I said is a comfort measure. When you thirst, you understand why that constriction of throat is not pleasant. Enteral fedings were certainly stopped. The patients I cared for died of organ failure, not starvation or dehydration. There's a difference. Hospice "care" in the Terri Schiavo case was a euphemism for a killing center. As Dr Cranston, the neurologist in the case at the end who is an advocate of not feeding Alzheimers patients even if they can take nurition per os, said, "he's done it dozens of times". (rough quote ... I think he specified between thirty or forty-five times, but I don't have his exact quote next to me).

April 01, 2005 7:59 AM  

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