As a medical student I vividly remember making rounds with the resident psychiatrist at a New York State insane asylum (that is what they were called then). He had a patient on a hunger strike whom he was force feeding temporarily. Apparently the patient’s prognosis was better than the patient’s perception of it. The psychiatrist injected a little water through the tube just as it reached the throat. During the reflex swallowing of the water the physician almost instantly got the tube clear into the stomach without any further maneuvering. I haven’t seen such agility with a gastric tube in the next 60 some years.
At about that time I attended a series of sessions on ethics for medical students offered by the local Catholic Diocese. I have remembered these sessions with gratitude through the years. They helped me to clarify my thinking and offended none of my personal biases. Abortion was illegal at that time and was not even mentioned (contraception was actually illegal in Connecticut then). The principle that I acquired from these sessions was that efforts to prolong life did not ethically require the use of extraordinary means—only ordinary means are required. Obviously the distinction between ordinary and extraordinary means is crucial.
The following discussion illustrates this point. At that time intravenous fluids frequently caused febrile reactions so that such infusions were used only when subcutaneous infusion was inadequate. There was some controversy as to whether the line between ordinary and extraordinary should be drawn between subcutaneous and intravenous infusions. Now that pyrogens, the fever-causing traces of bacterial products, are successfully removed from intravenous fluids, they too would become “ordinary” means of prolonging life. The intelligent solution was declaring ordinary means to be those that can be carried out without technical assistance such as providing food and all other necessary personal care and assistance.
An early dictum of the newly elected Pope Benedict was that all patients must be fed including tube feeding if that was required by the patient’s condition. Within a year he made the exception that tube feedings were not required after all if their use was too burdensome for that person. No doubt he became aware that, if a nasogastric tube is left in place even in cooperative patient for more than a week or so, it must be removed because of inflammation induced by the tube’s constant irritation in the throat. The way forward becomes a gastrostomy, an abnormal opening to the stomach through the abdominal wall. Reinsertion of the tube 2 or 3 times a day as the psychiatrist was doing would end up being even more burdensome. Even a gastrostomy is not proof against aspiration, choking, and pneumonia, but it greatly reduces the risk.
An occasionally sticky corollary to this precept is that means to prolong life that are not required ethically but which happen to have been initiated, can ethically be terminated. This may be true in principle, but may be difficult in the real world. For example, yesterday I read in the daily paper that an Italian man who had muscular dystrophy requiring a respirator for his survival was denied a church funeral because he had requested and been permitted to have his respirator turned off. Obviously the non-ecclesiastical funeral was more of a problem for his widow than for him. ( Suicides resulting from mental illness are forgiven.)
Getting back to feeding tubes: consider a nursing home patient who has stated in his health care power of attorney document that he does not want a feeding tube, and he happens to have a temporary condition such that a temporary feeding tube might permit survival in as good condition as before. Such a patient should be offered a feeding tube. In other words his previous statement should be interpreted to mean that he did not want to prolong his dying process with artificial feeding.
My experience with dying patients who are not eating is that the vast majority of them are not hungry. Nor does a moderate amount of dehydration cause thirst in this context—if anything it is equivalent to modest sedation. Finally normal hydration actually promotes convulsions in the case of renal failure.
John A. Frantz, MD
December 23, 2006