 | Tom Welk
DMin is Director of Pastoral Care & Professional Education at Harry Hynes Memorial Hospice. He also teaches at the University of Kansas School of Medicine-Wichita. He has certification with the American Association of Pastoral Counselors in Clinical Pastoral Education. His memberships include Park Ridge Center for Study of Health, Faith, and Ethics, and St. Louis University Center for Health Care Ethics, Charter Board Member Kansas Health Ethics, Inc., and Ethics Committee Member for National Hospice Organization. He has received the President's Award of Excellence for Public and Community Awareness, for the "Dying Well" project from The National Hospice Organization. Tom's group presentations include: Association of Kansas Hospices, Midwest Congress on Aging, and Kansas Health Ethics Conference. Tom Welk can be contacted by fax at (316) 265-6066, by e-mail at: twelk@hynesmemorial.org, or at his office at (316)219-1791. |
Hospice
2003-05-01 12:22:00
What about 'tube feeding'?
ANSWER: Food and water are essential for physical survival. Taking food by mouth (eating and drinking) is the way in which this basic need is usually met. In the not too distant past, when this ability was lost because of injury or disease, death would soon follow. Today this no longer is the case. Modern medicine has made it possible for food and water to be given in a variety of technical ways. There are too many to list in this article, but they generally are referred to as artificial nutrition/hydration, or in common language as tube-feeding. My personal preference is to refer to this technology as medically assisted nutrition/hydration. This designation indicates that these are medical interventions. Whether or not they are utilized in a life-threatening situation will be determined in the same way as all other medical interventions. That is, do they provide a benefit or not?For example, medically assisted nutrition/hydration will obviously be provided to an injured patient whose ability to eat/drink has been temporarily compromised. The medical assistance "buys time" for the individual to recover and resume quality living. In the case of a terminal disease such as advanced cancer, food and drink, however provided, will not change things. On the contrary, there is general agreement that forcing this (whether orally or mechanically) will probably make things worse, particularly in terms of comfort. Not eating/drinking is one of the characteristics of the dying process; it is not the cause of death. We have come to expect the utilization or non-utilization of medically assisted nutrition/hydration in the examples given above. The question becomes considerably more complicated in the case of neurological diseases like dementia, more commonly referred to as Alzheimer's disease. Alzheimer's is not seen as a terminal disease, and therefore makes the decision about providing medical intervention to provide nutrition/hydration a difficult one for both loved ones and the medical professional. Debate about providing/not providing this intervention centers around the following basic questions: 1) Does it provide comfort; 2) Do tube-fed patients live longer than those hand-fed; 3) Will it keep patients from developing aspiration pneumonia (caused by ingesting substances into the lungs); 4) Does it prevent the development of bed sores; and 5) Will it improve the patient's ability to function normally (mentally and physically)? Let me offer a few brief comments on each of these questions. Comfort - It is impossible to determine comfort level by asking demented patients themselves. But we do know from stroke and cancer patients that lack of food and water is not a source of discomfort. Mouth and lip dryness is generally identified, but this can be alleviated with ice chips or lip balm. Conversely, forcing food and drink is frequently identified as a source of discomfort. Length of survival - Numerous studies have shown there is relatively little survival difference between patients who were hand-fed and those medically assisted. As a matter of fact, feeding tube placement can cause death. Aspiration pneumonia - This is caused by substances being ingested into the lung, often by regurgitation. Tube placement will not prevent this, whether it be a gastrostomy (stomach) or jejunostomy (small intestine). Tube-feeding often increases the likelihood of aspiration pneumonia. Bed sores (pressure sores; decubiti). A study following 800 patients for six months reported that tube feeding showed no healing of bed sores or the prevention of new ones developing. Improvement of function - Dementia is irreversible. There is no present cure. No matter how much nourishment is provided, decline is inexorable. What can/should be done regarding the care of dementia patients? The most obvious is the provision of hand-feeding. Indeed, this is time consuming and poses a financial burden. But tube placement should not be initiated simply for convenience. What can never be neglected is the comfort of the patient. This will always be beneficial. As has been well-stated throughout its history, the role of medicine is "to cure sometimes, to relieve often, but to comfort always."
