An appropriate time to reduce hydration?

[beckycmarie]

This question about denying hydration is in the Ask an Apologist forum:

Q. If there is a person who is in a vegetated state (considerable brain loss) and is starting to balloon from the IV, can they be denied nutrition and hydration from an IV by their proxy since they will die soon?

-fish90

A. Hi,

Food and hydration are ORDINARY means and should NEVER be denied a sick person.
To die from dehydration is a slow and very painful death. To knowingly cause a person to die this way is mortally sinful.

Fr. Vincent Serpa, O.P.

Fish90 wasn’t very clear in his question, but if by saying the person is “starting to balloon from the IV” he means that the person’s kidneys are not processing the fluid, and the person is retaining fluid (often in the lungs), isn’t it appropriate to cut back the amount of fluid being provided since the hydration itself could kill the person by suffocation?

 

[Bluegoat]

This question about denying hydration is in the Ask an Apologist forum:

Fish90 wasn’t very clear in his question, but if by saying the person is “starting to balloon from the IV” he means that the person’s kidneys are not processing the fluid, and the person is retaining fluid (often in the lungs), isn’t it appropriate to cut back the amount of fluid being provided since the hydration itself could kill the person by suffocation?

Yes, I would think that was the case. I don’t think the hospital staff would normally let this go on. Too much fluid is a bad thing.

Perhaps the problem was the writing between the lines on this question - because this inability to process fluids is related to the body beginning to shut down, is it now ok to deny sustenance? So, no, it isn’t.

But really, I think the question is a scenario that needn’t be treated that way at all, if the situation is treated as it comes, without anticipating… If there is too much fluid, give less or none for a time. That is what good care demands at that time, it is what would be done for a person who was expected to live. Often in such a situation, there may never be a requirement to resume hydration and feeding because the person will die.

The comment that dying of dehydration is horrible, is a bit up in the air to me - yes, I would normally say that is true. I’m no sure it feels worse for a person in a vegetative state than having the organs shut down, and with death so close, is it really kinder? But that isn’t really the point, in the end, so I am not sure why it was even mentioned. The patient would suffer less if euthanized, but that doesn’t make it ok, if you see what I mean.

Overall, not a well thought out answer.

 

[Tosk]

This question about denying hydration is in the Ask an Apologist forum:

Fish90 wasn’t very clear in his question, but if by saying the person is “starting to balloon from the IV” he means that the person’s kidneys are not processing the fluid, and the person is retaining fluid (often in the lungs), isn’t it appropriate to cut back the amount of fluid being provided since the hydration itself could kill the person by suffocation?

I think it was just because the question wasn’t very clear. The person in that question wouldn’t be receiving hydration at all and pumping more water into them would likely hasten their death. Maybe in that case there is just no way to deliver hydration. I don’t really know their options.

I think the key is that we can’t deny hydration or nutrition to a person who can receive it. Sometimes things do go beyond our control though.

 

[Melissa]

Yes, when the expected lifespan has come down to hours/minutes, ordinary things like food and water (delivered by IV and/or feeding tube) can be discontinued. The cause of death is not the lack of food/water, but rather the massive systems shutdown that precedes natural death–complete renal failure is frequently involved immediately before the death of a person who has been ill. If the body has quit processing the food/water (evidenced visibly by the bloat/distended body parts), there’s no reason to continue a treatment that is useless AND painful to the patient. But again, we’re talking about the time when someone gets very close to death. I know of a friend of the family whose mother was dying of bladder cancer–death followed in under 12 hrs after discontinuing the IV, my grandmother’s death followed under 6.5 hrs after discontinuing feeding tube. These women were already in the process of dying, and the cause of death had nothing to do w/ discontinuing the nutrition/hydration.

I do not believe that the condition would present itself in a person who is not otherwise actively dying, barring a more localized infiltration of the IV line (in which case the appropriate action would be a relocation and further action to help resolve the swelling from the infiltration).

 

[Corki]

Yes**, when the expected lifespan has come down to hours/minutes, **ordinary things like food and water (delivered by IV and/or feeding tube) can be discontinued. The cause of death is not the lack of food/water, but rather the massive systems shutdown that precedes natural death–complete renal failure is frequently involved immediately before the death of a person who has been ill. If the body has quit processing the food/water (evidenced visibly by the bloat/distended body parts), there’s no reason to continue a treatment that is useless AND painful to the patient. But again, we’re talking about the time when someone gets very close to death. I know of a friend of the family whose mother was dying of bladder cancer–death followed in under 12 hrs after discontinuing the IV, my grandmother’s death followed under 6.5 hrs after discontinuing feeding tube. These women were already in the process of dying, and the cause of death had nothing to do w/ discontinuing the nutrition/hydration.

I do not believe that the condition would present itself in a person who is not otherwise actively dying, barring a more localized infiltration of the IV line (in which case the appropriate action would be a relocation and further action to help resolve the swelling from the infiltration).

Unofortunately, I had first hand experience with this a few months ago. There are two key factors. The first is that the reduction or end of hydration or food can not be done to hasten death (as in the Terry Schiavo case). The second is if the hydration is itself causing harm.

The body naturally stops processing hydration and nutrition as death nears. But this is, as far as I know, almost always when “near” is a matter of hours, not days or weeks.

In the case of my loved one, when he was in his final hours, the fluid from the IV was just building up in his body. They suctioned it out for a while but eventually couldn’t keep that up. They reduced his IV to just enough to keep the flow of pain killer going. We still kept him comfortable with small amounts of water to soothe his dry lips, so we weren’t “denying” him hydration. But that little bit was all his body could take. His death was only a few hours after they cut back his IV. His death was not due to dehydration, not even as a small factor and continuing the hydration would not have prolonged his life.

 

[Joe_5859]

See the Congregation of the Doctrine of the Faith’s document (and relevant commentary) on the matter:

• Responses to Certain Questions Concerning Artificial Nutrition and Hydration
• Commentary on the above Responses.

In particular, you will want to take note of the final two paragraphs of the Commentary (understood in relation to the rest of the Commentary, of course):

When stating that the administration of food and water is morally obligatory in principle, the Congregation for the Doctrine of the Faith does not exclude the possibility that, in very remote places or in situations of extreme poverty, the artificial provision of food and water may be physically impossible, and then ad impossibilia nemo tenetur. However, the obligation to offer the minimal treatments that are available remains in place, as well as that of obtaining, if possible, the means necessary for an adequate support of life. Nor is the possibility excluded that, due to emerging complications, a patient may be unable to assimilate food and liquids, so that their provision becomes altogether useless. Finally, the possibility is not absolutely excluded that, in some rare cases, artificial nourishment and hydration may be excessively burdensome for the patient or may cause significant physical discomfort, for example resulting from complications in the use of the means employed.

These exceptional cases, however, take nothing away from the general ethical criterion, according to which the provision of water and food, even by artificial means, always represents a natural means for preserving life, and is not a therapeutic treatment. Its use should therefore be considered ordinary and proportionate, even when the “vegetative state” is prolonged.

So, basically, there are three exceptions to the rule:
(1) In very remote places, or places of extreme poverty, it is impossible to administer nutrition and hydration by artificial means (this simply does not apply to the U.S.);
(2) The patient cannot assimilate the food and water, thus making it useless; and
(3) The artificial administration is “excessively burdensome” and painful.

The example in the OP might fall under #2. The important thing to keep in mind is that these are exceptions which the CDF repeatedly refers to as “rare” and “extreme.” In other words, though these exceptions occur, they are not the norm. We should not rush to assume that it is an exception but should only come to that conclusion after much deliberation and consulting with both competent medical professionals and some good priests.

 

[CB_Catholic]

I am not sure that the answer given was very well thought out, because if a person is in multisystem organ failure and the kidneys cannot handle the extra fluid they can go into pulmonary edema and have difficulty breathing. Plus, massive edema can be painful, the skin is fragile and is subject to tears and breakdown, making things even more uncomfortable for the person. And fluid leaks out of the skin, causing further breakdown. The eyeballs become edematous and bulge and the eyelids cannot close to protect the eyes. Feeding a person whose organs are shutting down via a tube is not only fruitless, but can be dangerous. The food is not digested and there is a risk of vomiting and aspiration of the stomach contents into the lungs, causing a person to choke to death. I worked in an ICU for nearly 20 years and saw this scenario many times. This is not a death with dignity, and there is no point to subjecting a dying person with organ failure to this. It is a horrible way to die.

The scenario with Terri Schiavo is an entirely different matter because her body was not dying. Her organs were working, and she was able to handle the fluids and nutrition. Also, if a person’s condition is treatable or there is hope for a cure, that is obviously another matter.

Also, there is the situation with Hospice Care, where terminally ill patients do not receive fluids and nutrition when they are dying and their organs are shutting down. Many Catholic hospitals have hospice care, and it is approved by the Church. So there seems to be a discrepancy here. We will allow a person to die a natural death in Hospice care without artificial means of fluids and nutrition, but not in a regular hospital? My MIL received Hospice care at home when she was dying of cancer, and when she quit eating and drinking, it was not forced on her. She was given pain medication by skin patches when she could not swallow the liquid Morphine, and died a peaceful death. No one even suggested IV’s or a feeding tube, and it was perfectly acceptable. She died of the cancer, not the lack of fluids.

I think the good Apologist needs to research this matter a little more thoroughly.

 

[CB_Catholic]

See the Congregation of the Doctrine of the Faith’s document (and relevant commentary) on the matter:

• Responses to Certain Questions Concerning Artificial Nutrition and Hydration
• Commentary on the above Responses.

In particular, you will want to take note of the final two paragraphs of the Commentary (understood in relation to the rest of the Commentary, of course):

So, basically, there are three exceptions to the rule:
(1) In very remote places, or places of extreme poverty, it is impossible to administer nutrition and hydration by artificial means (this simply does not apply to the U.S.);
(2) The patient cannot assimilate the food and water, thus making it useless; and
(3) The artificial administration is “excessively burdensome” and painful.

The example in the OP might fall under #2. The important thing to keep in mind is that these are exceptions which the CDF repeatedly refers to as “rare” and “extreme.” In other words, though these exceptions occur, they are not the norm. We should not rush to assume that it is an exception but should only come to that conclusion after much deliberation and consulting with both competent medical professionals and some good priests.

These may be exceptions, but let me assure you, they are not that rare or extreme. #2 and #3 happen all the time in ICU’s all over the country. That has been a major concern of nurses that work in these units for years. And I’m not talking about potentially curable conditions where there is a chance of recovery. I’m talking about terminal conditions with no hope of recovery. Finally, however, the medical profession is beginning to see this, and starting to address it.

 

[Joe_5859]

These may be exceptions, but let me assure you, they are not that rare or extreme. #2 and #3 happen all the time in ICU’s all over the country. That has been a major concern of nurses that work in these units for years. And I’m not talking about potentially curable conditions where there is a chance of recovery. I’m talking about terminal conditions with no hope of recovery. Finally, however, the medical profession is beginning to see this, and starting to address it.

You may very well be correct. I am in no position to disagree.

As others posted, it seems that #2 and #3 happens often when a person is within hours of death (and most of us can go several hours without food or water and feel just fine). Perhaps the CDF uses “rare” and “extreme” with regards to those situations where the person cannot assimilate food, but they are not at death’s door. In other words, those cases where the lack of food and water will hasten death or cause problems, but it is nonetheless the only option. Perhaps those cases are more rare?

 

[CB_Catholic]

You may very well be correct. I am in no position to disagree.

As others posted, it seems that #2 and #3 happens often when a person is within hours of death (and most of us can go several hours without food or water and feel just fine). Perhaps the CDF uses “rare” and “extreme” with regards to those situations where the person cannot assimilate food, but they are not at death’s door. In other words, those cases where the lack of food and water will hasten death or cause problems, but it is nonetheless the only option. Perhaps those cases are more rare?

It is not unusual for a people to not be able to assimilate food through the digestive tract, but have functioning kidneys and other organs and not be at death’s door. In these cases they are given nutrition intravenously in specially formulated solutions. And they should not be denied this care, and withholding it would hasten their death. However, in underdeveloped countries, or in countries with limited access to medical care, this option is not available and is very expensive. I think #1 would apply in these cases.

We in America are extremely fortunate in the medical technology we have available, and we take it for granted. But in many areas of the world, this technology is not available, and people die from illnesses and accidents that they would be able to survive from here. If you get to the point where you can’t take in food and water, you die. Plain and simple. It is my guess that in a significant portion of the world discussions of the moral issues we are talking about rarely takes place. And in America, even, it is a fairly recent dilemma. A hundred years ago we wouldn’t even be having this discussion. Basically, we are still trying to sort things out, even in the Church. And with the current health care crisis, I think things are going to get even more complex, and even more issues are going to be raised.