Respirator vs Feeding Tube

[gardenswithkids]

Yes, except in the case you cite death cannot take place as a result of the increase of narcotic medication. If it gets to a point where a person will either die from the medication or die naturally but with pain then we must allow them to die with pain because we cannot directly intend their death.

Yes, we can not directly intend their death. But in this example, the morphine administration is given with the intent of pain relief, not with the intent of death.

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In the case of feeding tubes, I’m still not entirely clear if the Church’s position is perfectly clear. A Magesterial document carries significanly more weight than a speech, and the document Evangelium Vitae discusses that we can refuse agressive care. It was in a speech about the specific medical situation of Persistent Vegetative States (PVS) that JPII declared that administration of food and water wasn’t a medical act, but a speech is not a Magesterial document. Was that John Paul II’s opinion? Did that statement apply to all medical conditions or just PVS?

In PVS, others sometimes want to remove feeding tubes that are already well established and that present little to no complications for the patient. Such removal of nutrition and hydration does seem dangerously close to euthanasia, especially if the intent is to hasten the death of a medically stable patient. It was at a conference on PVS where JPII made the comment that “administration of water and food, even when provided by artificial means, always represents a natural means of preserving life”

In the case where one reasons a feeding tube is burdensome, as in may cause chronic infections, is it just to withhold the tube even if the proximate cause of death would be starvation?

Or, what of demented patients who chronically pull out tubes and they cannot be managed with sedation? Can the cause of death ever be from direct starvation and dehydration and be licit?

I really don’t know the answer. The administration of water and food by artificial means in the case of the confused elderly person who pulls out the tube seems to me a different case from withdrawing nutrition from a person with PVS. We want to respect the dignity of the human person, and I wonder if long term sedation and restraint is consistent with that. By the time it reaches this point for an elderly confused person, there are frequently numerous other medical complications; while death may not be “eminent”, it is often close. The document Evangelium Vitae says, “It needs to be determined whether the means of treatment available are objectively proportionate to the prospects for improvement.”

 

[fix]

I really don’t know the answer. The administration of water and food by artificial means in the case of the confused elderly person who pulls out the tube seems to me a different case from withdrawing nutrition from a person with PVS. We want to respect the dignity of the human person, and I wonder if long term sedation and restraint is consistent with that. By the time it reaches this point for an elderly confused person, there are frequently numerous other medical complications; while death may not be “eminent”, it is often close. The document Evangelium Vitae says, “It needs to be determined whether the means of treatment available are objectively proportionate to the prospects for improvement.”

I welcome any new information. I think Mosher has the right take here. It would seem we may never intend to have death by dehydration or starvation. It must be an unintended consequence. Perhaps I have it wrong?

 

[HoppityRedux]

Yes, except in the case you cite death cannot take place as a result of the increase of narcotic medication. If it gets to a point where a person will either die from the medication or die naturally but with pain then we must allow them to die with pain because we cannot directly intend their death.

Wonderful. Medical care would then make the needs and wishes of the patient subservient to the feelings of the doctor. I’d suggest anyone carefully interrogate potential doctors to detemine if they will deliver the care the patient wants. This would include both the people who choose to die in pain and those who don’t.

 

[manualman]

This continues to be interesting and I find myself waffling.

Gardenswithkids makes a highly important point noting the context of some JPII remarks on feeding tubes being specific to PVS. I DO know that the church expressly DOES allow continued use of pain meds even if it has the unintended side effect of causing death sooner than NOT using such meds. (Darned if I can reference where I read that though).

Perhaps someone in end stage dementia need not be restrained or sedated merely to keep the tube in? As noted, such things are hardly compatible with human dignity when there is no reasonable expectation of improvement? Such a case is surely VERY different than, say, Terri Schaivo, who was medically stable and merely required a feeding tube due to damage to her swallow reflex portion of the brain.

 

[gardenswithkids]

Gardenswithkids makes a highly important point noting the context of some JPII remarks on feeding tubes being specific to PVS.

Thanks but to clarify, I threw that out as a possibility that perhaps his remarks were specific, but I don’t know if they were or not.

I tried to find the Church sources that said artificial food and hydration were no longer “extraordinary”, and what I turned up traced back to JP II’s talk at a PVS conference. I want to believe what the Church teaches, but I also want to be sure that the Church really teaches it, and (as much as possible) I like to understand the teachings. This one still has me puzzled.

 

[gardenswithkids]

I welcome any new information. I think Mosher has the right take here. It would seem we may never intend to have death by dehydration or starvation. It must be an unintended consequence. Perhaps I have it wrong?

I welcome new information on this too. Yes, I definately agree that we must never* intend* the death. That much I understand, and it is consistent with other Catholic teachings. (But I still don’t know what the Church expects when someone refuses to eat and then yanks out their own feeding tubes.)

 

[MikeinSD]

I understand what you are saying. Being on a vent is not a fun thing under any circumstances. My point is that there is a wide range of patient experiences that are based on how well the staff does their job. A properly managed patient, all things being equal, will have a better experience. There is no way to make it a happy experience.

Some people with COPD actually WANT to go on a ventilator. Anyway, I’m glad you are here to talk about it. Hopefully there are no vents in your future.

When I was on a ventilator, the doctors initially give me meds. At that time, I was a minor. When the meds wore off, I thought I was choking. I wasn’t given any more meds for 24 hours. Some family members had protested the medications. Called the hospital and threaten to sue. Thankfully, other family members who actually showed up at the hospital stepped in and authorized the medications.

Regarding end of life use of pain meds – same problem. In the last 4 days while my mom was dying from breast cancer, some family members tried to stop the hospice nurses from giving her pain meds. They said that her suffering while dying would somehow make her more fit for heaven. And they were also concerned that hospice might give her too much morphine and hasten my mom’s death. The hospice called me, my brother and sisters. We insisted on continuing the morphine. We also took turns guarding my mom so that the hospice nurses could do their jobs. My mom died peacefully.

Don’t understand some folks’ idea that making other people suffer brings them closer to God. I think that is evil.

 

[mosher]

OK, so when I read that folks say if they get in a situation when they are very ill and they have an advanced directive that declares they want to refuse feeding tubes we can conclude such a sweeping statement is morally wrong unless they carefully qualify it?

Yes because it does not respect the nuance of the particular situation that may be involved. We cannot predict the means of our death or debilitation so then it is always better to have a person who is other than the power of attorney called a medical power of attorney or health care decision maker (depending on the legal jargon of the region) to make real decision in real circumstances. This person should be well formed in the faith.

But in this example, the morphine administration is given with the intent of pain relief, not with the intent of death.

You are correct but there are cases where this practice is done to deliberately shorten a persons life. Such a case is unethical.

In the case of feeding tubes, I’m still not entirely clear if the Church’s position is perfectly clear. A Magesterial document carries significanly more weight than a speech, and the document Evangelium Vitae discusses that we can refuse agressive care. It was in a speech about the specific medical situation of Persistent Vegetative States (PVS) that JPII declared that administration of food and water wasn’t a medical act, but a speech is not a Magesterial document. Was that John Paul II’s opinion? Did that statement apply to all medical conditions or just PVS?

What must be considered is current medical advancement. Take as an analogy the use of the Death Penalty. In more advanced countries its use would be nearly nullified because there are other means of protecting society from that person. However, in a less advanced country it is expected that the frequency of the use of the Death Penalty will be higher because the skill to adequately detain this person may be lacking. This is also the case with certain medical procedures such as the insertion of a feeding tube. As medical science has advanced and as it continues to advance some things that are extraordinary will become ordinary. I think that the majority of Catholic biothicists would agree (based on the work in that field that I have read) would agree with the statement of JPII. Since this is the case it would be our responsibility to the virtue of prudence to follow such advice even in the absence of a specific magisterial document.

In PVS…

This is difficult because PVS is defined differently by different medical experts. So, we must be more specific in citing the particular situation. Does the person have discernible brain waves? Is there a possibility of recovery? Will the person continue to live if only nutrition is given? There are the most important of the questions that need to be asked in relation to the so called Perpetual Vegetative State.

Wonderful. Medical care would then make the needs and wishes of the patient subservient to the feelings of the doctor. I’d suggest anyone carefully interrogate potential doctors to detemine if they will deliver the care the patient wants. This would include both the people who choose to die in pain and those who don’t.

This is not a correct read of what is being said. In this case the doctor is a functionary and not a moral decision maker (in some respects). Rather the wishes of the patient can only be ignored if there is a grave moral reason. For instance if a patient asks a doctor to increase his narcotic pain medication to a point that he goes into cardiac arrest or renal failure then the doctor has a moral obligation to refuse these wishes just was would the family. The wishes of the patient are never valid if those wishes are immoral.

I tried to find the Church sources that said artificial food and hydration were no longer “extraordinary”, and what I turned up traced back to JP II’s talk at a PVS conference. I want to believe what the Church teaches, but I also want to be sure that the Church really teaches it, and (as much as possible) I like to understand the teachings. This one still has me puzzled.

Again I suggest a read of “Catholic Bioethics and the Gift of Human Life” by William May. He is the foremost expert on Catholic Ethics (of any sort) and can be trusted in his treatment of the subject. This book should be in any good catholics library.

(But I still don’t know what the Church expects when someone refuses to eat and then yanks out their own feeding tubes.)

Just as it is permissible to restrain a person with a mental defect and force medication or another treatment I would argue that in this case such means would be permissible.

 

[HoppityRedux]

Mosher wrote:
This is not a correct read of what is being said. In this case the doctor is a functionary and not a moral decision maker (in some respects). Rather the wishes of the patient can only be ignored if there is a grave moral reason. For instance if a patient asks a doctor to increase his narcotic pain medication to a point that he goes into cardiac arrest or renal failure then the doctor has a moral obligation to refuse these wishes just was would the family. The wishes of the patient are never valid if those wishes are immoral.

This is why it is important to make sure to have a doctor who is in agreement on on these issues. Get a doctor who does consider the wishes of the patient to be more important than the moral judgements of third parties. I would recommend this both for folks who agree with Mosher, and those who don’t.

 

[Zooey]

This is not going to help in the case of the person with dementia pulling out the feeding tube, but my own understanding is based on my own experiences, with my own health issues, & with being the POA & Health Care Proxy for my mother in her last illness.
As I have said, the respirator is extraordinarily uncomfortable & also, I would add, frightening.
A feeding tube is simply there; it does not cause pain or fear in the patient. (As far as I can tell: I was not the one with a feeding tube!)
So, in my own mind, this needs to be considered in determining what is extraordinary vs ordinary. I am NOT saying that we should base all our decisions on the question of comfort. My point is, that while one form of treatment may well be extremely stressful to a dying/drastically ill person, another may simply be a form of caring for them: dehydration is not painless. I have been hospitalized several times in my life for dehydration, & it is as close to what hell must be like as I ever hope to find out!!! You are cold & hot by turns, in pain, confused, hallucinating, and frequently unable to speak intelligibly. That tube feeding, or IV needle may make all the difference in the comfort of the patient. The respirator, it seems to me, is more aggressive, & I can well imagine that someone who is dying anyhow, may want it gone. This is not suicidal; it is an acknowledgment that death is near, & a desire to go quietly as possible…

As far as PVS is concerned, IMHO, it is, as someone observed on these forums at the time when Terri was being killed:" PVS is a diagnosis in search of a disease".