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Feeding Tube to Artificially Prolonging Life
If a terminally ill person does not sign an AMD and have the financial resources, most hospital system would have little choice but to go ahead with feeding tube. But, keeping a tube in a terminally ill person's nose or directly into her stomach for no reason other than just artificially prolonging her life is a dehumanizing existence for the patient. This sort of feeding, in some cases, can go on for months or years.
The most recent reported case in the newspapers is that of Terri Schiavo. She was an individual in a persistent vegetative state (PVS) for 15 years whose life was extended through the use of a feeding tube. She died on 31 April 2005. The main concern in this case was that her wishes were unknown and this spawned many debates about whether or not removing Terri’s feeding tube was ethically, morally, and legally “right.” [From wikipedia http://en.wikipedia.org/wiki/Terri_Schiavo_case,
The Whole Terri Schiavo Story from the WorldNetDaily in http://www.wnd.com/2005/03/29516/ and
The Lesson of Terri Schiavo in http://rossde.com/editorials/edtl_Schiavo.html]
Having read the above 3 write-ups plus others in the Internet, the lesson for me about Terri Schiavo case is that none of us should put our own family into a state where our family members may have to suffer because we did not sign an AMD ourselves through ignorance or non action. Family members will have great difficulty to decide—there will be some who are for keeping on feeding and some are for stopping the feeding after some time—when such cases of feeding tube occur. Thus, it is something to be discussed and thought through for all individuals to decide whether to sign an AMD or not, long before we are terminally ill (as defined in the Advance Medical Directive (AMD) Act of Singapore below).
My point is that how can any family member in Singapore be in a better position than the 5 specialist doctors (see below) to decide whether the patient is terminally ill and therefore does not want to continue with the tube feeding?
All of us are under the impression that when we are terminally ill, the primary treatment team in the hospital will be in the best position to advise us or to decide whether to continue with the feeding tube or to withdraw or withhold such treatment after some time. No hospital or doctor want to be sued. When the family member asks verbally, what do we expect the doctors to say? The more sympathetic doctor will say it will be best if you can get all your family members to come, the cautious doctor will say ‘I am cannot predict’ or something to that effect, the hurried doctor will just brush our question aside and we get a whole host of different answers. If the patient does not have a signed AMD, the family will be put into a position, after some time, of deciding whether to continue with the tube feeding or respirator or any aggressive cure treatment. The family members are not in a position to really know whether the patient is terminally ill or not. This is an unfair situation but a fact of the hospital system.
Thus, the only official way to obtain an expert professional certification as to whether the patient is terminally ill and thus does not want “Extraordinary life-sustaining treatment” or aggressive cure treatment is to go strictly by law and tell the hospital that the patient has signed and registered an AMD. The hospital will check with the Ministry of Health and must then initiate the following actions:
1. Three doctors, including the patient's hospital doctor must unanimously certify a patient's terminal illness. Two of the doctors must be specialists.
2. If the first panel of three doctors cannot agree unanimously that the patient is terminally ill, the doctor-in-charge will review his diagnosis. If he is still of the opinion that the patient is terminally ill, the matter will be referred to a second panel of three specialists, to be appointed by the Ministry of Health.
3. Can an AMD take effect if the second panel of doctors also cannot agree on the diagnosis?
No, the AMD cannot take effect if the second panel cannot agree unanimously that the patient is terminally ill. The patient's life will continue to be sustained and he will receive medical treatment as normal.
Thus, it is vitally important that an individual must decide for himself/herself whether he/she wants to sign the AMD. Even if he/she has signed the AMD, he/she does not have to immediately send it to the Ministry of Health. He/she can send it any time. Assuming that the patient is unable to talk or write or in anyway indicate that he/she has signed and registered an AMD, the family members do not have to tell the hospital for whatever reasons until they feel that it is time to so.
The expert hospice doctor, Dr Ira Byock, in his book “Dying Well,” have these comments on tube feeding:
“The family of a person who can no longer eat normally or communicate his desires often struggles with decisions about life- prolonging procedures such as surgery to place a tube for formula feeding. In deciding that a loved one will not be allowed to die of malnourishment, a family is making a tacit decision to let the person die of something else. Thus, the declaration by the daughter of an eighty-seven-year-old comatose patient, "I would never let Mom die of starvation," is a decision that Mom must, therefore, succumb to infection or stroke or seizure or blood clot or gastrointestinal hemorrhage. Each complication that is treated merely shifts the physiology of the person's dying, it does not halt it. A patient who is artificially fed and hydrated may live longer but is more likely to die with episodes of acute pain or breathlessness or, as in Michael's case, from a seizure.”(p.179-180)
“Q. Mom has never wanted to be hooked up to a feeding tube. But because of her Alzheimer's, she is eating less and has been losing weight.
A. It is important to begin by asking why she is not eating. Sometimes people with Alzheimer's disease or other dementias stop eating because their dentures no longer fit or they have a sore in their mouth or because they have a toothache that they are unable to tell anyone about.
With advanced dementia, however, people may reach a point when they are neurologically not capable of eating. If this is the case, before inserting a feeding tube, it is important to ask "What purpose will the feeding tube serve?" If the answer is "I won't allow Mom to die of starvation," the subsequent question might be "What would it be acceptable for her to die of?" These are the real issues. Too often, questions of this sort are not asked. Families go along with, or insist on, feeding tubes and, whenever there is a fever, IV antibiotics. After many months, a family member may voice anguish over the plight of their loved one who "just won't die." In truth, at the end of a long illness people often stop eating; this seems to be part of the "wisdom of the body," and is, undoubtedly, one of the most peaceful and comfortable ways of dying.
Remember that placing and using a feeding tube are medical procedures that should meet defined, achievable clinical goals. I suggest that if your mother's condition is advanced, and a medical evaluation (including an oral examination) does not resolve the problem, she should be assisted in eating. A speech or occupational therapist skilled in eating disorders can provide invaluable help. If she resides in a nursing home, and you are not directly involved in her physical care, arrange to observe her at mealtimes. Is she being helped with eating? Determine in your own mind if the encouragement and assistance she is receiving are sufficient. On the other hand, make sure such assistance is not overly aggressive and does not border on force-feeding. Talk to her doctor. Get a second opinion. Talk to the local hospice program for its perspective.” (p. 262-263)
“Q. Our mother had a stroke a year ago. She is comatose and on a feeding tube. She never wanted to be kept alive artificially, and my brother and I want the tube removed. Her doctor and nursing home are making us feel like we want to kill her. Would it be cruel to remove her tube?
A. No, it is not cruel; in some circumstances it may be the most merciful thing to do. Keeping a tube in a person's nose or directly into her stomach for no reason other than artificially prolonging her life can be senseless and inhumane. Are her hands restrained so that she does not reflexively pull at the tubes? Has she had pneumonias or other complications from the feedings? Is she more comfortable or less comfortable because of the feedings?
Dying of a progressive inability to eat is probably one of the most natural and physiologically gentle ways to expire. In the context of advanced illness, hunger is rarely, if ever, a source of discomfort. The same is true with thirst. Hospice patients who are dehydrated are regularly asked if they are thirsty; most answer no, but those who say yes are consistently and fully relieved by having their mouth and throat moistened. A recent study confirmed this experience. "Thirst," for people with advanced illness and dehydration, is a feeling of dryness, not the familiar sensation that can be quenched only by drinking substantial amounts of fluid. In any event, the discomfort associated with dehydration is easily prevented. Most important is your resolve to ask what is really right for your mother. Given that her death from this stroke is inevitable, think about how it might occur in a way that would honor and celebrate her. If tube feedings are stopped, the time remaining should be one of heightened care and attention. Think about simple rituals to mark this passage that would have meaning for her. Keeping a candle burning in her room or bringing a group of her friends and family together to read to her or sing to her--or simply to hold vigil--can be tangible ways of honoring her. The possibilities are limited only by your imagination.” (p. 266-267)
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