Extraordinary Measures or Not?

Rod Dreher’s blog, “Rod Dreher” is no longer active since he has moved to Big Questions Online which is just up and running.  I encourage you to check it out.

Today on that site I read an essay written by a woman who is worried that her elderly mother’s living will would not be honored at a Catholic hospital because of the new directive on health care issued by the Catholic bishops.  The directive basically says that they will not participate in the withholding of artificial hydration and nutrition in cases of persistent vegetative state or other cases in which the patient may live many years and is not actively dying.  The woman’s mother’s living will “specifies that no extraordinary medical measures — including artificial feeding — be used to prolong her life if there is no hope of recovery.”  I feel that the confusion over what constitutes “no hope of recovery” and “extraordinary measures” is largely at play in the controversy over artificial hydration and nutrition.  To that end I wrote what turned out to be a rather long comment to that essay.  I decided to reproduce it here.  I am more than happy to discuss the ins and outs of this subject regardless of your place in the debate, but I will ask that we keep it civil in the comments.

[My background includes 13 years of nursing, the last three of those dealing with gynecologic oncology patients. I’ve had one grandmother die from Alzheimer’s and one grandfather die from leukemia. In neither case were they given artificial hydration or nutrition.]

“I think that the public in general is not very well educated when it comes to terms like “persistent vegetative state” and “terminally ill”. This has serious repercussions when talking about high-charged issues like compassionate care versus starving someone to death.

If a patient is dying, toward the end of the dying process the body is no longer effectively capable of processing fluids. The kidneys begin shutting down and a lot of the fluid is no longer eliminated in urine. This causes among other things: edema including weeping of the skin, heart overload (trying to pump way too much blood), pulmonary edema (fluid “backs up” in the lungs causing the patient to ultimately drown) and altered consciousness caused by uremia (waste products not being removed from the blood and hence the body). You can imagine how uncomfortable these might be. There is a natural instinct on the part of the patent to refuse or severely limit fluid intake. If the patient is given intravenous fluids or nutrition at this point, their sufferings are only intensified but not necessarily prolonged. The behaviour of the kidneys when dying is only one mechanism that is affected by artificial hydration.

Persistent vegetative state, however is not synonymous with impending death. In this situation the body is quite capable of surviving without artificial ventilation and circulation. It is capable of normal digestion and elimination (although, I suppose, a catheter might be placed for comfort). It can maintain a normal temperature. This is not a dying body. If a person is “brain dead”, then the body is dead as well. The brain controls all of the above mentioned functions. The only thing the person in this state is not capable of (that is needed to maintain life) is chewing and swallowing purposefully.

Nutrition and hydration are provided via short-cuts to the stomach, either with a PEG tube (inserted through abdominal wall) or an NG tube (nasogastric). For long-term use, an NG tube is unadvised because of eventual erosion of the tissue it is in contact with. Therefore a PEG tube is generally inserted. This is not connected to feeding 24 hours a day, but is used for bolus feedings three to five times a day…like a meal.

Deciding to starve a patient in persistent vegetative state, or one who has been paralyzed by a stroke (such that swallowing is unsafe), etc., is in essence deciding that the patient is not worthy of life because he cannot swallow.

On whatever side of the argument you find yourself, these facts must be acknowledged.”

9 thoughts on “Extraordinary Measures or Not?

  1. After 30+ years of severe disability from a massive stroke, the last five in a NH, my dad suffered a brainstem stroke which left him unable to swallow or speak. Fortunately, he was able to decline the peg/ng route of his own volition. We took him home, where he died after a week, of dehydration and aspiration pneumonia. It was terrible, and yet after all the suffering and indignities of the previous years, far better than another year in the NH with bedsores, etc. I thanked God then and now that my mother, brother and I didn't have to make the decision. I honestly don't know what we would have done.

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  2. I remember you telling me about your father previously. Part of the problem stems from the decision about whether the person is actually dying (like, imminently). Strokes can vary in severity and location (within the brain) and so saying that someone “had a stroke” is not terribly illuminating. Your situation illustrates why it is necessary to have doctors' discretion involved.

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  3. This is a very interesting post. I'm glad I haven't had to face these issues yet, but my mother certainly had to with my grandmother. I cannot remember all the details, but ultimately her lungs did fill up with fluid and she drowned. At the same time, an acquaintance was dying of the same condition — her relatives made the opposite decision as my mother and my aunts, but her end was no less miserable. In a strange way, it was a consolation to both families, that there was no right choice.

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  4. Maria,

    People with right-sided heart failure will suffer pulmonary edema. [People with left-sided heart failure suffer peripheral edema.] The blood essentially backs up into the lungs causing high pressure in the vessels of the lungs. This in turn causes fluid to be pushed from the vessels into the lungs and you drown because you can't exchange oxygen when the alveoli (tiniest lung sacs) are “underwater”. Forcing fluids only makes this situation more extreme, but yes, unfortunately some people will go through it anyway because of the nature of their disease process. My condolences.

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  5. Thank you for these clarifications! My mother has been urging me to make a living will, and I hesitated because I really don't know enough about death and dying (and comas and vegetative states and such) to consider properly what I might want in those situations.

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  6. Yes, much education is needed. I remember when I worked in a nursing home and read a log that had a letter from the patient when the patient could still write. The patient wrote of his horror of one day not being able to talk or move on his own, both happened. His mind was still fully functional but his body was not. I will never forget him or his family that would come and visit him, and keep a quiet Christian radio station on for his comfort…

    Thank you for a post that is educational and kind.

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  7. I've always wondered about this. My grandmother had cancer throughout her entire body, and my mother had to make the decision to no longer have her hooked up to a feeding tube. At that point, death was imminent and the feeding tube would have dragged her suffering out longer. I always wondered how that decision was looked at from a Christian point of view. Thanks for sharing this.

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  8. Well said, Meg! Thanks for setting things straight. I was always so comforted by your knowledge and leadership with Grandmother. And, she did die in peace…I was so glad that she had that living will. Love, Aunt Susan

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