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June 20, 2003

Feeding Tubes and Hydration—What’s Best For Our Loved Ones?

doctorAt face value, providing sustenance and fluids for those who can’t swallow or feed themselves seems like fulfilling a basic need and hardly merits debate. Even individuals who don’t subscribe to the sanctity of human life often believe that everyone is entitled to basic health care services. Certainly, feeding someone or providing hydration through an intravenous line seems pretty basic. The technology is not complex and the actual cost of tube feeding or fluid replacement is relatively low. As such, the answer seems straightforward: Everyone deserves tube feeding and hydration. Right? Well, yes. Yet, like many seemingly simple questions, the answer may not be quite as simple when we consider individual cases.

A few years ago, one of my neighbors (I will call him Mr. Jones), a very personable man in his seventies, was told that he had advanced pancreatic cancer. Pancreatic cancer has a generally bleak prognosis—most people with pancreatic cancer will be dead in less than two years; up to 98% will die within five years. On learning of his poor prognosis, Mr. Jones began to get his affairs in order. As he would soon be unable to care for his wife who had early Alzheimer’s disease, he made arrangements for residential care for her. He elected not to undergo any treatment for himself. He told his doctors, his family and his friends that he wished to die at home, and he opted for comfort measures only.

Some might view such a decision as “giving up” or even indicative of a death wish. Others might see his attitude as simply being realistic and practical. Regardless of how one views my neighbor’s decision-making near the end of his life, the medical reality is that there is little that can be done to change the ultimate course of many illnesses. Mr. Jones was fully aware of this reality and wanted to avoid what he perceived as futile interventions that would (likely as not in his case) make his remaining life more difficult—or even shorten it!

In addition to refusing surgery, radiation, or chemotherapy, Mr. Jones also declined any so-called artificial feeding or hydration. (Food and water are hardly artificial, yet the placement of tubes or lines is not part of one’s natural state.) When Mr. Jones’ appetite waned, he stopped eating. He saw any such effort as futile—at best, making his life uncomfortable, at worst, (should complications have arisen in association with such interventions) potentially shortening his life. He did accept comfort care, including liberal dosages of pain medication. And, in the end, he died peacefully—and naturally—in his own home.

We should never withhold or forgo giving sustenance and hydration to patients who are open to this support. Yet, at some point in the course of an illness, an individual’s appetite or swallowing ability or wakefulness may wane to the point that minimal nutritional and hydration requirements cannot be met. Are we then compelled to insert feeding tubes? Are we always to encourage such patients and/or their families to accept feeding tube placement? Or, on the other hand, are we actively to discourage it for an individual in cases where we don’t think it will be helpful (or when we believe it might even be harmful—for example, increasing the chance of aspiration pneumonia)? Unfortunately, there aren’t absolute answers applicable to all cases. Such questions often must be answered, “It depends.”

Certainly it is not immoral or unethical to accept the inevitability of death. There is no Christian or other faith belief system that holds as a requirement that you or I must die with tubes in place. In most situations, declining a feeding tube is not tantamount to suicide. In fact, in many cases, the available evidence indicates that feeding tubes don’t prolong life. Thus, doctors who accept such decision-making are not assisting in suicide, and doctors who honestly explain to patients and families the pros and cons of tube feeding, are not promoting euthanasia. In my neighbor’s case, there was no doubt about the prognosis—at least, within the limits of today’s technology. He chose to live his life fully (and did) without artificial medical interventions that were (in his case) low yield, yet high risk.

At the same time, in many cases the prognosis is not so certain. Giving simple tube feeding and/or hydration may represent a “bridge,” allowing an individual to return to health. Certainly, that was true in the initial care of my father as he struggled to recover from a major abdominal surgery last year. After surgery, he couldn’t swallow for weeks. We elected to place a feeding tube (and, ultimately, a gastric tube). Without these tubes he couldn’t have survived. Clearly, for him, they were life-sustaining interventions for more than a month.

At the same time, he ultimately did experience a major complication from the use of gastric tubes. After he had been discharged and was clearly making progress with his rehabilitation, the tube came out. He was taken to an emergency room where a physician inadvertently re-inserted the tube into his abdominal cavity rather than his stomach. This led to a series of serious infections and ultimately, after 55 days of hospitalization, to his death.

Nevertheless, my father (were he still alive) and I would make the same decision to utilize tube feeding again. Thus, I share this story not to dissuade individual patients or families from opting for nutritional support, but merely to emphasize the significant complications that can occur (although this particular complication is completely preventable—tube placement needs to be verified by x-rays with contrast media to ensure the tube is in the correct location).

In short, the decision to utilize feeding tubes or provide intravenous hydration may be challenging for all involved. Nevertheless, when there is doubt about the natural course of an illness, the default should always be to err on the side of providing basic food and hydration. Furthermore, even when the prognosis is poor, if an individual or family wants to continue tube feeding or hydration, I believe individual physicians and our society have a responsibility to support their wishes and provide such basic care. It is only right.

Originally published in Life in Oregon, A Publication of Oregon Right to Life, Vol. 11, No. 3, June-July 2003.

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