Catholic Health World

Webinar cuts through misinformation on tube feeding, hydration

While clinical considerations underlie all initial discussions about starting or stopping tube feeding and hydration in individual patients, decisions on medically assisted sustenance are often influenced by moral judgment, and may be clouded by emotion or politics.

During a CHA-sponsored webinar last month, participants from 246 CHA member sites heard hospice doctor Ann Allegre and Fr. Gerald Coleman, SS, clarify aspects of medical and moral decision making related to medically assisted nutrition and hydration. Allegre is director of medical programs at Kansas City Hospice and Palliative Care in Kansas City, Mo., and medical director of the palliative care consult service for Providence Medical Center in Kansas City, Kan. Fr. Coleman is vice president of corporate ethics for the Daughters of Charity Health System in Los Altos Hills, Calif.

Allegre said food and water are symbols of caring; but, in certain patients who are no longer able to swallow or properly digest and absorb food or water, medically assisted hydration and nutrition can cause more harm than good.

Questionable efficacy
A wide variety of medical conditions could cause a clinician to consider medically assisted nutrition and hydration, Allegre said. For example, if patients have difficulty swallowing following a stroke or intubation, if they need support during intensive treatment, or have an obstruction in the upper intestine, tube feeding may be clinically appropriate.

Allegre said that when clinicians use medically assisted feeding, they likely have such goals as preventing complications related to malnutrition, reducing infections, improving strength and prolonging the patient's life, and improving life quality. While tube feeding may achieve these targets in some patients, it has been shown to cause suffering and hasten death in others.

Studies have shown shorter lengths of survival for tube-fed patients with chronic lung disease, kidney failure, sepsis, multisystem failure, advanced dementia and other conditions, as compared to patients who are not tube fed. Tube feeding has been shown to reduce cancer patients' responsiveness to chemotherapy, and increase their risk of infection, Allegre said.

Additionally, said Allegre, medically assisted feeding can lead to diarrhea and vomiting, aspiration pneumonia, abdominal pain, infection and fluid overload. And, she said, medically administered hydration in the last days or weeks of life when kidneys are shutting down can cause bloating, edema and congestive heart failure. Allegre said two studies have shown that dehydrated dying patients survive longer than patients receiving intravenous fluids.

Missed chances for intimacy
Allegre said patients fed through a tube also miss out on the pleasurable and social benefits of eating. When possible, hand feeding even small quantities of food is preferable to tube feeding, she said. She recommends stimulating a patient's appetite by presenting small portions of favorite foods artfully arranged. When a patient cannot take food by mouth, caregivers can substitute other forms of pleasurable interaction — such as massage, conversation and reading aloud.

It is natural for a dying person to stop eating and drinking, Allegre said. In this circumstance, disease, not starvation or dehydration, causes death.

An evolving debate
Fr. Coleman set the context for church deliberations grounding medically assisted feeding and hydration in the Catholic moral tradition. Conversations happening around the country around the topic of tube feeding led to the U.S. bishops' revision of directive 58 of the Ethical and Religious Directives for Catholic Health Care Services in 1994. Pope John Paul II's allocution on medically assisted feeding in 2004 and a response and commentary by the Vatican's Congregation for the Doctrine of the Faith in 2007 sparked the U.S. bishops' latest revision of directive 58 this year. Directive 58 deals with the use and withholding of medically assisted sustenance to all patients.

Fr. Coleman said that the deliberations leading up to the 1994 ERDs revision were prompted to a certain degree by the high-profile case of Nancy Cruzan, a car accident victim who was intubated and then diagnosed to be in a persistent vegetative state. Her family sought through the court system to have her feeding tube removed, and they won their case in 1990.

The bishops reflected on the morality of withdrawing medically assisted nutrition and hydration from a person in a persistent vegetative state and determined there should be a presumption in favor of continuing tube feeding and hydration as long as the benefits outweigh the burdens to the patient.

Benefits and burdens
In discussing the 1994 revision in directive 58, the bishops questioned the role of technology in sustaining life, acknowledged the importance of considering the patients' welfare and comfort and asked whether medically assisted feeding should be considered a medical treatment or ordinary care.

The pope's allocution, or address, called medically assisted feeding a natural means of preserving life and said it should be considered, in principle, an obligatory means of care for patients. The address, delivered in the year before his death, emphasized the personal dignity of the patient. Fr. Coleman pointed out the pope did not say that medically assisted nutrition could never be withdrawn.

The pope's statement generated much concern, with many asking whether his pronouncement overturned Catholic teaching in this area. To clarify the pope's statement, the Vatican's Congregation for the Doctrine of the Faith issued a response and commentary in 2007 reaffirming the spirit of the pope's allocution. Fr. Coleman said the commentary confirmed that for patients in a persistent vegetative state "medically assisted means of nutrition and hydration cannot be withdrawn even when competent physicians judge with moral certainty that this patient will never regain consciousness." He added that the commentary gave patients and physicians leave to end tube feeding in limited circumstances, for instance, when it no longer nourished or hydrated the patient.

In 2009, the U.S. bishops revised directive 58 to better reflect Pope John Paul's 2004 speech and the Congregation for the Doctrine of the Faith's 2007 statements. That directive now cites an obligation to provide patients with food and water, including tube feeding, but it notes that this type of feeding becomes optional when a patient is actively dying, the feeding is deemed excessively burdensome or it is causing medical complications. Fr. Coleman explained that if the use of tube feeding causes enormous pain, severe dread or great expense to a patient, for instance, there may be justification under the church's traditional teachings about ordinary and extraordinary care to forgo or withdraw a feeding tube.

Copyright © 2010 by the Catholic Health Association of the United States
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