By BETSY TAYLOR
Fr. Myles Sheehan, a physician and a Jesuit, gave a CHA webinar on Nov. 3 entitled "Medically Administered Nutrition and Hydration: Is it Ethically Required with Dementia and Stroke Patients?"
Fr. Sheehan provided an overview of types of feeding tubes and ethical and clinical considerations related to their use.
He explained some of the differences between feeding tubes used to provide nutrition and hydration. A nasogastric tube, inserted first into a nostril until it reaches the stomach, is often used as a temporary measure for a patient who is having trouble swallowing. Two other types of feeding tubes, often for patients who may need to use them for a longer period of time, are placed using a more invasive procedure. A percutaneous endoscopic gastronomy tube, or PEG tube, requires an endoscopic procedure to place the tube in the stomach. A jejunostomy tube is a tube placed through the skin of the abdomen into the small intestine.
Nutritional formulas, hydration and medication are delivered to a patient through a tube, either at specific intervals or in a more continuous manner.
Fr. Sheehan, who is assistant to the provincial for senior Jesuits for the U.S.'s Northeast Province, discussed medically assisted nutrition and hydration in the context of three of the Ethical and Religious Directives for Catholic Health Care Services
, numbers 56, 57 and 58. The first of these directives says a person has a moral obligation to use ordinary or proportionate means of preserving his or her life and that proportionate means are those that "in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community."
The next directive says, in part, that a person can forgo extraordinary or disproportionate means of preserving life. And directive 58 says, in part, "In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally." It also says such forms of nutrition and hydration become morally optional when they cannot reasonably be expected to prolong a life or would be excessively burdensome or would cause significant physical discomfort, such as complications from their use.
Fr. Sheehan said the term "in principle" means presumption in favor of use, but in some cases consideration of burden and benefit may show medically assisted nutrition and hydration is disproportionate and not ethically required.
He said the placement of a feeding tube needs to be carefully assessed. For instance, he said placing a PEG tube is normally safe, but there can be medical complications or even death resulting from its placement. There are medical complications from diarrhea to pressure ulcers to metabolic conditions. Sometimes patients have to be restrained to prevent tube removal, which they may attempt if they're uncomfortable and confused, he explained.
Fr. Sheehan did not discuss feeding tubes as they relate to someone in a persistent vegetative state at great length during the webinar, but before discussing the use of feeding tubes for patients with advanced dementia or stroke, said, persistent vegetative state is rare compared to these other conditions.
Advanced dementia is a fatal illness, he said. Multiple problems related to swallowing difficulties, aspiration pneumonia, and malnutrition are common. He said the American Geriatrics Society position statement on the use of feeding tubes in advanced dementia patients says, in part, when eating difficulties arise, feeding tubes are not recommended in advanced dementia. It says careful hand feeding should be offered because hand feeding has been shown to be as good as tube feeding for maintaining functional status and comfort. Tube feeding is not superior to hand feeding for patients with advanced dementia. The position statement also describes complications associated with tube feeding.
Tube feeding in advanced dementia patients offers little benefit and real burdens, he said. The patient's informed decision at an earlier stage of the disease regarding the personal impact of benefits and burdens is essential, so patients and their surrogates need education and good information. There should be respect for the informed wishes of a patient and his surrogate. And Fr. Sheehan said there's an ongoing need for programs that allow time for hand feeding.
Fr. Sheehan focused his remarks related to stroke patients primarily on those who have had ischemic strokes. According to the American Stroke Association, ischemic strokes occur as a result of an obstruction within a blood vessel supplying blood to the brain and account for 87 percent of all strokes.
He said patients who have had an ischemic stroke have a differing spectrum of outcomes compared to advanced dementia patients, with prognosis for survival in the acute phase related to stroke severity and the patient's age. He said generally "the older the patient, the bigger the stroke, the worse the prognosis."
He said factors that would make the use of a feeding tube more reasonable in a stroke patient with dysphagia are factors associated with improved survival, such as a younger patient with limited infarct — an area or areas of tissue death — and fewer clinical deficits.
Fr. Sheehan said recognizing a presumption in the ethical directives in favor of tube feeding for a stroke patient, the decision to place a feeding tube is tempered by patient wishes, prognostic indicators and an assessment of benefits and burdens.
He said the informed wishes of a patient are key. For instance, Fr. Sheehan said that he would respect the wishes of a patient who had made it known that he or she would want a feeding tube if unable to receive nutrition and hydration in another way.
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