End-of-life medical care often leads to that conflicting intersection of personal, medical, legal and policy issues that frequently spill over into the public arena. The medical profession, in concert with other interests, needs to focus more on what is best for a patient; that prolonging a life may not be the most compassionate medical course of action, the UTMB researchers reported.
Looking at ethical concerns, case studies, legal and medical discourse spanning 60 years, UTMB researchers say that it may be time to reconsider artificial nutrition and hydration for end-of-life patients.
“We seem to have forgotten the difference between people who died because they stop taking in food and water, and people who stop taking in food and water because of the natural dying process,” said Dr. Howard Brody, lead author of the study.
“There seems to be a growing disconnect between popular ethical conceptions and the palliative care medical community,” said Brody, who is director of the Institute of Medical Humanities at UTMB.
There is a presumption, Brody said, by many in our society, that the only way to show a patient compassion is to provide nutrition via a feeding tube. Conversely, palliative care medical professionals have said for decades that feeding tubes often make patients more uncomfortable at the end of life, and distressing symptoms can best be managed without them, Brody said.
Many factors influence decisions about tube feeding, including denial by a patient’s family that a loved one is dying. Other decision points include compassionate medical care, religious beliefs, legal findings and physician liability.
The UTMB authors reviewed the complex history of ethical thinking about tube feeding during the past 60 years. They traced legal, ethical, religious, medical and policy forces that caused physicians and patients to urge tube feedings during some periods and to be more skeptical about them in others. “If you don’t know that history, it’s less likely you’ll truly understand today’s ethical and policy issues,” Brody suggested.
As recently as the 1990s, the prevailing medical view was that tube feeding was effective in extending a patient’s life. But data began to emerge during that time that tube feeding for terminally-ill patients, especially those with advanced dementia, was futile. In fact, data showed no improvement in quality of life and often led to complications such as pneumonia, nausea and diarrhea, the UTMB researchers said.
Palliative medicine rarely involves tube feeding, recognizing that as a patient approaches end of life, bodily functions slow accordingly. And many terminally ill patients develop a loss of appetite and thirst that is complicated by difficulty in swallowing, paralleling a body’s inability to absorb nutrients.
“So today we think that the palliative care perspective is really the best one,” Brody said. “We think that it is ethically sound but that many practices and policies and public misconceptions get in the way of taking that approach.”
The study, “Artificial Nutrition and Hydration: The Evolution of Ethics, Evidence and Policy” was published in the Journal of General Internal Medicine.
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