Thursday, August 10, 2006

Death, dying and dehydration.

Fr Tim Finigan and Mac McLernon have mentioned this of late and I wanted to get some thoughts together about a fraught subject. The case cited in The Times seems the most appalling case of backdoor euthanasia.

In the main the general rule should be that proper hydration and nutrition is the duty of the medical and nursing staff caring for a patient. When a patient cannot swallow, for instance after a stroke, feeding needs to be given by a feeding tube (usually inserted via the nose into the stomach, not nice, but these are the facts). If swallowing is not possible within a couple of weeks the general principle should be to form a PEG tube (Percutaneous Endoscopic Gastrectomy) – a tube directly into the stomach through the skin over the abdominal wall, through which food and nourishment can be passed. I had one patient in the hospice some years ago who had a glass of red wine each evening via the tube. These carry some risk – anything that involves an incision (as this does) carries the risk of infection, bleeding or perforation – but the risk is relatively small (probably less than 5% for any adverse effect). Feeding and nourishing is an act of care and love and is the first instinct of a anyone who loves another, especially when they are dependent , as a child is dependent on its parents. We accept that we are dependent at the beginning of life – most of us will become so at the end of life but this doesn’t fit with the false god of complete autonomy.

I tell you solemnly, when you were younger you dressed yourself and went where you wanted; but when you are old you will stretch out your hands, and someone else will dress you and lead you where you do not want to go. John 21:18

Feeding and hydration at the very end of life are more difficult. Doctors are very bad at predicting or seeing death coming. Oncologists and palliative physicians (overoptimistic by a factor of 2) are better than generalists (overoptimistic about prognosis by a factor of 5).[1] At the very end of life (if death is predictable – for example in the latter stages of advanced cancer) organs begin to fail and the patient becomes catabolic – that’s to say the body stores of carbohydrate and fat get broken down to energy, carbon dioxide and water. At this stage patients will stop eating and drinking because in the process of dying the hypothalamus begins to fail. Families can become concerned that the patient is dying because they are not eating. The reverse is generally true – they are not eating because they are dying. At this stage the need for hydration is debatable – but this the very end of life, where unmistakable signs of dying are clear and one expects the patient to survive no more than 48 hours. One thoughtful review looked at the evidence and came to the conclusion that hydration was no better than good oral care in treating the symptoms of thirst at the very end of life (that is the last 24-48 hours).[2] Indeed there are some circumstances where artificial hydration can be positively harmful – overhydrating patients in heart failure will cause the excess fluid in their lungs to worsen- and thus hasten their demise and worsen their suffering. Likewise in patients with the unfortunately named “death rattle” – hydration will worsen this , although at this stage the patient is generally unconscious and the noise is more troublesome to relatives than the patient.[3]But prolonged dehydration in a patient who is not actively dying and catabolic is painful and cruel.

The shift of emphasis that needs to accompany the transition from “active treatment” to end of ilfe care is difficult to transmit at times to families especially when phrases like “there is nothing more we can do”are used. This is simply not true. There is plenty we can do – the control of symptoms and the addressing of spiritual issues. Care doesn’t stop when cure is not possible – it changes. Indeed there is a good precedent for saying "enough" when failing treatment beomes too much - for example keeping on with aggressive chemotherapy when cancer advances despite it. Pope Pius XII, speaking to a conference of anaesthetists in 1958 made clear:

"Normally one is held to use only ordinary means [to prolong life]—according to the circumstances of persons, places, times, and culture—that is to say, means that do not involve any grave burdens for oneself or another. A stricter obligation would be too burdensome for most men and would render the attainment of the higher, more important good too difficult".[4]

Note - he speaks of a stricter obligation being too burdensome - not the provision of the basics of human life: food and drink. Hopefully, at Judgement most medics will be able to hear their Master say:
"For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in"
Matthew 25:35



As Catholics we have to be clear about the language we use and not merely acquiesce in media obfuscation of terms.
Let me be absolutely clear:
(a)“Euthanasia”=killing people.
(b)“Physician Assisted Suicide”=giving people drugs so they can kill themselves.
(c)“Helping to die” sounds very cuddly but is in fact either (a) or (b).

“Dignity” has been hijacked of late by the euthanasiasts – how dignified is the end of life when the physician’s solution to the problem is as inelegant and ignorant as to kill the problem by killing the patient. I will return to the hijacking of dignity at a later date.Caring for people when they die is an act of charity, commended by the Catholic Church (did you realise palliative care is the only medical specialty mentioned by name in the Catechism of the Catholic Church.?)

2279 Even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted. The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only foreseen and tolerated as inevitable Palliative care is a special form of disinterested charity. As such it should be encouraged.

The care of the dying is a specialism but the skills are easily passed on to those who are willing to learn. Truth is, most medical students get less than a week of palliative care in the 5 years of training in the UK. The defence of the vulnerable dying is the responsibility of all of us, but as with abortion it is the Catholic Church that has the moral courage to stand up and be counted.

Finally, for a tale of dying in the midst of a loving family and with the last sacraments to sustain, I would recommend the story of Viola Davison


[1] Glare P, Virik K, Jones M, Hudson M, Eychmuller S, Simes J, Christakis N. A systematic review of physicians' survival predictions in terminally ill cancer patients. BMJ. 2003;327(7408):195.

[2] Dunphy K, Finlay I, Rathbone G, Gilbert J, Hicks F. Rehydration in palliative and terminal care: if not--why not? Palliat Med. 1995 Jul;9(3):221-8.

[3]Wee BL, Coleman PG, Hillier R, Holgate SH.The sound of death rattle I: are relatives distressed by hearing this sound?
Palliat Med. 2006 Apr;20(3):171-5.

[4]Pius XII (1958). The prolongation of Life. Pope Speaks 4:393-398

5 Comments:

Blogger antonia said...

Amen!

4:38 PM  
Anonymous Anonymous said...

The story is indeed very sad, but for balance the results of the enquiry: the coroner ruled that Mrs. Knockels did not die of starvation, and the hospital and staff were completely exonerated.

http://news.bbc.co.uk/1/hi/england/norfolk/6245439.stm

For a more detailed summary of the coroner's report, including the coroner's criticism of the original high court ex parte injunction, see http://new.edp24.co.uk/content/news/story.aspx?brand=EDPOnline&category=News&tBrand=edponline&tCategory=news&itemid=NOED09%20Jan%202007%2020%3A38%3A42%3A620

12:11 AM  
Anonymous Anonymous said...

I'm on day three of restricting all fluid consumption. Where my body and mind have been pierced with the saber of doom. My dearest has passed on. The pain is numb yet excruciating. I shall surrender; I've been defeated. The void in my life scalds my mind each and every day. I've been a survivor before, yet, I'm ready to surrender. Withholding fluids from my body is going to be a taxing process. It should take another week for the transformation to fully engage. I'll tolerate any discomfort of the dehydrating process since the pain of losing my dearest is the most intense I've ever felt. So help me God.

3:48 AM  
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