Withdrawing life support from the terminally ill.

• Author: Fade, Anne E.

Does artificial nutrition and hydration represent comfort care or extraordinary medical measures for dying patients?

Deciding to stop life support for a loved one always is wrenching emotionally. For many families, the toughest decision is whether to use artificial nutrition and hydration (tube feeding) when someone is dying.

"It is very common for people near the end of life to quit eating, or at least quit eating much, and quit drinking," explains Joanne Lynn, a geriatrician and senior associate professor at Dartmouth Medical School. "The question becomes whether we should use artificial means to circumvent their stopping eating, and the answer to that question turns on whether it does them any good."

How could being fed not do good? Most people assume that it must be painful to go without food, to die from malnutrition or dehydration. However, the medical evidence contradicts this assumption. Legal aspects of refusing tube feeding must be considered as well.

The Supreme Court and leading medical organizations agree that tube feeding is a medical treatment, and patients can accept or refuse it, just as they could ventilators, surgery, or antibiotics. Before making such a decision, though, it is important to understand what tube feeding is, how it works, and what happens when it is not given to patients at the end of life.

Tube feeding is the provision of a chemically balanced mix of nutrients and fluids. Most commonly, a feeding tube is inserted into the stomach via the nasal passage (nasogastric or NG tube) or through the wall of the abdomen (gastrostomy tube) by means of a surgical procedure. Another type of feeding tube is inserted surgically through the abdominal wall into the small intestine (Jejunostomy tube). Fluid alone can be supplied directly into a vein through an intravenous (IV) line. Nutrition and hydration may he supplied temporarily, until the person recovers adequate ability to eat and drink, or indefinitely.

When it contributes to over-all treatment goals, tube feeding can be a tremendous benefit to some patients. It can help those who are unable to swallow, eat, or drink enough food and fluid to maintain proper nutrition and hydration. For instance, short-term tube feeding often is provided to patients recovering from surgery, greatly improving the healing process. It also may be given to people with increased nutritional requirements, such as burn victims, or those who can not swallow because of an obstructing tumor. Total parenteral nutrition, a highly sophisticated form of artificial nutrition, can be given to individuals who have serious intestinal disorders that impair the ability to digest food. In each of these examples, tube feeding is a boon that allows people to recover completely or live fairly normal lives.

However, the benefits of tube feeding are not so apparent when it is given to individuals who are near the end of life. For example, it frequently is used for individuals with serious neurological conditions, such as advanced Alzheimer's disease or severe stroke, who can not lead ordinary lives and never will recover. To comprehend why tube feeding may not be beneficial to such patients, it is necessary to understand the important ways in which it differs from ordinary feeding. First, tube feeding is a medical procedure. Technical skill is required to insert the tube and make decisions about how much and what type of feed is given. As with any medical procedure, side effects can occur, even with skilled care...