Sunday, November 30, 2008

2 Withold & When Not 2 Withold & How 2 tell the Difference

Tuesday, July 29, 2008
When to Withhold & When NOT 2 Wthhold & How 2 Tell the Difference
Backdoor euthanasia


James Paul, Specialist registrar in palliative medicine
Kilburn, London NW6 7HH

Intravenous and enteral fluids may cause rather than alleviate suffering

Editor—Recent articles in the general1 and medical press2 on “backdoor euthanasia” illustrate the confusion that surrounds the subject. This is especially true for decisions to withdraw or withhold food and fluids from ill patients. Focusing on the issue of the intention behind such actions may help to achieve some clarity.

Current research, although limited, suggests that the desire for food and drink lessens in terminally ill patients and that artificial hydration neither prolongs survival nor alleviates symptoms.3,4 Furthermore, drips and nasogastric feeding tubes can cause unnecessary distress to patients and their relatives. In such cases the withholding of these treatments is entirely appropriate as the intention is to save the patient from a treatment that has no medical benefit.

But what about those who are not in the terminal stages of an illness—for example, heart patients, COPD patients, or those who have had a recent stroke or with acute infection? In most instances death is not imminent. However, not providing food, fluids & proper nutrients would certainly lead to death. In this case the intention behind the omission is to let the patient die. It fulfils the definition of an act of euthanasia and as such is morally unjustifiable.

This leaves one further question: when is a patient's condition terminal? That is, when is a patient at a stage where recovery is highly improbable and provision of artificial nutrition and hydration is of no benefit? This is not always easy to answer. Clinical signs and biochemical tests act as a good indicator, as does experience in dealing with such cases. But when there is doubt, as there often is, it seems common sense to err on the side of caution and provide all reasonable means to aid recovery, including the basic human needs for food, drink and proper nutrition.
" src="" border=0>Intravenous and enteral fluids may cause rather than alleviate suffering
Intravenous and enteral fluids may cause rather than alleviate suffering in the terminally ill in their end days....

Bliss, Mary (Bryning Day Hospital, Homerton Hospital, London E9 6SR).
Editor—I am worried by the recent reporting and police investigation of “euthanasia” deaths due to dehydration.1-1 I was distressed by articles in the Times which seemed to exploit bereaved families who had supported the decline and death of their relatives over many years, by suggesting that they may have suffered unnecessary pain and distress because of poor, or even criminal, mismanagement.1-2

Not all doctors and nurses agree that giving intravenous or enteral fluids to dying patients who can no longer swallow or feel thirst eases suffering. Many experts in palliative care believe the contrary. Zerwekh, a clinical coordinator of the Hospice of Seattle, observed that giving fluids and interfering with the natural course of dehydration can cause acute discomfort to the patient near death and emotional distress to the family.1-3 He commented that if the kidneys have not shut down, the fluids can sharply increase the flow of urine. If patients are extremely weak, have lost bladder control, or are in a coma, this increase may necessitate insertion of a catheter. The fluids also significantly increase gastrointestinal fluids, which is a major problem for patients whose vomiting is difficult to control, especially when there is bowel obstruction requiring a nasogastric tube. Intravenous fluids also tend to increase respiratory secretions, making it more difficult for patients to catch their breath or cough, and suction may be required. Fluids can also cause a flare up of oedema and ascites and expand the oedema layer around tumours, aggravating symptoms, particularly pain.1-3

With increasing reliance on technology rather than nursing and family support for dying patients, we seem to be following North American medicine into the hole that it is currently trying to climb out of. A study of long term patients found that tube feeding did not prevent aspiration pneumonia. The authors concluded “for almost all conscious patients we suggest a dedicated attempt at feeding by hand.”1-4 As the nurses at Kingsway Hospital observed,1-2 over zealous nil by mouth orders can also cause unnecessary dehydration and suffering. We need to remember the real meaning of the word euthanasia—a quiet and easy death. This is what we all want for ourselves and need to strive to achieve for patients by individual assessment of their needs, not by adherence to prescriptive protocols.
Dyer C. Police investigate “euthanasia” deaths. BMJ. 1999;318:143. . (16 January.). [PubMed]
Various articles on euthanasia Times 6 January 1999:1, 2, 9, 17.
Zerwekh JV. The dehydration question. Nursing. 1983;13:47–51.
Finetune TE, Bynum JPW. Use of tube feeding to prevent aspiration pneumonia. Lancet. 1996;348:1421–1424. [PubMed]
Various articles on euthanasia Times 6 January 1999:1, 2, 9, 17.
Dyer C. Police investigate “euthanasia” deaths. BMJ. 1999;318:143. . (16 January.). [PubMed]
Ellershaw JE, Sutcliffe JM, Saunders CM. Dehydration and the dying patient. J Pain Symptom Management. 1995;10:192–197. [PubMed]
Dunlop RJ, Ellershaw JE, Baines MJ, Saunders CM. On withholding nutrition and hydration in the terminally ill: has palliative care gone too far? A reply. J Med Ethics. 1995;21:141–143. [PubMed]
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