Forced Nutrition

[lord Martiya]

Because of the Englaro case here in Italy, I'd like to ask you what do you and your countries think about stopping the forced nutrition to a woman in permanent vegetative state from 16 years.

[Darth Wong]

Because of the Englaro case here in Italy, I'd like to ask you what do you and your countries think about stopping the forced nutrition to a woman in permanent vegetative state from 16 years.

I think they should stop it and let Sarah Palin pass away naturally.

[Executor32]

Ooh, ouch.

I'd say pull the plug, yeah. It's what I thought during the Terry Schiavo case as well. If you don't know, that was a similar situation here in the States back in 2005. She had actually been in such a state for a slightly shorter time than Englaro has been, but after a bunch of reactionary bullshit from conservatives, up to and including Congress passing legislation to move the case to the Supreme Court, she was finally allowed to die in peace.

This CT scan of her brain from 2002, when she had been in a vegetative state for 12 years, showed that much of the brain tissue had atrophied and been replaced by cerebrospinal fluid:



I'd wager that Englaro's brain (what's left of it, anyway) is at a similar stage of atrophy, if not worse.

[Serafina]

Well, most people , no matter what their opinion is, say something like "this is a complicated case of morality, but...".

I disagree with that - its all about one question: How likely is recovery?

This may be a difficult question to answer, but its the only thing that can be universally answered.

However, in this case, its fairly simple: After being comatose for 17 years, there is next to no chance she will recover.
Thus, cutting the lifesupport ist not "murder" or something along that line. Letting someone die who has no chance of recovery at all is an act of mercy, not violence.

[andrewgpaul]

This CT scan of her brain from 2002, when she had been in a vegetative state for 12 years, showed that much of the brain tissue had atrophied and been replaced by cerebrospinal fluid:
http://msnbcmedia3.msn.com/j/msnbc/Comp ... medium.jpg


I'd wager that Englaro's brain (what's left of it, anyway) is at a similar stage of atrophy, if not worse.

Can you explain which bits of that image are what, Executor?

[The Spartan]

The dark bits in the middle are voids in her brain. The lighter parts are what's left of actual brain tissue. The bits that haven't basically liquefied. The really bright bit is her skull.

[Solauren]

You know, I remember something that was in a M.A.S.H episode. I think Hawkeye said it.

"The part that was your buddy died when the bullet passed through his brain. The rest of the body just didn't know when to quit.

That's my take on this. The part of this person (or any person in a similiar condition) that makes them a person, is dead. Let them die. The only time there should be an exception is when it's a pregnant woman, so the baby can be born.

[Zablorg]

It looks like her occipital and parietal lobes were shot, among other things. Even if she could have woken up she would lack any spatial sense and would probably be blind.

[Broomstick]

Oddly enough, my family may shortly be faced with stopping the forced nutrition of a woman who is NOT in a vegetative state. (My sister is currently reviewing the law in Michigan regarding end of life, feeding tubes, and what my mother's living will covers just in case we get to that point)

Look, if recovery is likely, or even possible, keeping the body alive makes some sense. But if I'm not willing to stick a feeding tube into my own dying mother's stomach just to keep her alive a few more miserable or even agonizing days or weeks I'd have to say no, I do not support continued "forced nutrition" to a woman in a persistent vegetative state for a decade and a half unless the woman in question left a clear directive that she would have wanted to exist as a curled up, oversized fetus that is fed and watered like a decorative fern, but somewhat less attractive. And maybe not even then. Allow enough time to permit recovery, if possible, eliminate locked-in syndrome as a possibility, then, if the verdict is "nobody is home - and never will be again" pull the life support and let nature take its course.

[mr friendly guy]

Can you explain which bits of that image are what, Executor?

The black bits correspond to the cerebral ventricles. Basically they are what stores the cerebrospinal fluid (CSF). Fluid will appear black on a non contrast CT. The parts surrounding the ventricles are the rest of the brain. In a CT brain of a normal person, the ventricles take up a much smaller area.

What this means in her case is exactly what Executor said, the brain tissue has gone and is replaced by CSF.

Back on topic, I see nothing wrong with simply ceasing nutrition in this case. In fact I would argue that if someone is demented and will not feed themselves adequately, we should not be forcing nutrition down them. Note, by this stage we would have tried things like supplements which are low in volume but high in calories, so even if they don't eat much, they may get enough of their daily energy requirements.

If there is some reversible process its fine to feed them until they recover and feed themselves, but dementia at this stage is irreversible. We can delay its worsening, but I wouldn't call it much of an existence nor having much quality of life to have tubes stuck in me just to feed me, when I am barely aware of my surroundings. If that was me, I would want them to just let me go quietly.

That being said, in medical practice I have observed PEG tubes being put down in such patients at the family's insistence. Essentially a PEG tube connects the stomach to the outside and food supplements are fed via the outside connection. They can still take food orally, but usually they don't take enough to feed themselves, hence the need for a PEG. Ideally doctors should take the time to actually explain what this thing entails, ie not just if you don't put the PEG tube in, the patient will die. One should explain things in terms of quality of life, and frankly it isn't much. I find once people realise this, the family tend not to push the issue after some discussion. Those patients with dementia will eat, just not enough and eventually pass away.

[Broomstick]

That being said, in medical practice I have observed PEG tubes being put down in such patients at the family's insistence. Essentially a PEG tube connects the stomach to the outside and food supplements are fed via the outside connection. They can still take food orally, but usually they don't take enough to feed themselves, hence the need for a PEG. Ideally doctors should take the time to actually explain what this thing entails, ie not just if you don't put the PEG tube in, the patient will die. One should explain things in terms of quality of life, and frankly it isn't much. I find once people realise this, the family tend not to push the issue after some discussion. Those patients with dementia will eat, just not enough and eventually pass away.

^ That's my mother right now.

She eats, but not nearly enough. We're trying the calorically dense supplements on her, but she's only taking in about half as much as needed to sustain life. As her current state is recent and precipitated by a bout of pneumonia we're currently waiting to see if she is able to recover to a meaningful quality of life. The family is against a PEG unless it will actually improve the situation, but lack of appetite is a symptom of the problem, not the the cause of all her woes.

Unfortunately, my sister with the MD has told us that post-Terry Schiavo some asswipe in New York State passed a law that unless someone has SPECIFICALLY documented an objection to a PEG doctors have to install one even over the objections of the family, even over someone with legal authority to make medical decisions for the patient. Sister is currently trying to figure out the law in Michigan, were mom resides. My dad is currently re-drafting his living will but mom is not able to re-do hers. I really hope we do not have to face that because my mother has spent 20 years expressing her views of end-of-life and we're clear on what she wants, but it's unfair to expect laypeople to anticipate every single medical contingency possible. Power of attorney to make medical decisions was supposed to get around that, but apparently other people are fucking that up. Of course.

[mr friendly guy]

What does specifically document an objection mean in legalese? Does that entail a proper legal document or is it just enough for the doctor to write in the patient's notes, discuss with family/legal guardian/ next of kin, they do not want PEG?

Because over here, if a patient is made not for resuscitation, or not for such and such a procedure it usually is either written in the patient's notes or in some cases a special hospital form is filled out.

[Junghalli]

I'd say if someone is a permanent vegetative state it is ethically neutral to stop keeping them alive. The essential person is basically dead anyway; it's just the empty shell that you're keeping alive at that point.

[Broomstick]

What does specifically document an objection mean in legalese? Does that entail a proper legal document or is it just enough for the doctor to write in the patient's notes, discuss with family/legal guardian/ next of kin, they do not want PEG?

Keeping in mind that I am neither a doctor nor a lawyer, my understanding that it would be best, legally, if there was an actual document such as a living will or advanced medical directive, which is a legal document witnessed by two disinterested parties (i.e. not family, not in the will, etc.) and signed by witnesses and person giving the advanced directive. In this case, "Under X circumstances I do not want a PEG".

Next best would be, for example, letters in which such a person is saying "I would not want that" or, probably in this day and age, e-mail or a post on a message board or other written statement.

After that, statements witnessed by disinterested parties.

Statements by family can be suspect, as some people are, shall we say, eager to inherit. There can also be dissension within a family. As it happens, there is no fortune to inherit here nor is there disagreement within the family. Mom's various documents concerning her wishes do not mention tube feeding (in addition to dad, all of us kids have copies). Our concern is if some busybody legislator decided to interfere in what is and should be a matter for family and the medical professionals at the scene.

Because over here, if a patient is made not for resuscitation, or not for such and such a procedure it usually is either written in the patient's notes or in some cases a special hospital form is filled out.

Yes, here as well. Mom is noted as both DNR and DNI (do not resuscitate/do not intubate) in her chart and also on her wristband. They have had copies of mom's medical directives for the past 10 or 15 years, but they ask for any updates on readmission (mom had her second bypass surgery at this hospital, in 1988 - they have a substantial history on her). Since we're not certain whether or not a PEG would be useful we haven't pressed dad to make a firm decision on the issue, but he is thinking it over and we are discussing it.

Although recent developments may make it moot - mom is having a GI bleed every other day. That's not compatible with life for very long.

[lord Martiya]

Thanks for your opinion.
You know, now they're making an indecent mess: there's a definitive sentence from Milan's Court of Appeal, sentence confirmed by the Corte di Cassazione (Italian version of the Supreme Court, it can decide if a sentence is right and make it definitive), that grants to Englaro's family the right to remove the feeding tube, but our premier-wannabee dictator is doing everything he can 'think' to stop the removing, even going to thrust Italy in a constitional crisis when the president stopped his decree. I hope that Berlusconi will stops this mess before the president will be forced to arrest him, not because I'd like to have him rule (I voted against him and I still hope that God decide to prove his existance by hitting him with the Father of All Lightings) but because I fear that his arrest will spark chaos.