Artificial Nutrition & Hydration: & Catholic Teaching

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Artificial Nutrition & Hydration: & Catholic Teaching. Philip Boyle, PhD Vice President Mission & Ethics Catholic Health East. Goal. Review major questions & theories of withholding & withdrawing Explore cases Examine Church teaching on: Nutrition & hydration Vegetative state. - PowerPoint PPT Presentation

Transcript of Artificial Nutrition & Hydration: & Catholic Teaching

  • Artificial Nutrition & Hydration:& Catholic Teaching

    Philip Boyle, PhDVice PresidentMission & EthicsCatholic Health East

  • GoalReview major questions & theories of withholding & withdrawingExplore casesExamine Church teaching on: Nutrition & hydrationVegetative state

  • Public controversiesover H2O and PVS

    Quinlan: 1975 1985 Cruzan: 1983 1990 Schiavo: 1990 2005Dates indicate the time from their medical event to their death

  • Cultural Controversy over Nutrition and HydrationFood and WaterThe MealPhysical suffering and comfortStarvation and DehydrationEmaciationHope: At least we are doing something

  • Prevent aspirationImprove/prevent pressure ulcersReduced risk of infectionsImprove functional statusProlong lifeImprove comfort

    Commonly Cited Reasons for Feeding/Tube

  • Nutrition & hydrationEffective for:Stoke head injury, failure to thrive, short bowel, Not effective for:Dementia, dying pts, renal failure, CA pt in terminal condition, increased risk of pressure sores, UTIs, brain swelling

  • Comfort Feeding & DementiaJournal of the American Geriatrics Society, March 2010Comfort feedingEvidence: longer life without feeding tube

  • Questions at end of lifeWho decides?Informed ConsentAdvance Directives

    What is the basis for termination?Autonomy & self determinationFutilityQuality of lifeBurden-Benefit ratio

    Can the institution cooperate?

  • Moral complexityIf there is disagreement with reason to forego, one might conclude we have the wrong decision-maker

    If the right decision maker is identified, one might infer the institution has no choice

  • Case 1Martha 49-yr-old Hypertension, quit smoking After stroke living will, but no DNR2nd stroke, coma then PVSNG-tubeHusband asks for stop quality of lifePriest starvingLaw requires terminal conditionHusband asks to do something to hasten death

  • Case 2 Marge 60 advanced Alzheimers Refusing food, combativePeg tube counter indicatedSister alleging starvation and causing suffering

  • Case 3Henry 60-yr-old alcoholicFall & head bleed5 week coma then opens eyesNo advance directiveFamily wants nothing done

  • Theories of terminationAutonomy/self determinationQuality of lifeFutilityBurden-benefit ratio

    What distinguishes appropriate from inappropriate terminations?Letting die v. killing

  • Theories of terminationQuality of lifeCommon usageQALYsFrom whose perspective?Subjective judgment that can be biased

  • Development of killing & letting dieSt. Antonius of Florence 1450 Can monks fast to the point of death or do they have to eat more than bread and water?

    Francisco DeVitoria 1550would a sick person who does not eat because of some disgust for food be guilty of a sin equivalent to suicide?...And answers, If the patient is so depressed or has lost his appetite so that it is only with the greatest effort that he can eat food, this right away ought to be reckoned as creating a kind of impossibility, and the patient is excused, at least from mortal sin, especially if there is little or no hope of life.

  • Theories of termination: Burden-benefit ratio Pius XII The Prolongation of Life 1958Normally one is held to use only ordinary meansaccording to the circumstances, places, times, culturethat is to say means that do not involve and grave burden for one self or others. A more strict obligations would be too burdensome for most people and would render the attainment of a higher more important good too difficult. Life, health and all temporal activities are subordinated to spiritual ends. Appropriate v. inappropriate Extraordinary v. ordinary

  • History Declaration on Euthanasia CDF 1980people prefer to speak of proportionate and disproportionateit will be possible to make a correct judgment by studying the type of treatment, its degree of complexity of risk, costs and possibility of using it, and comparing these to the results to be expected taking into account the state of the sick person, and his or her physical and moral resources.

    Appropriate v. inappropriate terminationDisproportionate v. proportionate

  • Directive 32While every person is obliged to use ordinary means to preserve his or her health, no person should be obliged to submit to a health care procedure that the person has judged, with a free and informed conscience, not to provide a reasonable hope of benefit without imposing excessive risks and burdens on the patient or excessive expense to family or community.

  • Directive 57

    A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patient's judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.Appropriate v. inappropriate extraordinary v. ordinary

  • Directive 60Euthanasia is an action or omission that of itself or by intention causes death in order to alleviate suffering. Catholic health care institutions may never condone or participate in euthanasia or assisted suicide in any way.Appropriate v. inappropriateLetting die v. euthanasia Secondary intent v. direct intent to cause death

  • Double EffectAll choices have many effectsPrimary choice needs to be good or at least neutralSecondary effect must not be a means to the good or neutral effectSecondary effect is see and accepted

  • CasesContinuum

    Simplest ComplexDying patient Non-dying patientCapacitated IncapacitatedAdvance directive No advance directive

  • Old Directive 58 There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient.

  • Directive 58 As a general rule, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic conditions (e.g., the persistent vegetative state) who can reasonably be expected to live indefinitely if given such care. Medically-assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be excessively burdensome for the patient or [would] cause significant physical discomfort, for example resulting from complications in the use of the means employed.

  • Directive 58 For instance, as the patient draws close to inevitable death from an underlying progressive and fatal condition, certain measures to provide nutrition and hydration may become excessively burdensome and therefore, not obligatory in light of their very limited ability to prolong life or provide comfort.

  • Case 1Martha 49-yr-old Hypertension, quit smoking After stroke living will, but no DNR2nd stroke, coma then PVSNG-tubeHusband asks for stop quality of lifePriest starvingLaw requires terminal conditionHusband asks to do something to hasten death

  • Case 2 Marge 60 advanced Alzheimers Refusing food, combativePeg tube counter indicatedSister alleging starvation and causing suffering

  • Case 3Henry 60-yr-old alcoholicFall & head bleed5 week coma then opens eyesNo advance directiveFamily wants nothing done

  • Nutrition & hydrationSimplest case: grave burdenClose to deathFeeding cause pain/agitationModerate case: Advanced Alzheimer'sRefusing to eatDifficult case: non-dying (Schiavo)

    Simplest Difficult

  • Does the obligation to provide nutrition and hydration change depending on:

    coma

    vegetative state

    minimally conscious state

  • Definitions and Diagnostic Criteria

    Coma: Definition (MSTF, 1994)____________________________Coma is a state of sustained pathologic unconsciousness in which the eyes remain closed and the patient cannot be aroused.

  • Vegetative State: Definition (Aspen Workgroup, 2001)The vegetative state is a condition in which there is complete absence of behavioral evidence for awareness of self and environment, with preserved capacity for spontaneous or stimulus-induced arousal.

  • Minimally Conscious State (MCS)(Giacino, et al., Neurology, 2002)

    The minimally conscious state is a condition of severely altered consciousness in which minimal but definite behavioral evidence of self or environmental awareness is demonstrated.

  • Moral issues of PVSThe mere fact of the state is not sufficient justification for termination of nutrition and hydration.

  • SummaryDoctrinal clarificationNo categorical prohibition on ANHAlways a presumption in favor of ANHClearest cases: Capacitated patients Patients with clear directivesPatients with little burden/ large benefit/ primary intent is death (i.e., sole reasons is PVS)

    ****Group(s) on part five report. Here the discussion leader will draw attention to key points and ideas found in the numbered directives to Part Five.Presenter should comment that this presentation is limited to FOUNDATIONAL material in the ERDs. Most of these topics could generate considerable and in depth discussions which cannot take place in the context of this Foundations course.Invite participants to follow along. # 55: Reiterates the need to view and treat patients holistically# 56-57, #59: Reiterate rights of patients to make treatment decisions# 56-57: Reiterate the right of patients to decide when treatments are too burdensome or disproportionate, and th