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

Public controversies over H2O and PVS Quinlan: 1975 – 1985 Cruzan: 1983 – 1990 Schiavo: 1990 – 2005 –Dates indicate the time from their medical event to their death

Cultural Controversy over Nutrition and Hydration –Food and Water –The Meal –Physical suffering and comfort –Starvation and Dehydration –Emaciation –Hope: “At least we are doing something”

Prevent aspiration Improve/prevent pressure ulcers Reduced risk of infections Improve functional status Prolong life Improve comfort Commonly Cited Reasons for Feeding/Tube

Nutrition & hydration Effective 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 & Dementia Journal of the American Geriatrics Society, March 2010 –Comfort feeding –Evidence: longer life without feeding tube

Questions at end of life Who decides? –Informed Consent –Advance Directives What is the basis for termination? –Autonomy & self determination –Futility –Quality of life –Burden-Benefit ratio Can the institution cooperate?

Moral complexity If 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 1 Martha 49-yr-old –Hypertension, quit smoking –After stroke living will, but no DNR –2 nd stroke, coma then PVS –NG-tube –Husband asks for stop “quality of life” –Priest –”starving” –Law requires terminal condition –Husband asks to “do something” to hasten death

Case 2 Marge 60 advanced Alzheimer’s Refusing food, combative Peg tube counter indicated Sister alleging starvation and causing suffering

Case 3 Henry 60-yr-old alcoholic Fall & head bleed 5 week coma then opens eyes No advance directive Family wants nothing done

Theories of termination Autonomy/self determination Quality of life Futility Burden-benefit ratio What distinguishes appropriate from inappropriate terminations? –Letting die v. killing

Theories of termination Quality of life –Common usage –QALYs –From whose perspective? Subjective judgment that can be biased

Development of killing & letting die St. 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 1550 –“…would 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” 1958 “Normally one is held to use only ordinary means— according to the circumstances, places, times, culture—that 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 1980 “…people prefer to speak of proportionate and disproportionate”…it 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 termination Disproportionate v. proportionate

Directive 32 “While 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 60 “Euthanasia 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. inappropriate Letting die v. euthanasia Secondary intent v. direct intent to cause death

Double Effect All choices have many effects Primary choice needs to be good or at least neutral Secondary effect must not be a means to the good or neutral effect Secondary effect is see and accepted

Cases Continuum Simplest Complex Dying patient Non-dying patient Capacitated Incapacitated Advance 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 1 Martha 49-yr-old –Hypertension, quit smoking –After stroke living will, but no DNR –2 nd stroke, coma then PVS –NG-tube –Husband asks for stop “quality of life” –Priest –”starving” –Law requires terminal condition –Husband asks to “do something” to hasten death

Case 2 Marge 60 advanced Alzheimer’s Refusing food, combative Peg tube counter indicated Sister alleging starvation and causing suffering

Case 3 Henry 60-yr-old alcoholic Fall & head bleed 5 week coma then opens eyes No advance directive Family wants nothing done

Nutrition & hydration Simplest case: grave burden –Close to death –Feeding cause pain/agitation Moderate case: Advanced Alzheimer's –Refusing to eat Difficult 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 PVS The mere fact of the state is not sufficient justification for termination of nutrition and hydration.

Summary Doctrinal clarification No categorical prohibition on ANH Always a presumption in favor of ANH Clearest cases: –Capacitated patients –Patients with clear directives –Patients with little burden/ large benefit/ primary intent is death (i.e., sole reasons is PVS)