Tuesday, March 16, 2010

Most Doctors Would Refuse a Feeding Tube For Themselves; Why Do They Place Them So Often?

Dr. Kirsch from MDWhistleblower has a new post on feeding tubes:

Last week, I was asked by a primary care physician to place a feeding tube in an NNHP, a nonagenarian nursing home patient. The patient had a panoply of active medical issues, and was at the end of life. The feeding tube was advised because the patient’s swallowing function was impaired and he was, therefore, at risk for pneumonia if he ate. These swallowing evaluations are generally performed by speech pathologists, whom I have found to be dedicated and competent professionals. As an aside, they often uncover swallowing defects that suggest that eating regular food may be unsafe, even though I suspect that these ‘defects’ were present for several years. Somehow, these patients ate regular food and survived.

As the patient was not capable of providing informed consent, I contacted the patient’s legal guardian, who is his grandson and a physician. While I was hoping that he would decline the tube and opt for comfort care, he was adamant that the tube be placed. I did so on the following day. Yesterday, a day after the tube was placed, he died, not from a complication of the procedure, but because he had reached the end of his life.

In 20 years, I’ve place over a hundred feeding tubes, primarily in elderly and demented individudals. In most of these cases, I serve as a technician. I am not consulted for my advice on whether a feeding tube is in a patient’s interest, but am asked to insert one after the decision has already been made. More than any other gastro procedure I perform, placing these tubes, called PEGs by physicians, is the most troubling. There is no question that gastroenterologists like me are placing more of these tubes than are medically necessary. Over the past few years, several
medical papers have documented that providing tube nutrition for patients at the end of life, or with advanced dementia, provides no benefit. It does not prolong or improve life for many of these patients. Why, then, do we do it so often?

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You're Dying; When Do You Turn Off The Defibrillator?

From MSNBC, a very good question: When during the dying process do you turn off your heart defibrillator? A new study in the Annals of Internal Medicine examines the challenge of deactivating heart defibrillators in the dying:

Carol Filak had heard about painful, repeated shocks that people sometimes experience from those implants in their final days. So when her father, Joseph Hoffman, was diagnosed with terminal cancer, she asked at his cardiologist's office: What about the defibrillator he'd had implanted years earlier? It's too soon to worry about, she was told.

Two months later, Hoffman, 81, entered hospice care in his West Orange, N.J., home and still Filak had to make numerous calls to the cardiologist before someone arrived to deactivate the defibrillator. "You need to be told that this is something that's not going to prolong his life," says Filak. "When he died, it was a very peaceful death."

It's not unusual for health professionals to avoid the topic, says Dr. Nathan Goldstein of New York's Mount Sinai Medical Center. His research, published this month in Annals of Internal Medicine, suggests most hospices — expert in end-of-life care — aren't making defibrillator decisions part of their routine. Nearly 60 percent of hospices he examined had at least one patient shocked within the past year, sometimes multiple times at once. Yet just one in 20 hospices had a method even to identify who harbored the implant when they entered the program.

But with more than 100,000 implantable cardioverter-defibrillators, or ICDs, inserted every year, more and more families like Filak's will face the question.

"We're trained to save, save, save, cure, cure, cure," says Goldstein, who has studied end-of-life defibrillation since seeing a dying lung cancer patient brought to the emergency room because his implant kept firing. "There are some folks we can't cure. We have to make them as comfortable as possible."

I like this issue because in many ways it forces us to face the challenge of dying in a world where technology has solved many functionality problems but has only complicated the definition of death. Once was a time where death meant the rather simultaneous cessation of breathing, heart beat and brain function. But technology can now sustain the former two almost indefinitely with respirators and defibrillators. Terri Schiavo's heart, for instance, was shocked back into operation by paramedics when she was found after her collapse. For the first few years she was kept breathing by a respirator, then was slowly weaned from it. But her lack of brain function remained. What does death mean now?

As the discussion regarding defibrillators in the dying comes to the fore, necessarily, I think it helps us to clarify what is meant by prolonging life and prolonging death.

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