artificial feeding-Terri Schiavo - page 20

I posted this here becaue I think this subject is something that we as nurses deal with on a regular basis.....Many many people state that they have a big problem with the feeding being stopped... Read More

  1. by   NurseDreams
    Quote from Fuzzy
    I guess that I have worked around animals too much. It also doesn't help that I watched my mother die of cancer as a teen. I remember her trying to eat/drink and vomiting and crying because she couldn't keep any food/liquid down. She was wanting to eat and drink but couldn't. I was relieved when she died. Her battle with the pain was over. I see the same thing in the terminal animals that I treat--except most are helped along the way with a bit of euthanasia solution before it becomes so extreme as it did with my mother. If I ever get to the point that my mother did, I hope that I have a little Fatal Plus or SP6 available (euthanasia solutions). If not just put a pillow over my face----just don't let me die by dehydration or starvation.
    I couldnt agree with you more!!!!!!!! I dont want to die that way. I watched my grandfater die that way and to me it was horrible! Just give me a shot and let me go!
  2. by   nurse4theplanet
    Quote from NurseDreams
    My father and I were discussing this issue not long after my grandfather (his father) passed away. He had had a massive stroke and they stopped feeding him or giving him fluids so he could go in peace. My father and I both agree on this issue (for once we agree on something LOL).

    Why is it humane to let a human starve to death but it isnt humane to euthenize a human? However, it's not humane to starve an animal, but it is humane to euthenize. I just dont get it. I dont think that someone who just doest want to live for mental reasons should be allowed to get "put to sleep" but I dont see how this process couldnt be more effective in cases such as my grandfather. I dont care what anyone says, he starved to death, feeling those hunger pains for 4 days. That is cruel in my opinion. I would much rather have had someone give him a shot to allow him to go quickly and painlessly. JMHO and I am sticking to it.

    Please dont flame me. I am not posting this to start a flame war or anything of the sorts. I am however, interested in hearing what others think of this topic on a civilized level.
    Starvation and witholding artificial nutrition are not the same. Apparantly most people have these two concepts confused. Starvation is deliberately depriving a person/animal of the right to food and water when that person/animal is otherwise healthy. If Terri could consciously swallow, this would be a whole new issue. They could not withold food then because it would be starvation. But because Terri is classified as terminally ill and in a PVS then removing the tube (witholding artificial nutrition that is prolonging her life) is acceptable because it would cause natural death by dehydration (which is part of the natural dying process and does not cause pain but a state of euphoria to allow a peaceful passing).

    But just for irony's sake..... If her parents felt the same way as the husband and she was in the EXACT same condition no one would care! That is an interesting thought to consider....
  3. by   head injury unit RN
  4. by   UnewmeB4
    Quote from stevielynn
    This is how I feel too. Life is a precious gift. We are made in the image of God. It seems silly to think that just because we believe in an afterlife, then we should do something like your example, jump off a bridge, to get to heaven sooner.

    It is respect for life.

    I don't believe in actively taking an innocent person's life.

    When we take them off the vent, even when it is their wish( a person with MD, or ALS, who is conscious), is that murder? If a patient refuses to go to dialysis anymore, is it suicide? If they have COPD and have been on the vent and are not able to be weaned, is discontinuing the vent(even though they are not "brain dead") murder? Does refusing to sign for your mother with severe dementia to have open heart make you a murderer?

    It is never black and white.

    What one sees as a respect for life, another sees as cruel punishment.
  5. by   nurse4theplanet
    Utilitarianism.... we all learned about it in school. Part of ethics...

    Which decision would benefit the greatest number of people?

    Option A: Terri's tube is re-inserted

    Her husband would not have closure.
    Her parents would continue to put false hope in her recovery and continue to grieve for her and her circumstance.
    Terri remains in total care, strapped down to keep her from pulling the tube out (that came off her parents website)
    Millions of taxpayers dollars will be paid for care

    Option B: Terri's tube is left out

    Her husband can move on with his new family
    Her parents can complete the grieving process
    Terri passes naturally and enters the Kingdom of God where she will be restored
    Millions of taxpayers dollars will be redirected to others who CAN recover from dibilitating accidents

    the choice seems clear to me...
  6. by   underwatergirl
    I have been following this forum for a while...I don't deny that what Terri may experience isn't going to be pretty...the thing is I don't know and neither do you what all was damaged in the brain...particular nerons may or may not be there for her to feel the symptoms, I pray they are not.

    In comparison to what she has gone threw for 15 yrs of life...and what we all know will happen if she has the tube me that is worse. I stand by the fact I don't wanna live like that..what quality of life do you have in a bed??? Not any imo!

    If the government/courts feel Micheal is so wrong, grant him a divorce...hence removing his legal obligations and rights and make her family pay for the medical care that she is recieving. I have said this once before and I will say it again...if this wasn't a power trip for the family they should have offered to pay all medical cost...sign legal aggreements...if the government feels this is wrong...then they should grant him a divorce...plain and simple.

    I understand why he has moved on. In respect to the blinds being closed, lots of camera's would love to get pictures of his would you feel with your wife stuff in a bed, brain dead to your knowledge, not particularly looking the best, those things I can understand...

    Now if he denied treatmeant to make her more comfortable that isn't right, if he denied treatment because he felt if would be more harm then good.

    IMHO, the family needs to stop fighting the tube issue and fight for the courts to grant a divorce and then take over all legal obligation of the patients medical cost and them be her HCPOA. To me this seems like a huge power trip of a womens is a whole lot of hearsay...Why haven't the family requested to take over the cost? Fight the courts for a divorce for her daughter? Or ask Micheal for a divorce? That to me makes there story fishy...

    I have read what that nurse states in the sworn statement...alot of it to me sounds ridiculous and as if she is trying to get back at that LPN, which what was the point of mentioning her name?? It really made no sense, also IMO she didn't stand up to her obligations as a nurse..if she really saw or believed half of the things she is saying then why didn't she do more than just chart??? Is this nursing home being investigated for fraudulent records??? I think if that came out that state board of nursing would be all over that...Also if she has sworn this why hasn't it been on tape of him saying those things...because those are death threats and simple law enforcement can interact with that...also if she saw her chart notes being deleted, why didn't she start to copy them or print them out depending on the system used? As for the nursing home following what micheal says about not calling the family...THAT IS THE LAW, unless Terri says or has something put into place...that nurse could have been/probally was in deep trouble for calling the family. Don't get me wrong I think the family should know too, but it isn't my place to decide that or tell them that. Finally, if I thought a patient of mine was being abused by spouse/family, I sure the hell wouldn't sit back and not open the door...I would use excuses like time for this or that, or Micheal you have a call...come on this is a nurse who sounds like she messed up and is trying to fix it or make her record of employeement look clean. If she came and stated some of things she did then fine but some of it is just to far fetched...She is accusing this nursing home of corrising with Micheal...that is a conspiracy..don't you think that the Fed. Govern. would be getting involved right about now???

    In conclusion imo, the fight shouldn't be about the tube it should be about the family taking over financial responsibility and getting the courts to grant a divorce.

    What Terri may have to go threw is horrific, but the fact remains that Micheal is in control, we can't change that..however the family could if they would fight for legal rights and get that divorce. I just keeping asking myself, why hasn't that been done or thought of yet??? Perhaps because it is more of a power trip than a love trip???
  7. by   NRSKarenRN
    [color=#660066]from [color=#660066]end-of-life options: tube feeding

    [color=#660066]what happens when one forgoes food and fluids at the end of life?
    • starvation? no: starvation is a long, drawn out (and typically painful) process that can take anywhere from 30 to 60 days to run its course. dying patients who stop taking in food and fluids do not starve to death.
    • dehydration: while the body can sustain itself for up to two months without food, it can sustain itself no more than about two weeks (at most) without fluid intake. unlike starvation, however, dehydration is typically not a painful or even an uncomfortable process, especially when good comfort care measures and undertaken. in fact, many patients report less discomfort and there is less request for pain medication as dehydration runs its course.
    • the dying process: patients who stop taking in food and fluids drift into a state of unconsciousness. this phase of the process may take from 5 to 8 days if the patient is fully hydrated when food and fluid intake is stopped. patients will typically die peacefully several days after that. if the patient is already partly dehydrated when fluid intake is stopped, the dying process will be compressed and may only last a couple of days, or less.
    • nature's course: dehydration is a natural part of the dying process. it tended to be an indirect cause of most natural deaths (those not associated with violent trauma or acute infection) before the widespread use of tube feeding began in the 1960s and 1970s. even today, it is generally accepted that food intake decreases naturally with age and that often elderly people report a decrease in appetite as they progress toward the end of life.

    [color=#adb87f]"tube feeding" -- right or wrong: the medical, legal and ethical issues
    [color=#adb87f]david e. milkes, m.d.
    [color=#adb87f]pegs and the law
    starting with the case of karen ann quinlan in 1976, the united states courts have spoken loud and clear about the use of life-sustaining treatments and artificial nutrition and hydration. the courts have repeatedly upheld the principle that competent patients may refuse or withdraw any medical treatment, even if that treatment is necessary to sustain life.

    in the nancy cruzan case in 1990, the majority ruling of the u.s. supreme court held that there is no difference between the termination of artificial nutrition and hydration, and other forms of treatment.14 furthermore, the american medical association, a president's commission and almost every appellate court decision have agreed that artificial nutrition and hydration is a form of medical treatment that may be legally refused.15 competent patients have the legal right to refuse tube feedings.

    but what about patients who cannot express their own wishes? in the quinlan case, the court determined that family members may refuse life-support on behalf of an incompetent patient.16 only two states, new york and missouri, have strict requirements that surrogate decision-makers present "clear and convincing" evidence that the patient, if he or she were competent, would not have wished artificial nutrition and hydration given their present medical condition. courts have recognized written statements and conversations with family and friends as constituting "clear and convincing" evidence.

    to assist physicians and families in making medical decisions for incompetent patients, most state legislatures have passed laws allowing advance directives to be honored. an advance directive is a statement that a person makes, while competent, expressing their wishes about treatment in the future, should they lose the capacity to make decisions. it may provide written instructions about treatment (a living will) or may designate another person to make treatment decisions (a proxy or durable power of attorney).

    all health care facilities receiving medicare or medicaid are legally obligated to provide their patients with written information about their rights to accept or refuse medical treatments. patients admitted to these facilities must be provided the opportunity to complete advance directives. in cases where no family member or legal instrument are available to determine the wishes of an incompetent patient, physicians generally err in the direction of preserving life as long as the anticipated benefits of treatment outweigh the burdens.

    although each state has its own set of laws about terminating life-support, there is usually nothing to prevent tube feedings from being legally withdrawn after they have been initiated. with the exception of illinois, no state requires a physician to seek a court order to withhold or withdraw tube feedings. rather, the courts overwhelmingly favor allowing such personal and emotional issues be dealt with directly by family and through the physician-patient relationship....

    furthermore, families must also realize that once a peg has been placed, it is both legal and ethical to withdraw the tube, should the patient's suffering become extreme. ideally, the conditions under which the peg might be withdrawn in the future should be discussed and agreed upon prior to peg placement....

    read more:


    from: north carolina medical society

    guiding the decisions of physicians and families in end-of-life care:
    [font=myriad-roman]the case of long-term feeding tube placement

    tube feeding does not necessarily provide medical benefit to the dying patient by enhancing quality of life nor by reducing suffering.

    [font=agaramond-regular]tube feeding is associated with increased agitation and may reduce quality of life and dignity because it increases the need for physical restraints;[font=myriad-roman]7[font=myriad-roman]

    [font=agaramond-regular]typically, dying patients do not experience hunger or thirst;[font=agaramond-regular]

    [font=agaramond-regular]malnutrition, a concomitant of the natural dying process, should not be confused with "starvation";


    [font=agaramond-regular]while dry mouth commonly occurs in dying patients, tube feeding does not relieve it;

    [font=agaramond-regular]complete relief from symptoms associated with dry mouth may be achieved with ice chips, moist sponge, sips of liquid, lip moisteners, hard candy, and mouth care."


    american dietetic association (ada)

    ethical and legal issues in nutrition, hydration, and feeding

    ...the multi-society task force on persistent vegetative state defines the persistent vegetative state as "a vegetative state present one month after acute traumatic or nontraumatic brain injury or lasting for at least one month in patients with degenerative or metabolic disorders or developmental malformations" (7). since the patient in this condition cannot feel pain, the burden cannot be physical. however, can the burden be emotional or financial? can treatment be medically futile but of emotional benefit? arguments that feeding is a benefit because of the sanctity of life can be countered with arguments about the dignity of death. if care providers decide that there is an obligation to feed the persistently unconscious patient, they may change the moral obligation to a moral option after the passing of time suggests that the patient's state will be permanent.

    according to tong, a singular patient goal of prolonging life is not an independent goal, but, rather, it is a dependent goal. the physician's responsibility is "restoring and correcting" (8). while there is general agreement that patients have the right to refuse treatment, the question is whether they have the right to demand treatment if it is nonbeneficial or medically inappropriate. the wanglie case examines this issue. the debate on the definition of futility is in the early stages and incomplete. public values and standards of care for persistently unconscious patients will evolve. angell states "that any solution must be a principled one that applies generally and is established by consensus, in the same way that death was redefined as brain death" (9).

    an additional issue in the treatment of patients is the "need to ensure a just and fair allocation of scarce resources" (6).the question of whether cost should be a factor in clinical ethical decision making will intensify as resources become more scarce. the central question remains what the patient prefers, but allows for what providers consider worthwhile. this can be formulated into the key ethical discussion of what is wanted and what is warranted. what is wanted by the patient or family and warranted by evidence-based medicine. it may be that what is wanted is not warranted or what is not wanted is warranted. how to clarify and then resolve this conflict is the essence of the ethical deliberative process, (see figure 1).

    the issue of justice and patient feeding may intensify, especially for the permanently unconscious. tong suggests that with respect to permanently unconscious patients, legislative or social changes may be the solution (8 ). for instance, if the definition of death were changed to be the death of higher brain functions, the permanently unconscious patient might be considered dead. this change would mean that society, rather than the physician would decide when a patient is dead; however, the lack of diagnostic certainty complicates this approach. or to deal with the rationing of health care debate, it could be required as a principle of justice that people who want to live in a permanently unconscious state purchase such insurance or pay for the care and feeding. angell suggests that the presumption should be that the permanently unconscious patient would not want to be alive in that state (9).

    the distinction between physician aid in dying and the withdrawal or withholding of artificial nutrition and hydration is widely recognized. withdrawing or withholding nutrition and hydration centers on the physician's obligation to honor a patient's refusal of life-sustaining treatment. such a refusal requires the physician to carry out an action or omission. these acts and omissions are morally and legally required because it is the patient's right of refusal that is overriding. such acts and omissions are not defined as "physician aid in dying" because the physician has not provided the necessary medical means for the patient to commit suicide. patients, without being terminally ill, may refuse medical treatment, including food and fluids. a position paper by the american college of physicians recommends honoring "voluntary refusal of hydration and nutrition" (10). health care providers must uphold the patient's wishes whether they agree or disagree, or transfer the patient to another health care provider (11).

    Last edit by NRSKarenRN on Mar 20, '05
  8. by   nurse4theplanet
    excellent research! Thank you for that!
  9. by   renerian
    I am curious to know how many here have looked at this situation and made or revised their advance directives?

    I did. No articial feedings, ever, whatsoever.........never. EVeryone in my family knows it.

  10. by   Chad_KY_SRNA
    I did the exact same thing, I told my friends, family and coworkers that I would haunt them until the day that they died if I was in that situation. Its gotten pathetic to me. I feel so sorry for that woman in that bed. The families are acting like two spoiled chidren fighting over a toy. The husband is the POA he says pull the tube, doctor ok's it, fine pull the tube. It's not pleasent to some but thats how our laws are set up.

    In an MSNBC poll 58% of 74,801 people who have voted online say the tube shouldn't be reinserted.
  11. by   KARRN3
    It seems to me, the one piece being missed here is that this woman has already been in a vegetative state for fifteen years. The family stating that they think she can get better makes it sound like this just happened last week and already her husband wants to disconnect life support. What kind of life does this woman have, who would want to exist like that. It's a disgrace that the politicians and the courts have gotten into this power struggle. I believe her husband is fighting for what he knows she would want. If he didn't care about her, he would just take the path of least resistance, divorce her and let her live in this vegetative state forever. The other piece to this is, who is paying for her to live in this vegetative state in a time when almost a quarter of our people have no health coverage,.
  12. by   decoopa
    Well, In an effort to answer your question #1 IT IS NOT DIFFRENT from any other case. The public is being drawn into a family feud with money via the gracious black journalism we have come to know and love. It is ignorance to think that this is the first time this scenario has been played out. It was just before; there wasn't the money to be had by the players to take it into the public stage. And now congress is getting involved, OH God please help us when we the public need the government to TELL get involved even more than they are in our personal lives. This is not about Terri but about a struggle over WHO has control over her.
    #2 How to handle this type of situation with family members? I have to admit it is a gray area with a potential slippery slope; but given REAL information with data from MD's with the backbone to state "the EEG is Flat! " etc. Allows the family permission to let go and come together and grieve together.
    The general public cannot understand the personal motivations of her husband or her family. I can say he's standing his ground against pushy and unrealistic in-laws. But what does it matter except now the government is getting way to involved into the private matters of personal lives; to answer the basic underlying question "Who IS the POA " the husband or can someone else cause enough stir and confusion in the name of "HUMANITY" to take it away.
    AS long as there have been medical advances that change and alter the disease process alleviating death, this scenario will continually repeat itself.
  13. by   Kyriaka
    Quote from stevielynn
    I'm already reading the attitudes I'm afraid of . .. . calling a human being made in God's image a "vegetable". Like she isn't worth anything. Like she is garbage.

    That is the slippery slope, come home to roost. Already.

    Some human beings aren't worthy of life . . .so let's kill them.

    It is a scary world.

    But you see, it is easier to view a person in this way.

    If you ever saw the movie Awakenings, Robin Williams character tells another Dr., "how do you know there is no consciousness there"? Speaking of people who appear to be in a catatonic state.

    And the Dr. replies, "because to think otherwise is the unthinkable".

    Based on the true story of a research physician who uses an experimental drug to "awaken" the catatonic victims of a rare sleeping sickness.