Vol. 83, No. 7, July 2010
Death is Inevitable; Make Treatment Decisions Now
Thank you to Gary Magnarini for a very thorough article on the law regarding withholding of feeding tubes in dementia patients (May 2010). This article, however, raises several issues that require further thought. First, as Mr. Magnarini suggests, it is necessary to have a thorough discussion with all the persons involved before signing an advance directive. Because it is difficult to cover all contingencies, the special-provisions section should thoroughly outline a rational plan for decision-making based on a careful and in-depth risk-benefit analysis rather than simply trying to cover all specific cases. This statement can also include a discussion of the principal’s faith or other philosophical tenets on which decisions should be made.
However, it needs to be understood that enteral nutrition via a feeding tube is not a panacea for inability to swallow and the risk of aspiration. Tube feeding simply provides a more controlled situation whereby the risks and consequences of swallowing difficulties can be lessened; there is still considerable risk, nevertheless. There also are risks associated with the procedure itself and of subsequent complications, including skin breakdowns, heightened risk of infection at the ostomy site, and other problems that may require replacement of the ostomy and other substantial risks of continuing morbidity and mortality. Maintaining caloric and nutritional/metabolic requirements, hydration, and mineral balance can present considerable challenges for the physician who orders tube feedings. This requires constant monitoring and adjustments, which are not easy. These risks are partly responsible for the very high one-year mortality. Contrary to popular belief, most patients who are terminally ill do not receive any form of nutrition at the end. The standard intravenous fluid provides solely hydration, not nutrition. Nor does the lack of nutrition create additional suffering, as many surmise. One can get along without nutrition, in contrast to hydration, for quite some time. Much of the discussion in this regard involves emotions surrounding food and its provision.
In the last analysis, we are all destined ultimately to die in this life. Our life on earth is finite, and there comes a point at which no medical treatment, including enteral nutrition, can prevent that. Many people have a difficulty with that concept, but it is true. While modern medicine can do a lot of things, there is a point at which further treatment is useless, and we need to keep in mind the ultimate goals of any treatment – it should not be to keep someone alive at all cost. Not even the parens patriae power of the state extends to keeping someone alive forever – that is simply an impossibility, and it is not good use of scarce resources to try. Accordingly, we need to come to grips with the inevitability of death to make appropriate treatment decisions for ourselves and others, including with regard to nutrition and hydration and feeding tubes.
Atty. Philip M. Kober, M.D., Ph.D.
Kober Law Office, Watertown
Consequences of Returned Mail
I have had an overwhelmingly positive response from folks who read the article “Consequences of Returned Mail: Postage Due” (June 2010), and several attorneys actually contacted me with questions about their mailings and compliance. Thank you for the opportunity to contribute to the publication, and I think the Postal Service will be very appreciative as well if the last few days’ discussions improve mailing conditions statewide.
Atty. Faith Mondry
U.S. Postal Inspector, Milwaukee