Discontinuing Respiratory Assistance Compared to Discontinuing ANH

For the sake of simplification let us compare  respiratory assistance (RA) by a mechanical ventilator via a tracheostomy and tubal feeding((ANh) via a PEG

It will be useful to agree on a definition of “killing the dying”  I propose the following: 1

To kill the dying: To deliberately introduce for the purpose of death  a new cause of death by action or omission. Alternative: To deliberately set in motion a new cause of death by action or omission.

Intention in Discontinuing RA:

There are many intentions possible. The happiest is the goal of weaning the patient of a troublesome  and confining machine. Another may be motivated by the recognition that the machine is not curing the patient and the underlying illness is advancing and will soon kill the patient anyway. Discontinuance here is motivated by the uselessness of the machine in achieving the two legitimate goals of medicine: to cure and/or keep comfortable . Another motive would be objection to the high cost of the RA in terms of resources and stress to the patient and caretakers and the minimal benefits in terms of actually curing a lethal condition. A foreseen side effect may be an earlier time of death  but whose cause is  the underlying illness or trauma.

Evidence of Non-Lethal Intention:

That the intention is not the asphyxiation of the patient is clear, If the patient begins to breathe independently measures will not be taken to stop the breathing. If the patient begins to struggle for breath, measures can be taken to make this struggle less distressing. Medicine, however, does not have the obligation to make dying take as long as possible. Choosing an earlier  time of death is not to kill or commit suicide,[2] provided that no new cause of death is introduced. At times choosing an earlier time may actually be a moral obligation, as for example when the cost of RA is bankrupting the family and not curing the lethal condition.

That removal of RA is not the cause of death is evident in that there is an adequate cause of death present and active. Removal of RA is then a true case of “letting die.”

Intention in Discontinuing ANH:

Except for occasions when introducing food into the stomach is either painful or useless because it cannot be retained or digested or death is  imminent, AHN achieves a natural goal of hydration and nourishment. In and of itself hydration and nourishment is life sustaining via natural processes in the gut. Moreover AHN is often resorted to because hand-feeding is too time consuming.[3] The intention in removal of AHN is the  removal of its life sustaining function.

Evidence of Lethal Intention

That the direct intention is the death of the patient is seen in several ways. Removal of  ANH has no other end point than death, unless the underlying cause of dependency on ANH achieves death earlier. Other justifications of rejection of a medical device such as distress to the patient or cost to the family are minimally present.

  • Patient comfort is enhanced by ANH
  • The PEG procedure (and even a nasal tube) is straight forward and not expensive, and can often be done with local anesthesia and in an out-patient facility.
  • Home health-care can suffice to maintain it.
  • Cost to the family, financial and emotional, for the care of the patient is due to the continued life of the patient and all the care  that  entails and insignificantly due to ANH.[4]
  • In exploring the objection that ANH is burdensome to the patient and is seen so by the patient, it will often be admitted that the burden is in its ability to keep the patient alive.
  • A query as to what adjustment to the ANH technology would make it less a burden gets no answer except: “Defects in ANH are not the issue.”
  • If it is admitted that the patient receiving ANH is not dying but that a confident prognosis of death upon extubation is possible, it becomes clear that the cause of death is the withdrawal and the purpose of the withdrawal.
  • ANH is being rejected because it is successful, not because it is failing.
  • ANH is often used in patients who are unable to feed themselves due a disease or trauma which has done damage but is now arrested and for which no therapy is possible or for which therapy is making progress. It is the very capacity of ANH to sustain life while the therapy progresses, or for an indefinite time while none is  being applied which makes it objectionable.. Its very success at sustaining life, however reduced its quality, motivates its removal.
  • The inevitable death is due entirely to the withdrawal of ANH, a death cause  which is entirely new and by which alone the patient changes from living to danger of dying and finally to dying, by processes entirely unrelated to the underlying causes of incapacity to self nourish.

 

 

 

 

 

 

 

[1] If for some reason these forms of assistance cannot be used, adjustments to the opinions stated here may have to be made.

[2]  Consult my definitions at http://www.csus.edu/indiv/d/dundons/pasdefs.htm  or my  longer defense of this distinction at:http://www.springerlink.com/content/w615v8620021367l/

[3]  This was apparently the case with Terri Schiavo

[4] I am indebted to Christopher Tollefsen (Artificial Nutrition and Hydration, The New Catholic Debate, Springer, Dordrecht, 2008) for this section of my comments.

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