December 17, 2005
Did we purposefully starve patients before PEG's?
I am occasionally positively amazed by what I find on the front page of the Wall Street Journal. Though generally not the choice for news for many who trend to the old gray lady, Warren Buffett's newspaper, and increasingly online sources, with some frequency WSJ takes on the major healthcare issues of the day.
My amazement could come from surprise at seeing them there. But I don't see similar quality of in-depth stories either at the gray lady or at Buffett's place.
I recently read a story by Mark Fritz entitled: "How a Simple Device Set Off a Fight Over Elderly Care." Mr. Fritz engages the issue of the appropriate and inappropriate uses of feeding tubes, the right to die, the right to life--all in all a complex subject for a business journal.
I am old enough to have practiced when tube feeding was not a routine but an extraordinary procedure. As anorexia—which means loss of appetite—is integral to all progressive disease and a part of the dying process, I never felt like we were “starving people to death” when we didn't engage tube feeding. Neither did anyone else. Now it is the central focus of cultural and political wars.
Here are the predicates on the feeding tube debate as presented in the article:
“The answer lies in the unusual history of the feeding tube, a simple, inexpensive medical product at the center of a growing cultural battle over end-of-life care for the elderly. At this same hospital (University Hospitals of Cleveland) 26 years ago, two doctors inserted the first modern feeding-and-hydration tube to save a sick infant. One of them dubbed it the "percutaneous endoscopic gastrostomy" nozzle, or PEG. Today, PEGs are most often used on people with late-stage terminal diseases such as Alzheimer's who can no longer eat on their own. About 300,000 people received tubes this year, PEG pioneer Michael Gauderer says, nearly double that of a decade ago. Roughly 75% are 65 years or older, specialists say.”
“As feeding tubes have shifted far away from their original use -- emergency care for younger patients -- some now argue that failing to use them on the elderly is tantamount to euthanasia.”
This leads to a set of interesting tensions around healthcare decision making including the concept of the “good death”, individual autonomy, the rights of individuals to guide their own lives clear through the last act, who gets to decide what, the interests of the state in personal matters, the imposition of shifting moral values, the loss of classical moral attitudes toward death, the imposition of state mandates on individual decisions that don't affect the state directly, and the like.
For those who would like a deeper dive into some of these issues, I highly recommend The Foundations of Bioethics, 2nd edition, by my colleague, H. Tristram Engelhardt, Jr. starting on page 340.
Some more of the article:
“Several studies have found that PEGs don't extend the lives of terminally ill elderly people and are fraught with complications. Yet widening use of feeding tubes has been driven by market forces, the aging population, fear of liability and economic inducements tied to insurance payments. The federal government and private insurers typically reimburse nursing homes for patients with feeding tubes more than those without them. It's often easier for overworked nursing homes to use tubes to feed frail, demented patients who can't feed themselves. And religious and right-to-life groups also are fighting to expand the use of PEGs in elderly people nearing death, challenging anyone who would allow these patients to die.”
The most pernicious part of this debate in my opinion concerns the willingness of so-called religious groups to challenge living wills and other statements of intent by individuals regarding their view of the “good death”. “Recently, some religious groups have actively challenged living wills that call for incapacitated patients to die without having a feeding tube put in. One is Agudath Israel of America , a New York-based activist group which has sought on several occasions to use feeding-tube litigation to advance orthodox Jewish religious convictions. Like other religious groups, it has lobbied against withholding hydration and nutrition from the elderly, saying it violates religious teachings about the sanctity of life.”
“Some groups treat the PEG as an issue akin to stem-cell research and abortion. Burke Balch, director of the National Right to Life Committee's Robert Powell Center for Medical Ethics, says the Washington , D.C. , pro-life group's interest in end-of-life care is "equivalent" to its concern over abortion. The Schiavo case spawned scores of statehouse bills that will heighten the debate next year. Lawmakers in dozens of states have sought rule changes that would make it harder to remove feeding tubes. The Right to Life Committee has won sponsors in more than 10 states for legislation requiring courts to presume a mentally incapacitated patient would want to live.”
So there it is, a real mess. Politics in medicine is bad medicine.
Physicians often take the path of least resistance since they know the patient will die with or without the PEG, and they get paid to install and oversee the use of the device. And, after all, dead people don't sue you. Many physicians will abrogate their duty to the patient's wishes and acquiesce to the strong position and legal threats of a family member. And hope that the patient doesn't suffer too much along the way.
When one assesses the family circumstances, the legal threats are often financially driven such as the continuation of the receipt of a pension check, but cloaked in some moral position. My experience taught me that some children will allow their parents to suffer for a couple hundred bucks a month in Social Security checks.
As my good friend Tris Engelhardt notes in his book, “Death requires choices. The good death, as the good life, requires forethought and planning. It is unlikely to happen by chance.”
The decisions in this regard can only be made by individuals in consultation with whomever they choose—physicians, religious advisor, friends, family—or no one else at all. The state should stay out of it, especially the state as influenced by special interests with an agenda to advocate and the desire to impose their peculiar set of values on everyone else by legal fiat.
Robert B. Teague is a pulmonologist and business consultant who is based in Houston, Texas. E-mail him.
Read other blogs in this series.
