December 2006. One of the very practical concerns that patients face near the end of life involves the question of feeding tubes. How can we discern whether a feeding tube is morally required? The answer always depends on the particulars of a patient's situation, but there are a few broad considerations that can help in the discernment process. As a general rule, we ought to die from a disease or an ailment that claims our life, not from an action (or inaction) by someone that causes our death (for example, withholding hydration). Our death, in other words, should result from the progress of a pathological condition, not from a lack of food or water if it could have been readily offered to provide comfort and support to a patient.
In general, there should be a presumption in favor of providing nutrition and hydration to all patients, including those who require the assistance of a feeding tube. A feeding tube can be conceptualized as a kind of "long spoon" that assists us in feeding someone who has difficulty swallowing. The proper starting point for the discussion, therefore, is the recognition that feeding tubes should be offered to patients because they are likely to provide two benefits: they bring comfort to the patient and alleviation of the suffering that comes from hunger and dehydration, and they may also serve as a bridge to healing, depending on the details of the disease.
Does this stance imply that feeding tubes must always be used, no matter what? Certainly not. There will be circumstances where feeding tubes will become "disproportionate" or "extraordinary" and will not be morally obligatory. One very clear example would be the situation in which a feeding tube fails to provide nourishment to the patient. If somebody has advanced cancer of the digestive tract, for instance, so that he lacks a functional stomach or intestines, and cannot absorb nourishment, a feeding tube would not be required, since this would constitute a futile kind of "force feeding."
Several other examples where feeding tubes would not be required could be mentioned. In some cases, feeding tubes may actually cause significant problems of their own for a patient. For example, if someone is very sick and dying, perhaps with partial bowel obstruction, the feeding tube may cause them to vomit repeatedly, with the attendant risk of inhaling their vomit, raising the specter of lung infections and respiratory complications. The feeding tube under these conditions may become disproportionate and unduly burdensome, and therefore non-obligatory.
In some instances, providing drips and naso-gastric feeding tubes can interfere with the natural course of dehydration in a way that causes acute discomfort to the patient near death. When the kidneys have not shut down, the fluids can sharply increase the flow of urine. If patients are extremely weak and have lost bladder control, they may need to have a catheter inserted, which can be distressing to patients and their families. Intravenous fluids also tend to increase respiratory secretions, making it more difficult for patients to catch their breath or cough, and suction may be required. Providing IV hydration can also cause a flare up of fluid accumulation in the abdomen and expand the edema layer around tumors, aggravating symptoms, particularly pain. Hence the use of IV drips and feeding tubes will always have to be evaluated in terms of the totality of the patient's condition, taking into account any undesirable effects, and the likelihood of benefit.
Other circumstances must also be considered. Is the patient suffering from dementia, perhaps due to Alzheimer's or another nervous system ailment? Demented patients present a special challenge, as they may need to be restrained in order for a feeding tube to be inserted, and that restraint may need to continue so as to prevent them from pulling the tube out. Both the restraint and the presence of the tube can cause fear and anxiety in the demented patient, and one must therefore carefully consider whether such a tube would really be proportionate to the patient's health care needs, especially in advanced dementia at a point close to death. Our desire to comfort and palliate those suffering from an end stage disease is an important part of the equation in mapping out the best options for health care treatment. If we have to tie down our loved ones and cause them grave discomfort and uncontrollable anxiety in order to provide a feeding tube, such a tube may well become disproportionate and non-obligatory.
These considerations hold most notably for patients who are near death, where it is clear that we are not obligated to extend or "string out" an imminent death, and where the benefits of the feeding tube will be subject to considerable discussion. It should be emphasized, however, that in weighing the propriety of tube-feeding, we must specifically examine the burden of the technique itself, and not try to make some kind of global assessment about whether we believe that person's life in general is burdensome or "not worth living." Life can be burdensome, as it is for all of us at times, but that doesn't provide us with license to shorten it by refusing a standard and effective intervention.
Sometimes when families are discussing whether to provide a feeding tube to a loved one who is dying, there may be concern that such a tube, once inserted, can never be ethically removed after it has been put in place. In point of fact, however, such an understanding would be incorrect. Merely because a feeding tube has been placed does not say anything about whether that tube can later be withdrawn. If the patient's circumstances change so that a feeding tube has now become a burdensome and extraordinary intervention, that tube can be withdrawn without hesitation or compunction. We must be concerned first and foremost with providing the best possible health care interventions for our loved ones, and feeding tubes will oftentimes, but not in every circumstance, assist us in exercising proper stewardship over the great gift of human life that each of us has received from God.
Rev. Tadeusz Pacholczyk, Ph.D. earned his doctorate in neuroscience from Yale and did post-doctoral work at Harvard. He is a priest of the diocese of Fall River, MA, and serves as the Director of Education at The National Catholic Bioethics Center in Philadelphia. See www.ncbcenter.org