Denying food and water to a permanently comatose patient is a charged issue. While nourishment is a basic right of all patients, should it be forced on those in the process of dying? That is the issue at the heart of the case involving 32-year-old Nancy Cruzan; the Supreme Court yesterday blocked the parents of the Missouri woman from ordering the removal of feeding tubes.
Many believe that permanently comatose patients require little maintenance and should be allowed to continue to occupy beds. In fact, feeding and hydrating an unconscious patient is difficult at best, requires intervention and comprises only part of the vast care needed to "maintain" such patients in what is rightly called a vegetative state.
Nourishing the unconscious person requires bypassing the normal chewing and swallowing process, and at times avoiding the gastrointestinal tract altogether. A nasogastric tube bypasses mouth and esophagus to deliver liquid nutrition directly to the stomach. The presence of the tube keeps the gastro-esophageal sphincter, between the esophagus and stomach, open.
Combine this with the reclining position of comatose patients, the fact that normal digestive processes are slowed in the unconscious and the danger that feedings divorced from hunger signals may exceed the gastric capacity. Thus we create an ideal situation for stomach contents to be regurgitated and inhaled into the lungs, where bacteria foreign to the respiratory tract cause aspiration pneumonia.
Because long-term use of a nasogastric tube for feeding almost guarantees an aspiration pneumonia, a gastrostomy, a surgical procedure in which a tube is placed connecting the abdominal wall to the stomach, may be ordered. The procedure carries the risk of bleeding and infection, and the gastrostomy skin site where delicate stomach tissue is sewn to the skin surface remains susceptible to infection.
Merely getting food to the stomach of a comatose patient is an invasive procedure, with the risk of complication for the duration of time that the patient is fed. And what comes out of the patient creates as much difficulty as what goes in. Because they are incontinent, liquid stool may seep constantly, providing a rich source of bacteria that can spread infection.
Urinary tract infections are common in the comatose because most are catheterized with a tube through the urethra into the bladder for urine to drain into a bedside bag. Catheterization predisposes the patient to such infections, which may ascend to the kidneys andcause a generalized infection called urosepsis.
Infections in the comatose may quickly become life-threatening. Urinary tract infections, wound infections and aspiration pneumonias are the most common hospital infections, and hospital-acquired bacteria are highly resistant to antibiotics. Medications to treat an infection are usually administered by an intravenous line.
Patients who have been in the hospital for long periods rarely have usable veins left to accept an IV. In this case, a central line is inserted in a large vein in the neck, under the collarbone or in
Even under the best of circumstances, skin breakdown can occur, resulting in bedsores. Difficult to heal, prone to infection and liable to worsen, infected bedsores can seed the blood with bacteria and result in overwhelming infection.
A patient who is placed on a respirator faces more problems. Prone to respiratory-tract infections, the patient must be suctioned vigilantly. Adequate oxygen levels in the blood must be determined regularly by taking blood samples. The respiratory muscles weaken and eventually prevent the comatose patient from ever getting off the ventilator.
Some patients are more deeply comatose than others. Some do not respond to any stimuli; some flinch reflexively as we try to obtain blood samples. Another may not flinch but may utter animal-like sounds; another may seem to react to nothing -- until one notices a tear running down an expressionless face.
We pump a warm corpse full of air, water, nutrition; we channel urine into plastic bags, and we battle the attempts of the body to die. We are not extending lives, we are extending deaths.
Adriane Fugh-Berman is a physician and a board member of the National Women's Health Network in Washington.
Second Opinion is a forum for points of view on health-policy issues.