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Terminal Patients Need Facts About DNR, Tube Feeding

Terminal Patients Need Facts About DNR, Tube Feeding

NEW YORK--Good communication about the dying process can reduce fear and promote decision-making, but accurate information about resuscitation and artificial hydration and feeding is often not communicated, Judith C. Ahronheim, MD, said during a teleconference on communication of end-of-life issues organized by Cancer Care, Inc.

"In a setting of advanced metastatic cancer, the chances of surviving cardiac arrest are slim, and that should be communicated to patients," said Dr. Ahronheim, an internist who specializes in geriatric care and is also deputy executive director for Choice in Dying, an organization that fosters patient autonomy in medical decision-making.

She stressed that when discussing Do Not Resuscitate orders, "it is very important to let the patient or loved one know that going without CPR will allow death to occur peacefully and naturally."

Although patients in intensive care are generally receiving a number of life-sustaining treatments, people view the respirator as the prototype of the treatment they want to avoid at the end of life because they fear it will be uncomfortable and unnecessarily prolong life.

Dr. Ahronheim said that the respirator and accompanying treatments can be uncomfortable, but, she pointed out, many patients are sedated during this time, either intentionally with medication to keep them comfortable and keep their breathing synchronized with the respirator, or naturally because the disease produces a natural sedation.

If the Patient Is Alert

She noted that many people would rather be alert while on a respirator, but when they are alert, "the situation changes." If the patient is expected to recover, use of the respirator is generally not an issue, but patients who are aware or fear that they're going to die may be preoccupied with thoughts of dying and fear having the respirator disconnected.

"They need to talk about this in advance and be reassured that their dying can be made peaceful if they are taken off the respirator," she said.

Dr. Ahronheim believes that myths have grown up around artificial hydration and nutrition, and thus patients may base their decisions about receiving such treatments on inaccurate information.

In her research (Clin Geriatric Med, May 1996), she has found four common myths .

Four Common Myths About Tube Feeding

  1. Tube feeding is ordinary care.
  2. Tube feeding prevents aspiration pneumonia.
  3. Tube feeding prevents a cruel, painful death associated with starvation.
  4. Swallowing evaluations can predict who will benefit from tube feeding.

With few exceptions, she said, there is little evidence that tube feeding provides comfort to dying patients. "In most cases, a patient will be more comfortable if food and fluids are given according to his or her desire," she said.

Tube feeding also has many potential side effects and is often very poorly tolerated, she said. Theoretically, nasogastric feeding could impair swallowing and reduce the competence of the lower esophageal sphincter, while gastrostomy tubes might enhance gastroesophageal reflux, she commented.

As for preventing aspiration, Dr. Ahronheim said there is no reliable information that tube-fed patents do better or worse than impaired spoon-fed patients, and a review of the literature fails to demonstrate any evidence that any form of tube feeding reduces the risk of aspiration pneumonia.

Forgoing artificial nutrition and hydration at the end of life will not lead to a painful death, Dr. Ahronheim said. Rather, it is consistent with a peaceful and pain-free death, as occurs when a patient is in a coma. Life-sustaining treatments may awaken patients from this natural anesthesia, preventing death from occurring peacefully and naturally.

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