Gastrostomy in Terminal Dementia?

abstract & commentary

Source: Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med 2000; 342:206-210.

Gillick from the hebrew rehabilitation center for the Aged in Boston challenges the status quo with her title. She estimates that percutaneous endoscopic gastrostomy tubes have been inserted in at least 35,000 overwhelmingly demented patients in the United States during a recent year. Presumably this and other such approaches to hopelessly demented patients that they have no choice but to reach a permanent vegetative state. Furthermore, she accurately and compassionately points out that nasally inserted tube feeding inevitably draws complications that void possible help for the patient. Her editorial emphasizes the complex and painful experience of upper endoscopy, intravenous sedation, and ultimate incision of the abdominal wall. Actually, her empathetic approach to the problem indicates that gastrostomy produces far more irritation than it does to soothe the patient’s long-lost capacity to perceive suffering by his/her once-conscious brain. Supporting this concept, Gillick points to a survey that stated via a questionnaire, "among 421 randomly selected, competent patients who were living in 49 nursing homes, only one-third would favor a feeding tube if they were unable to eat because of permanent brain damage."

Neurologists know more about the brain, its wonderful scientific accomplishments, and, unfortunately, its converse potential for disintegration and permanent loss of consciousness at the end of life. Surgeons may have skillful hands and general practitioners may know about functioning visceral organs, but, as a specialty, neurologists know all too well that when a degenerating or overwhelmingly injured brain has lost its capacity for awareness, there is no turning back. Even the American Supreme Court has accepted the principle that nutrition is not a constitutional requirement for patients experiencing total loss of awareness.

commentary

Alert shares Gillick’s beliefs that scientifically and ethically prepared neurologists must assist medical professionals and other caregivers to recognize that severely worsening dementia is terminal and no therapy will turn back the inevitability of death. The sad part of this is that, for whatever reason, many professionals remain resistant to biologically consistent examples that pass before them. —fp

Nutrition is a constitutional requirement for patients experiencing total loss of awareness. True or false?

a. True

b. False