Terminal Patients Need Facts About DNR, Tube Feeding

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

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

She stressed that when discussing Do Not Resuscitate orders, "itis very important to let the patient or loved one know that going withoutCPR will allow death to occur peacefully and naturally."

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

Dr. Ahronheim said that the respirator and accompanying treatments canbe uncomfortable, but, she pointed out, many patients are sedated duringthis time, either intentionally with medication to keep them comfortableand keep their breathing synchronized with the respirator, or naturallybecause 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 patientis 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 preoccupiedwith thoughts of dying and fear having the respirator disconnected.

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

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

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

Four Common Myths About Tube Feeding

With few exceptions, she said, there is little evidence that tube feedingprovides comfort to dying patients. "In most cases, a patient willbe more comfortable if food and fluids are given according to his or herdesire," she said.

Tube feeding also has many potential side effects and is often verypoorly tolerated, she said. Theoretically, nasogastric feeding could impairswallowing 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 reliableinformation that tube-fed patents do better or worse than impaired spoon-fedpatients, and a review of the literature fails to demonstrate any evidencethat any form of tube feeding reduces the risk of aspiration pneumonia.

Forgoing artificial nutrition and hydration at the end of life willnot lead to a painful death, Dr. Ahronheim said. Rather, it is consistentwith 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.