At the Bedside

In Must We Preserve Life? (4/19), Ronald Hamel and Michael Panicola present a forthright and cogent summation of the church’s traditional teaching on nutrition and hydration, drawing particular attention to the subtle, and now not-so-subtle, attempts of some to restrict this teaching narrowly during the last 20 years.

Must we preserve life? Each human life is sacred, given dignity by the Creator’s hand, and therefore always and everywhere to be preserved as unique and precious.

Central to this dignity, however, is the belief that the same Creator’s hand will raise up this mortal body to new and eternal life. Human life therefore is understood in the continuum of life here and life hereafter. This then becomes the primary context for our ethical analysis and the implications for care of the sick and dying.

There comes a time when the healing process ends and the dying process begins. Unfortunately there is no clear line of demarcation for this. But there iswith best medical judgment, in consultation with a team of holistic health care providers and with respect for the patient’s wishesa way of determining when this shift appears to be happening, and then of appropriately responding with care by either natural or artificial means.

Artificial nutrition support, whether by means of intravenous catheters or by feeding tubes into the gastrointestinal tract, is a medical therapy. The therapy has greatly evolved over the last 40 years and continues to evolve today. But make no mistake, the physical placement and maintenance of such devices, and the provision of refined nutrients, requires a high level of clinical skill in order to initiate this therapy safely and avoid harm to the patient. The choice of which approach is taken is based on the route of administration that will mostly like be assimilated, irrespective of the patient’s condition.

The decision to initiate and/or withdraw nutrition support is a difficult decision, but should be guided by prognosis. Patients with a prognosis for survival of less than three months, for example, might benefit from a nutrition support intervention that provides limited quantities of nutrients, with a principal emphasis on maintaining fluid and electrolyte (sodium, potassium, etc.) balance. For other patients with a somewhat longer or uncertain prognosis, but nonetheless an ultimate terminal outcome, the same approach may be considered. Alternatively, consideration may be given to complete nutritional support in this setting, when the shift from a healing to dying process is not certain. The decision to intervene is not diagnosis-specific, but rather prognosis-specific, and offered in a manner that preserves the dignity and comfort of the patient and significant others. Initiating nutrition support may occur prior to the final prognosis, but should not preclude its subsequent withdrawal.

Both of us, a clinical researcher and a chaplain, stand on the side of the bed holding not only the technology to assist in the healing or dying, but also the hand of the one we are helping in their healing or dying. Both of us are concerned with the physical and spiritual sustenance the person needs either to gain strength toward healing or to provide comfort in dying.

When we are in a healing process, nutrition and hydration can be physically administered in such a way as to strengthen the person toward recovery. Similarly, out of our sacramental tradition, we administer the Eucharist as food to strengthen the person and fortify him or her spiritually in the journey toward healing.

But when we are in the dying process, nutrition and hydration, whether administered artificially or in the normal course of attentive care, is offered in such a way as to bring comfort to the persona different kind of carein the last part of their journey. In like manner, we administer the Eucharist as the last sacrament, known as viaticumlikewise a different kind of care: food for the journey to the life hereafter.

Prior to the technological advances that have proved to be both benefit and burden, human beings in the home setting naturally followed the process of caring and being cared for, in being nurtured back to health or being nurtured through their dying. As history shows, there were always ethical concerns. But it seems there was a fundamental respect for the difference between the healing process and the dying process. Food and water were given and received in both instances, but always with careand with the appropriate means.

David F. Driscoll