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Sep 17, 2009, 9:31 AM
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By Dr. Michael Gordon
I was the on-call covering physician. The medical resident was bringing me up to date. I could see from the corner of my eye a middle-aged woman and her two young adult children looking in our direction. She came over and asked if we would have time to speak to her about her mother. After we finished our rounds, we met the family in the quiet room.
“When do you think the swallowing study will take place?” the woman asked. “I know it is the holidays, so I guess it could be a few more days.”
I knew from the discussion I’d had with the resident that the issue here was one of recurrent aspiration pneumonia, which means the contents of food and what is normally in back of the mouth enter the lungs and cause pneumonia. Although each pneumonia episode might respond to antibiotics, there are often recurrent bouts of infection because the underlying condition causing the pneumonias is often difficult to treat and each infection is a step in the direction of the final fatal illness that no longer responds to treatment.
The ill person often suffers from a neurological disorder such as strokes or late-stage dementia. It is very unlikely that the swallowing mechanism will improve substantially. In order to confirm that there is a severe swallowing disorder, one does a swallowing study in which X-ray contrast material is swallowed, and if it goes into the lungs rather than the esophagus, the risk of aspiration is confirmed.
If this is found, the usual recommendation is to insert a feeding tube directly into the stomach so that nutrition can be provided without the risk of the food being inhaled and causing aspiration pneumonia again.
I asked the woman’s daughter, “Have you ever discussed with your mother or with your father [who we learned was cognitively aware and living at home] whether she would want a permanent feeding tube if she were not able to eat?”
As I expected the answer was, “We would never have discussed such an eventuality.”
I said, “Even in the absence of direct discussions, from knowing your mother’s values, what do you think she might have said to that prospect?”
“I do not know, but my father seems to be going in the direction of stopping the suffering and letting nature take its course.”
I continued, “If you really believe that putting in a feeding tube is not what she would have wanted and your father would perhaps be the best judge of that, then doing a swallowing study may not be necessary. No matter what is found, you will have already decided that a tube is not what she would want.”
I could see that this discussion was not one that they had contemplated. “If the decision is that a tube will not be used, then we can decide to do our best to feed her whatever she can tolerate and focus on making her comfortable, rather than pursuing all modern medicine’s technological possibilities such as X-rays and feeding tubes,” I said.
From the point of view of law and of ethical principles, not putting in a tube and withdrawing a feeding tube are the same, but in general people react differently to the two acts – one seems to be accepted as a rational choice, the other an act tantamount to “killing.”
I asked the daughter and her children to have that deeply meaningful conversation with their family and consider their choices before making a final decision.
These are not easy decisions, but if done with thought and care, they can ease the decision-making process.
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Dr. Michael Gordon is Medical Program Director, Palliative Care Baycrest Geriatric Health Care System in Toronto, Canada and Professor of Medicine, at the University of Toronto. He is co-author with Bart Mindszenthy of Parenting Your Parents.
Parenting Your Parents is available in bookstores and online at: Indigo-Chapters, Amazon and Barnes & Noble. It is available in a US edition: Parenting Your Parents: Support Strategies for Meeting the Challenge of Aging in America.
For bulk orders email info@dundurn.com. Call: 416-214-5544 or Fax: 416-214-5556
Dr. Gordon is the author of the engaging memoir Brooklyn Beginnings: A Geriatrician's Odyssey, published by I-Universe.
Brooklyn Beginnings is available in bookstores and online at: Indigo-Chapters, Amazon.ca, Amazon.com, Barnes and Noble and I-Universe
Visit Dr. Michael Gordon's website.
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