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  • Tom asks, "Is it ethical to remove a feeding tube, even to prevent further suffering? Isn't this euthanasia?"
  • Dear Tom,
  • Your concerns about euthanasia versus preventing suffering are similar to those that I've heard physicians and members of the clergy debate many years ago. I have sat through so many hours of ethics discussions on this over so many years that it is difficult to condense it all into a few paragraphs. It is not at all surprising that you have concerns also.
  • Very few members of the medical community would be willing to participate in euthanasia, even if legalized, no matter how much they might sympathize with the suffering of the individual requesting it. Euthanasia is the deliberate ending of life with a drug or device that has no other purpose but to cause death. Doctors will, and should, do all in their power to relieve suffering. That is quite different from deliberately ending a life. Over the years it has gradually become accepted that God did not necessarily mean people to suffer. Slowly it became okay to provide relief from the pain of childbirth. Yes, there was a time when the bible was interpreted to prove this was wrong. Then this was extended to relieving the pain of someone dying from cancer. As their pain increased so did the need for medication. A few rigid health care providers protested, "But they will become addicted!" As if this could be a legitimate reason to ignore suffering in someone with only a few months to live! Concerns about addiction are no longer an excuse for not relieving pain.
  • The next barrier to break was providing enough medication to relieve pain even if that medication also started to compromise breathing. It took years to get past that concern. It is now accepted that the relief of pain in the TERMINAL patient is always the primary goal. If that compromises breathing, it is a secondary result, not primary, and so is acceptable, even if it possibly hastens death.
  • Finally, of great interest to all of our readers, medical science now recognizes the shortness of breath of end stage patients dying from emphysema or other lung diseases as a form of pain. This step took a long time, or so it seemed to those of us working for its recognition. Now patients at the end of their life span with emphysema no longer need fear suffering with severe shortness of breath, even though the medication used to prevent it also may compromise their already limited ability to breathe. The irony of this accomplishment has been that these patients often now live longer and more comfortably with regular doses of morphine or similar drugs ... drugs that supposedly make their breathing "worse"... than they did when they suffered severe shortness of breath without these drugs.
  • As these goals were accomplished, we had to start working on giving our patients the option of coming off of life support when there was no chance for any improvement or a meaningful life. This is commonly known as "pulling the plug". I cannot begin to tell you the fear my patients used to express in pulmonary rehab that they might be put on a ventilator and never get off until they died months later. For this reason, many refused even temporary ventilator assistance of a few days to recuperate from an acute infection. They died rather than taking the chance that ventilator support might be needed permanently, despite the possibility that temporary assistance might have enabled them to live good lives for years longer. Now that any patient has the right to request removal of the ventilator, this fear no longer need exist. Now even severely compromised patients are willing to "try it" for a few days, knowing they can be taken off at any time they desire it.
  • Finally it was also accepted that in some cases IV's, antibiotics and feeding tubes were also artificially extending life. When the terminal patient finally decides to be taken off the ventilator to die peacefully we have again seen a great irony. Many patients actually improve for a few days, or even longer, when first taken off the ventilator that was supposedly necessary for life. With the assistance of small doses of morphine to relieve their shortness of breath, they are often able to rest comfortably and quietly, and to peacefully say farewells to their families. They no longer suffered the frustration of trying to communicate around the intubation tube and over the noisy ventilator.
  • We were not put on this earth to live forever. In very few countries other than the United States is artificial extension of life continued for any length of time after it is determined that nothing can be achieved. Removing artificial support is not a decision made lightly or quickly. Various tests are required to document that the patient is terminally ill OR wishes this done. Depending on the individual case, several doctors may be called in to concur in their interpretation of the physical exams, CT scans, EEG's etc. The extent of this varies with the individual diagnosis, the age, previous advanced directives, as well as family disagreements. It was a simple, uncomplicated decision for my 92-year-old mother, who was terminally ill. A few weeks earlier she had flatly refused a feeding tube. She had clearly written advanced directives and a family who supported her wishes.
  • It is often very difficult for a family to accept that the end is near. They beg their loved one to "hang on" It is painful beyond words to give that loved one permission to stop fighting and to sleep in peace if that is what is wanted. People have been dying quietly since the beginning of time. I would like the same for myself. I do not want any of the miracles of the 20th and 21st century keeping my body alive with "heroic measures" month after month when nature has decreed it is time to go. However, this is a decision that each of us is able to make for ourselves, no matter what your state on consciousness might be at that time. You can still remain in control of your body and the decisions made about it if you complete an Advanced Directives.

  • Do you have a question about respiratory disease that has been bothering you? If so, feel free to write and ask us, either through our web site or by mail. We answer all of your letters.