I have been on vacation in Europe for the last two weeks, doing my best to forget the culture of death. But it hasn’t been easy. I have been barraged by readers and media about questions of how and why Casey Kasem can be denied tube feeding.
This can be a delicate and highly nuanced matter, dependent on the fact circumstances of each situation. Moreover, I don’t want to comment on his particular case because I don’t know all the facts. Pay attention to the italicized part of the CNN story I quote below:
He’s suffering from dementia and bedsores, and his body is shutting down at a hospital in Washington state, court documents say. On Wednesday, a Los Angeles County judge gave daughter Kerri Kasem the authority to have doctors end his infusions of water, food and medicine.
The ruling reinstates the 82-year-old’s end-of-life health directive. Kasem doctor concluded that continuing the artificial nutrition and hydration would only “at best prolong the dying process for him and will certainly add suffering to an already terribly uncomfortable dying process,” said Kerri Kasem’s lawyer, Troy Martin.
The key factual and ethical question here is whether his body is shutting down as part of the natural dying process. In that situation, people often stop eating and drinking spontaneously. In such cases, it can be medically inappropriate to force sustenance into a body that can’t process it. Not knowing about Kasem’s individual circumstance, I will not opine about his particular case.
Second, if Kasem’s advance directive said he did not want tube-supplied food and water under these circumstances–whatever we each might think of the morality of that–he had the legal right to so instruct because tube-feeding is considered a medical treatment.
But let’s look at the broader issue. There has been increasing advocacy of late to deny tube supplied–or, as I have recently noted, even spoon feeding–to Alzheimer’s patients who can process sustenance. What about them?
Many bioethicists, and some doctors who treat Alzheimer’s patients, increasingly argue that these patients should be denied sustenance as a matter of supporting their best interests. I am not referring to decisions made in accordance with an advance directive, but to the increasing assertion that the standard of care should be to deny feeding tubes. From the position paper of the American Geriatric Society:
Percutaneous feeding tubes are not recommended for older adults with advanced dementia. Careful hand-feeding should be offered for persons with advanced dementia, hand feeding is at least as good as tube-feeding for the outcomes of death, aspiration pneumonia, functional status and patient comfort. Tube feeding is associated with agitation, increased use of physical and chemical restraints, and worsening pressure ulcers.
Rationale: The current scientific evidence suggests that the potential benefits of tube feeding do not outweigh substantial associated treatment burdens in person with advanced dementia.
Recommendations are one thing. Labeling feeding tubes in late-stage Alzheimer’s patients as “inappropriate care” to allow bioethics committees to impose the death decision under a “futile care” protocol is another. And that is where I think we are headed–just as we are in patients with long-term diagnosed persistent unconsciousness.
So, I can’t say whether Kasem is a new Terri Schiavo–because her tube feeding was clearly medically appropriate as she was not otherwise dying. Thus the question in her case involved “quality of life” and egregious conflicts of interest on the part of Terri’s husband.
In contrast, I can say that Alzheimer’s patients generally are being looked upon increasingly as people who should not be sustained nutritionally after a certain point, even if that is what the patient or family wants. Also, under Obamacare’s eventual cost/benefit protocols, I believe a time will come in which sustaining such patients will not be a covered procedure. Ditto, people with long-term profound cognitive disability.
Bottom line: Alzheimer’s patients in all fifty states who can process food and water are denied medically supplied food and water. Such decisions are legal and deemed “ethical” by many, an opinion with which I dissent.
Post Script: Kasem died shortly after the court ruling described above. It would thus appear that he did not dehydrate to death.