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Wednesday, August 4, 2010

Comfort food

I haven't decided what I think yet about the idea of "comfort feeding" rather than using a feeding tube.  Comfort feeding refers to giving normal food and drink by mouth to someone unable to feed himself, up to his tolerance for the process and the ability to swallow without choking.

Employed in patients with advanced Alzheimer's disease, whose brains are degenerating to the point of them forgetting how to eat and drink, it appears to be a way of providing comfort, nutrition and hydration that does not distress the patient or require sedation or restraints.  It enables the caregiver to feel like she's not starving or dehydrating Dad to death, while at the same time providing direct nurturing care to a loved one.  It would be used instead of a feeding tube.  The tolerance level of the patient, though, virtually ensures that too little nutrition and hydration are given.

The feeding tube has the advantage of ensuring that the patient receives adequate nutrition.  It has the disadvantage of being very uncomfortable and restrictive for someone in the last weeks or months of life as a terminal disease inexorably progresses.

The ethical question for the caregivers -- the patient's loved ones and the health professionals -- is whether their responsibility to the patient involves feeding or nutrition.

The statement by the US Catholic Bishops cited in the article suggests an obligation to nourish and to hydrate the patient.  The NYT points out, however, that feeding tubes do not necessarily prolong life.

The logic is clear: Is there a moral obligation if the outcome -- longevity -- does not improve?

Outcomes are only part of the equation, however.  Human beings need water and nutrition.  These are necessities, not means to any particular end other than to provide what every human being needs without depriving them.  The ability of hydration and nutrition to prolong life seems irrelevant: As long as the patient lives, he needs hydration and nutrition, and we have a duty to provide him with what he needs.

Comfort feeding almost seems more like it comforts the caregiver more than the patient.  I am also concerned about the slippery slope: If food and drink are given in accord with the patient's tolerance to eat and drink, at a certain point it becomes frustrating to continue to give food, whether it be "right now" at a given feeding, or day after day after day. Caregivers can easily give up when they ought to persist, and over years and years with this policy, it eventually morphs into a pro-forma "I tired to give him food but he wouldn't take it so I didn't force him" -- at the slightest resistance -- and then, eventually, getting to the point of asking, "Why bother even trying?"

And, by the way, since when are Alzheimer's patients competent to determine their own care?

I appear to be arguing myself out of comfort feeding, and I have to admit, it makes me, well, uncomfortable.  But I haven't decided yet.

This I know: There is no wrong in giving someone adequate hydration and nutrition.  It's a matter of how best to do that. Each way appears to do well in some respect while falling short in another, albeit in opposite ways.  I need to think about it some more.

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