Is feeding tube/TPN required?


#1

A woman is dying. She has stopped receiving most medical treatment, although that would resume in the unlikely event that she became stronger. She does not wish to receive food via a feeding tube or catheter, but does want to live in accord with the teachings of the Church. She is awake, alert and able to converse most of each day.

Her immune system is extremely impaired, so that there is a significant risk that total parenteral nutrition would result in a rapidly fatal infection. But dental problems make it painful to eat and she is starving. I do not believe that TPN would add more than a couple weeks to her life, but I hold onto the slender hope that with better nutrition she would regain enough strength to resume treatment.

What does the Church say for a case like this? Can you point to some authoritative document?


#2

No one is required to use a feeding tube for any reason if they regard it as something they could not bear. I do not know what TPN is. The rule is that we are never required to use extraordiary means for any reason, at any time. That would include financial as well. If she has been diagnosed and is dying, I would try to make her feel comfortable with her decision. And you should feel comfortable as well. How do you think people coped with death before all these modern methods? They accepted death as a normal pattern of life, they did what was possible to make the dying comfortable and that was that.

Linus2nd


#3

The body of a person who is in the process of dying starts shutting down bit by bit, so there comes a point where feeding the person is not helping and could actually cause pain. Any particular situation ought to be discussed with a god priest, well-versed jn these issues (perhaps a hospital chaplain receives special training?).

If she is allowing death to occur naturally rather than attempting to hasten it, then as a general rule, that would be ok. Also, the fact that the benefit of feeding is outweighed in her case by the possibility of infection would contribute to its being moral.

I am speaking very generally here, as I am just a random person on the internet with no knowledge of the actual particular situation.


#4

Use of a feeding tube is considered ordinary care, not extraordinary. This does not mean that it is always mandated, but refusal or withdrawal is treated differently in moral theology than is, say, chemotherapy or transplant surgery.


#5

I just completed “My Five Wishes” living will on-line this morning so my last wishes about such issues are known to my family and healthcare providers. I encourage everyone to have a living will or advanced medical directive.


#6

Contact the National Catholic Bioethics Center for guidance on these specific circumstances.


#7

I find it a bit overwhelming to search the Vatican’s official website, but If you scroll down on this link and go to #471 it will give you an idea on where to start with your question:

vatican.va/archive/compendium_ccc/documents/archive_2005_compendium-ccc_en.html#The Human Community

When death is considered imminent the ordinary care owed to a sick person cannot be legitimately interrupted. However, it is legitimate to use pain-killers which do not aim at in death and to refuse “over-zealous treatment”, that is the utilization of disproportionate medical procedures without reasonable hope of a positive outcome.

In my personal Catechism, Part III, Article 5, Section 1, **CC2278 **states:

“Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of “over-zealous” treatment. Here one does not will to cause death; one’s ability to impede it is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected.”


#8

With regard to the above,

I have read what seems to be conflicting ideas on when it is appropriate to refuse end-of-life care, and you might receive differing opinions on this. I can only provide my own understanding of CC teaching:

With regard to the woman of whom you speak, there are a few important factors and questions to consider:

  • Though she may be “awake and alert”, is she mentally competent to make decisions for herself?

  • Is her illness fatal; as in, does she suffer from a prognosis in which her situation is irreversible? You say that she is dying, but that doesn’t necessarily point to whether or not imminent death is due to factors which are beyond the control of medical personnel.

  • You say that her immune system is extremely impaired. As it relates to CC2278 “Discontinuing medical procedures that are. . . dangerous. . . . or disproportionate to the expected outcome can be legitimate”. In the situation you described, there is indeed elevated risk of infection that comes with any sort of invasive procedure done toward an immunocompromised patient. So the question I would ask myself is “will life-extending measures be likely to worsen her situation?”

(Just as a side note: TPN (total parenteral nutrition) is not quite the same thing as what many people envision when they think of a “feeding tube”. Ideally, a person requiring long-term feeding would undergo enteral nutrition, which makes the use of the gastro/intestinal tract instead of the venous system. TPN is typically recommended for people whose digestive systems can’t support feedings, such as those with bowel obstructions or inflammatory diseases, etc. It’s often used for emergent situations, and comes with its own potential risks. )

  • Her presumed future quality of life is also to be taken into consideration, as per my understanding of the term “burdensome” and “without reasonable hope of a positive outcome”. Will she be in a better or more uncomfortable position than before if she accepts the suggested treatment?

I want to make it clear that I’m not giving any advice here, and I’m only offering my take on the Catechism’s directives. The woman of whom you speak would have to discuss this with her doctor and an informed theologian.

I couldn’t tell if your post is hypothetical or if it reflects a current reality. If someone you know if suffering from this, I offer a sincere prayer for you and her.


#9

Withholding food and water (through the feeding tube or TPN) is serious.

Feeding someone is normal. If they start having serious issues with reflux or something similar with a feeding tube, it could rise to being overly burdensome.

Many people have conditions that are not going to get better, but are not immediately fatal. Causing them to starve as a way to hasten death is not right.


#10

Feeding someone by feeding tube is not normal. It can be considered ordinary care but that doesnt mean its a normal way to treat a dying person who has loss of appetite or trouble swallowing. TPN is not typical end of life care. JP 2 had temporary nasal feeding tubesone or twice but when he died he was not receiving any tube feeds.

So to answer the original question it ok not use TPN and to decline surgery for a feeding tube to be installed if the pt is terminally Ill


#11

Thank you to each of you. I will read each of your answers carefully, and more than once. I am talking about a real person, my closest friend, who I love like a sister. Her mind is fuzzy at times, but she is still competent to make decisions for herself, especially given time to think things over, and she has been thinking about this for the last couple of months. The only thing that would change her mind is evidence that her decisions are out of line with what the Church teaches.

At the present time she can still swallow and digest food, and sometimes enjoy it. Just last Saturday, she was talking cheerfully about the food she was looking forward to eating when she got out of the hospital. But then eating became very difficult this week because of a dental problem that could not be treated due to her low platelet and white blood cell counts. She has had recurring problems with nausea the last few months, both because of cancer and chemotherapy.

I think that she would be less disturbed by TPN [IV feeding] than by a nasogastric tube. She probably won’t get either, though. I haven’t even been able to get her to try drinking Ensure (sort of a vitamin-rich milk-shake). I have only mentioned this other stuff very briefly, and won’t again, unless I have something definitive to offer. Her odds of recovery are not good. Her nurses talk about hospice, and quality of life, rather than a cure. If she were just stronger, there are more treatments that could be reasonably tried. But she keeps getting weaker, in part from prolonged malnutrition.


#12

I understand that in order to avoid euthanasia, you have to continue to give her fluids - IV fluids, because without these she would surely die. As for the TPN, this can be continued if her body allows it - either by an NG tube or IV, and I would think that it should be. The issue is that if the TPN is discontinued, she must still receive fluids continuously in order to avoid euthanasia. That is my understanding.


#13

It’s not *quite *that cut and dry (there are extenuating circumstances in which feedings can be rejected), but the OP’s recent post does provide some encouragement - that she was until recently able to swallow and digest food.

TPN isn’t done via an NG tube; TPN goes through the venous system only. Parenteral nutrition means that the feeding is going directly into the bloodstream and completely bypassing the entire gastro-intestinal tract. An NG tube is a catheter that goes directly from the nose into the stomach.

No, not necessarily. Her priest must advise her on this with regard to his understanding of the medical advice she is given.


#14

Not when death is imminent. From the Catholic Medical Quarterly
" Hydration and nutrition are essential to all human existence. Therefore, access to food and water is a basic human right. Doctors, relatives and carers have a corresponding duty to provide patients with such sustenance. This basic form of care is not considered ethically obligatory where:

(a) the patient is actually dying, when the provision of tube feeding might be considered unduly intrusive and unnecessary. (Death from dehydration may take a few weeks, which is immaterial to the patient facing imminent death).

(b) where the means of providing adequate nutrition might be unduly hazardous, as in the second case report. Nevertheless, neither of these exceptions removes the duty to care for the dying or severely handicapped and to relieve mental and physical distress. "

cmq.org.uk/CMQ/1998/Tube_Feeding.html


#15

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