Hope I'm not coming off self-righteous. I dealt with this issue when my Mom died after a terrible accident and a month in a burn unit. It was very painful. I might be wrong about Michael and the rehab therapy. If so I apologize and I mean no personal judgements about the husband or any particular glorification of the parents. I don't know any of them personally.
I don't think that Max directed his remark in your direction at all. I appreciated your posting of Marta's article. Marta Russell herself says, though, that "[i]n the end the Shiavo bill only applies to her!" ("Bush's Smokescreen," March 24, 2005). So, the institutional, economic, and cultural problems may be best addressed without them being unnecessarily tied to the exceptional case of Terri Schiavo.
At 8:57 AM -0800 3/25/05, adrienne lauby wrote:
There is a great financial incentive for institutions to cut off care. This makes this case problematic as a media frame of "persistent vegetative state" means a diagnosis that makes it okay to starve someone.
The Schiavo case doesn't turn on her ability to pay: "Schiavo resides at a nonprofit hospice that has assumed part of the cost of her care. Medicaid pays for the rest. According to this AP story, keeping her alive costs about $80,000 per year, and at least $350,000 of the malpractice settlement awarded to Schiavo and her husband in 1992 has been spent on her care. Florida Medicaid normally offers hospice coverage for those with a life expectancy of no more than six months, but Schiavo has received assistance from the state for the last two years" (Daniel Engber, "The Terri Schiavo Roundup," <http://slate.msn.com/id/2115064/>, March 18, 2005). Recall that it is neither the hospice nor Medicaid that wants to end tube feeding. The conflict is between Terri Schiavo's husband and parents, who had diametrically opposed conceptions of what she would have wanted done (I assume that both love her very deeply).
Aside from the Schiavo case, as far as the decision to tube-feed or not to tube-feed is concerned, there may be an opposite financial incentive, more often than not.
According to Susan L. Mitchell, Dan K. Kiely, and Muriel R. Gillick's article "Nursing Home Characteristics Associated with Tube Feeding in Advanced Cognitive Impairment"(Journal of the American Geriatrics Society 51.1, January 1, 2003), which studied nursing home residents aged 65 and older with "advanced cognitive impairment," among the factors associated with "greater use of tube feeding" is "higher proportion of Medicaid beds," "a lack of specific directives against tube feeding," and "nonwhite race." Other things being equal, poor people of color are more likely to be tube-fed than hand-fed (p. 75).
For the disabled due to their age, greater use of tube feeding may be even harmful: "nursing home residents with major aspiration do not stop aspirating when a feeding tube is placed. Moreover, tube-fed aspirators have been shown to be more likely to die from pneumonia than aspirators who are not tube fed" (p. 78).
At 8:57 AM -0800 3/25/05, adrienne lauby wrote:
Cultural -- in terms of the stigma and fear around disability. That's the issues I don't see widely discussed about this specific situation which is currently so media saturated, we discuss people as stereotypes -- which I slipped into when talking about Terry's husband.
There is a social and cultural problem of discrimination against the disabled, but it doesn't look as though patients' family members and doctors were all rushing to discontinue tube feeding prematurely. If anything, the most prevalent feeling is probably the opposite: to place a feeding tube unless there is the patient's advanced directive not to have one placed:
<blockquote>Despite an extensive bioethical literature arguing that the use of feeding tubes is not mandatory3,4 and despite the opinion by a majority of the Supreme Court justices that artificial nutrition and hydration constitute a form of medical care,5 family members repeatedly state that they cannot let a relative "starve to death." They often feel they have no choice but to authorize the placement of a feeding tube.6 Furthermore, many physicians are either unfamiliar with or unpersuaded by the bioethical arguments or the law. A study of 1446 physicians and nurses found that 34 percent of the respondents who were medical attending physicians and 45 percent of those who were surgical attending physicians believed that even if all forms of life support, including mechanical ventilation and dialysis, are stopped, nutrition and hydration should always be continued.7 As a result, when patients with advanced dementia start to have difficulty swallowing or lose interest in eating, as happens frequently in such patients,8 the decision is often made to insert a feeding tube. Percutaneous endoscopic gastrostomy tubes are being used with increasing frequency. In 1995, gastrostomy tubes were inserted in 121,000 elderly patients in the United States9; approximately 30 percent of these patients had dementia.10
(Muriel R. Gillick, "Rethinking the Role of Tube Feeding in Patients with Advanced Dementia," New England Journal of Medicine 342.3 [January 20, 2000], <http://content.nejm.org/cgi/content/full/342/3/206?journalcode=nejm&minscore=5000&qbe=nejm%3B336%2F23%2F1671&searchid=1111758233443_2173&FIRSTINDEX=0&minscore=5000&journalcode=nejm#R16>)</blockquote>
What is most tragic is that restraints are often placed on disabled patients with advanced dementia or another form of advanced cognitive impairment, because they tend to yank out feeding tubes:
<blockquote>The most serious potential adverse consequence of tube feeding is the need to restrain the patient. A patient with advanced dementia does not have the cognitive capacity to understand why a tube is protruding from the abdominal wall and often pulls it out. To prevent the patient from removing the tube, the physician frequently orders the use of restraints. In one study, 71 percent of patients with dementia who had feeding tubes were restrained, regardless of the type of tube used.30 Even with educational programs designed to reduce the use of restraints in nursing homes, the presence of a "treatment device" such as a gastrostomy tube was associated with the use of restraints.31 The experience of being tied down is distressing, even to persons with severe dementia, and it often results in agitation, which in turn may lead to the use of pharmacologic sedation.32 In summary, data collected over the past decade suggest that gastrostomy tubes are not necessary to prevent suffering and may actually cause suffering.
(Muriel R. Gillick, "Rethinking the Role of Tube Feeding in Patients with Advanced Dementia," New England Journal of Medicine 342.3 [January 20, 2000], <http://content.nejm.org/cgi/content/full/342/3/206?journalcode=nejm&minscore=5000&qbe=nejm%3B336%2F23%2F1671&searchid=1111758233443_2173&FIRSTINDEX=0&minscore=5000&journalcode=nejm#R16>)</blockquote> -- Yoshie
* Critical Montages: <http://montages.blogspot.com/> * Greens for Nader: <http://greensfornader.net/> * Bring Them Home Now! <http://www.bringthemhomenow.org/> * OSU-GESO: <http://www.osu-geso.org/> * Calendars of Events in Columbus: <http://sif.org.ohio-state.edu/calendar.html>, <http://www.freepress.org/calendar.php>, & <http://www.cpanews.org/> * Student International Forum: <http://sif.org.ohio-state.edu/> * Committee for Justice in Palestine: <http://www.osudivest.org/> * Al-Awda-Ohio: <http://groups.yahoo.com/group/Al-Awda-Ohio> * Solidarity: <http://www.solidarity-us.org/>
