Food and the Dying Patient
The
patient had dementia and could no longer swallow. The intricate
workings of the muscles of her throat were failing, and she was no
longer able to move food or liquids reliably into her stomach. Instead,
they too frequently ended up in her lungs, and she drowned a little more
with every swallow. She was admitted to my intensive care service with
pneumonia from aspirated food that had turned the bottom part of her
left lung into a wet sponge. Her blood oxygen levels had dropped so low
that we had to support her breathing by inserting a tube.
Now, after she was on
powerful antibiotics and life support for three days, her oxygen level
had improved and her fevers had abated. She was getting better, in a
manner of speaking.
This pneumonia was her
third, and easily her worst, in four months. This pattern is typical of
end-stage dementia, when patients lose control of their swallowing
mechanism and often die from the pneumonias that result from food
lodging in the lung. Usually, these patients have gone in and out of the
hospital through a sort of revolving door; as soon as one pneumonia is
chased away by antibiotics, another emerges.
Our medical system
deals well with organ dysfunction. When a kidney isn’t working, we can
clean blood with a dialysis machine. When a person can’t breathe, we can
push air into the lungs. And if there is trouble swallowing, we can
bypass the throat with a feeding tube that goes through the abdominal
wall directly into the stomach.
That last option had
been offered to this patient’s family when she was admitted to the
emergency room. “If she makes it through this, she could get a feeding
tube so that this doesn’t happen again,” they were told. And so now that
she was improving, her family was asking for the tube.
But contrary to
popular belief, a feeding tube does not prolong life in a patient with
dementia. It actually increases suffering. A stomach full of
mechanically pumped artificial calories puts pressure on an already
fragile digestive system, increasing the chance of pushing stomach
contents up into the lungs. And surgically implanted tubes are a setup
for complications: dislodgments, bleeding and infections that can result
in pain, hospital admissions and the use of arm restraints in already
confused patients. But maybe most important, the medicalization of food
deprives the dying of some of the last remnants of the human experience:
taste, smell, touch and connection to loved ones.
So why do so many demented patients die with feeding tubes?
Food is how we know
best to care for one another, from breast to deathbed. And thus it runs
contrary to every impulse we have as humans to stop feedings. As a dying
person becomes unable to process food on her own, our tendency is to
plug life into her with a tube pumping artificial nutrition.
Since the beginning of
time, humans have fed their dying by hand. Spooned slowly so as not to
overwhelm, a trickle of broth or a favorite food ground up to taste may
be the last small pleasures for a dying body.
But hand feeding has
increasingly become a quaint piece of human history. We fed until they
would take no more, and knew that we had done everything we could. But
with the feeding tube, we can, and feel we must, keep going. Patients
frequently die with plastic tubes weaving mysteriously under their
gowns, entering bodies at unnatural angles, rendering them a little more
alien to us. Those who are most needed sit a little further away from
the bed, afraid to dislodge tubes that are supposedly keeping their
loved one alive. And the patient’s mouth will usually remain dry and
empty until the end.
My last conversation
about the patient’s feeding took place on my way to my car Friday
afternoon. The patient’s sister was walking in as I was walking out. She
thanked me for the care I’d provided and told me they had decided to go
with the tube. “I couldn’t not feed her,” she said. “I can’t leave her
starving.”
The next day, my
patient was wheeled down to the operating room for her feeding tube,
then a few hours later wheeled back to intensive care. Over the next
couple of weeks, her sister sat on a chair beside her most days, wearing
the requisite paper gown and gloves for guests of patients with
resistant bacteria from prolonged hospital stays. She sat off to the
side, separated from her sister by tubes, bedrails and the bustle of
activity around them.
But the patient never
went home to her sister and their beloved soap operas. She died two
weeks later in the intensive care unit, a different pneumonia in her
lungs.
In the face of death,
food and hope are highly seductive. But once again, I was left
wondering: Does our need to feed our dying loved ones blind us to what’s
really best for them?
Jessica Nutik Zitter
is an attending physician at Highland Hospital in Oakland, Calif. She
is board certified in critical care and palliative care medicine.
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