COMMENT: by John J. Billings MDNews Weekly
Allowing nature to take its course is not euthanasia
, May 3, 2003
Reading the article entitled "Euthanasia: Tribunal orders death by starvation" (News Weekly, April 5, 2003), in comparison with the decision of the Victorian Civil and Administrative Tribunal, indicates that your author was handicapped by having very little information about the reasons which led to the decision that was made.
Various small extracts were published by the newspapers of the "Summary of Decision and Reasons for Decision", but no truly comprehensive account of the problem was provided.
The Summary was a fair analysis of a larger document which contained discussions of many matters judged not to be relevant. The reasons for decision is the only authoritative statement for consideration.
Before any evidence of the onset of Pick's Disease, the patient and her husband had discussed together and sometimes with the two eldest daughters, as to whether they would want their lives to be prolonged if they ever developed incapacity; they all expressed the opinion that they would not wish to live any longer if such serious disability ever occurred.
The husband and all six children now support the idea that the mother should be allowed to die, although one son mentioned that if he thought that his mother could get better (which is impossible) he would have a different view.
The matter concerned was an application to the Tribunal for a guardianship order by the husband of a woman now almost 70 years old. The woman herself cannot make decisions regarding her medical treatment. In 1994 she had been diagnosed with Pick's Disease, a form of dementia and she has now reached the terminal stage. Pick's Disease is of unknown origin but can be diagnosed by demonstration of progressive wastage of the frontal and temporal lobes of the brain on both sides.
As the woman's condition progressed she was admitted to a nursing home about three years ago and there she received full nursing care. A considerable time before she was admitted to the nursing home a surgical operation had been performed to provide nourishment and mild sedation, because for some time she had become unable to communicate, to move or to take any food or liquid by mouth.
The surgery was carried out on the abdomen (which is not the stomach) in order to gain access by an incision in the abdominal wall to the abdominal cavity. The organ which is correctly named the stomach is located at the upper end of the gastro-intestinal tract within the abdominal cavity, just below the diaphragm, so the tube which was to carry the nourishment from outside the abdomen could be directed across the abdominal cavity and then inserted through an incision into the stomach.
This operation was performed between 5 and 7 years ago, since when all the nourishment had been injected into the stomach in this way.
Because she is unable to swallow any food or fluid given by mouth, she is doubly incontinent, that is of bladder and bowels, and spontaneous emptying of these organs occurs through the action of spinal reflexes. As a result the patient now requires to be moved by a hoist to the shower and after cleaning there is an application of pads, to protect her skin as far as possible.
She requires regular avoidance of pressure, having previously developed some pressure ulcers which were healed as a result of the excellent care she had received in the hospital; they remain a threat of recurrence as a result of her continuing deterioration. She has no cognitive capacity at all and appears to be unable to appreciate any painful stimuli. She is incapable of any movement but will follow with her eyes anyone who comes to her bedside.
There is no treatment known that has any curative influence upon the progressive deterioration which occurs in Pick's Disease until the patient dies. The performance of the operation and the continual use of the aperture made in the abdominal wall to deliver nourishment and sedatives to the stomach takes the treatment beyond the range of what is called Palliative Care.
This was clearly understood by all those who participated in the discussions regarding management of the present situation, just as it was as clearly understood that the discussions were in no way a consideration of euthanasia.
Withdrawing burdensome treatment which has no useful influence upon an incurable disease is not euthanasia.
Discussions have now occurred between this devoted husband and a public advocate regarding a guardianship order with respect to the patient, and the husband stated that he would be agreeable to this authority being given to the public advocate as they had found that their opinions were in agreement, each with the other. If the nutrition and fluid administration were discontinued, the mild sedation could be continued and it is unlikely that the woman would be conscious of any serious discomfort.
The valid conclusion to be made is clearly that which the woman had made many years ago and with which all the members of the family now agree, that it would be a mercy to release her from her undignified and grave incapacity by discontinuing the tube feeding and allowing her to die.