Artificial Nutrition and Hydration and the Permanently Unconscious Patient: The Catholic Debate

1. Position of the American Academy of Neurology on Certain Aspects of the Care and Management of the Persistent Vegetative State Patient

฀ 9 1 Position฀of฀the฀American฀Academy฀of฀ Neurology฀on฀Certain฀Aspects฀of฀the฀฀ Care฀and฀Management฀of฀the฀Persistent฀ Vegetative฀State฀Patient American฀Academy฀of฀Neurology I.฀The฀persistent฀vegetative฀state฀is฀a฀form฀of฀eyes-open฀permanent฀unconsciousness ฀in฀which฀the฀patient฀has฀periods฀of฀wakefulness฀and฀physiological฀sleep/ wake฀cycles,฀but฀at฀no฀time฀is฀the฀patient฀aware฀of฀him-฀or฀herself฀or฀the฀environment .฀Neurologically,฀being฀awake฀but฀unaware฀is฀the฀result฀of฀a฀functioning฀ brain฀stem฀and฀total฀loss฀of฀cerebral฀cortical฀functioning. ฀ A.฀No฀voluntary฀action฀or฀behavior฀of฀any฀kind฀is฀present.฀Primitive฀reflexes฀ and฀vegetative฀functions฀that฀may฀be฀present฀are฀either฀controlled฀by฀the฀brain฀ stem฀or฀are฀so฀elemental฀that฀they฀require฀no฀brain฀regulation฀at฀all. Although฀the฀persistent฀vegetative฀state฀patient฀is฀generally฀able฀to฀breathe฀ spontaneously฀because฀of฀the฀intact฀brain฀stem,฀the฀capacity฀to฀chew฀and฀swallow ฀in฀a฀normal฀manner฀is฀lost฀because฀these฀functions฀are฀voluntary,฀requiring฀ intact฀cerebral฀hemispheres. B.฀The฀primary฀basis฀for฀the฀diagnosis฀of฀persistent฀vegetative฀state฀is฀the฀ careful฀and฀extended฀clinical฀observation฀of฀the฀patient,฀supported฀by฀laboratory ฀studies.฀Persistent฀vegetative฀state฀patients฀will฀show฀no฀behavioral฀response฀ whatsoever฀over฀an฀extended฀period฀of฀time.฀The฀diagnosis฀of฀permanent฀unconsciousness ฀can฀usually฀be฀made฀with฀a฀high฀degree฀of฀medical฀certainty฀in฀cases฀ of฀hypoxic-ischemic฀encephalopathy฀after฀a฀period฀of฀one฀to฀three฀months. C.฀Patients฀in฀a฀persistent฀vegetative฀state฀may฀continue฀to฀survive฀for฀a฀prolonged ฀period฀of฀time฀(“prolonged฀survival”)฀as฀long฀as฀the฀artificial฀provision฀ of฀nutrition฀and฀fluids฀is฀continued.฀These฀patients฀are฀not฀“terminally฀ill.” D.฀Persistent฀vegetative฀state฀patients฀do฀not฀have฀the฀capacity฀to฀experience฀ pain฀or฀suffering.฀Pain฀and฀suffering฀are฀attributes฀of฀consciousness฀requiring฀ cerebral฀cortical฀functioning,฀and฀patients฀who฀are฀permanently฀and฀completely฀ unconscious฀cannot฀experience฀these฀symptoms. There฀are฀several฀independent฀bases฀for฀the฀neurological฀conclusion฀that฀persistent ฀vegetative฀state฀patients฀do฀not฀experience฀pain฀or฀suffering. First,฀direct฀clinical฀experience฀with฀these฀patients฀demonstrates฀that฀there฀is฀ no฀behavioral฀indication฀of฀any฀awareness฀of฀pain฀or฀suffering. Second,฀in฀all฀persistent฀vegetative฀state฀patients฀studied฀to฀date,฀postmortem฀ examination฀reveals฀overwhelming฀bilateral฀damage฀to฀the฀cerebral฀hemispheres฀ to฀a฀degree฀incompatible฀with฀consciousness฀or฀the฀capacity฀to฀experience฀pain฀or฀ suffering. Third,฀recent฀data฀utilizing฀positron฀emission฀tomography฀indicates฀that฀the฀ metabolic฀rate฀for฀glucose฀in฀the฀cerebral฀cortex฀is฀greatly฀reduced฀in฀persistent฀ vegetative฀state฀patients,฀to฀a฀degree฀incompatible฀with฀consciousness. II.฀The฀artificial฀provision฀of฀nutrition฀and฀hydration฀is฀a฀form฀of฀medical฀ treatment฀and฀may฀be฀discontinued฀in฀accordance฀with฀the฀principles฀and฀practices ฀ governing฀ the฀ withholding฀ and฀ withdrawal฀ of฀ other฀ forms฀ of฀ medical฀ ฀ treatment. A.฀The฀Academy฀recognizes฀that฀the฀decision฀to฀discontinue฀the฀artificial฀ provision฀of฀fluid฀and฀nutrition฀may฀have฀special฀symbolic฀and฀emotional฀signi ficance฀for฀the฀parties฀involved฀and฀for฀society.฀Nevertheless,฀the฀decision฀to฀ discontinue฀this฀type฀of฀treatment฀should฀be฀made฀in฀the฀same฀manner฀as฀other฀ medical฀decisions,฀i.e.,฀based฀on฀a฀careful฀evaluation฀of฀the฀patient’s฀diagnosis฀ and฀prognosis,฀the฀prospective฀benefits฀and฀burdens฀of฀the฀treatment,฀and฀the฀ stated฀preferences฀of฀the฀patient฀and฀family. B.฀The฀artificial฀provision฀of฀nutrition฀and฀hydration฀is฀analogous฀to฀other฀ forms฀of฀life-sustaining฀treatment,฀such฀as฀the฀use฀of฀the฀respirator.฀When฀a฀ patient฀is฀unconscious,฀both฀a฀respirator฀and฀an฀artificial฀feeding฀device฀serve฀to฀ support฀or฀replace฀normal฀bodily฀functions฀that฀are฀compromised฀as฀a฀result฀of฀ the฀patient’s฀illness. C.฀The฀administration฀of฀fluids฀and฀nutrition฀by฀medical฀means,฀such฀as฀ a฀G-tube,฀is฀a฀medical฀procedure,฀rather฀than฀a฀nursing฀procedure,฀for฀several฀ reasons. ฀ 1.฀First,฀the฀choice฀of฀this฀method฀of฀providing฀fluid฀and฀nutrients฀requires฀ a฀careful฀medical฀judgment฀as฀to฀the฀relative฀advantages฀and฀disadvantages฀of฀this฀ 10฀ ฀ ฀ treatment.฀Second,฀the฀use฀of฀a฀G-tube฀is฀possible฀only฀by฀the฀creation฀of฀a฀stoma฀ in฀the฀abdominal฀wall,฀which฀is฀unquestionably฀a฀medical฀or฀surgical฀procedure.฀ Third,฀once฀the฀G-tube฀is฀in฀place,฀it฀must฀be฀carefully฀monitored฀by฀physicians,฀ or฀other฀health฀care฀personnel฀working฀under฀the฀direction฀of฀physicians,฀to฀ ensure฀that฀complications฀do฀not฀arise.฀Fourth,฀a฀physician’s฀judgment฀is฀necessary ฀to฀monitor฀the฀patient’s฀tolerance฀of฀any฀response฀to฀the฀nutrients฀that฀ are฀provided...