I approach this task with
trepidation. What right do I have to don the mantle of spokesman? I, in fact,
claim none and therefore let no one read into my words the language of psak
halacha - a language reserved for the ears of the individual questioner on
these complex and often intimately personal issues. These life and death
medical decisions are highly fact-sensitive and Rabbinic authorities together
with the physicians in each case, must make a careful evaluation of a
multiplicity of factors.
There is no area of
human concern which Judaism fails to address. The very word halacha is derived
from the verb “haloch”, meaning to walk. Halacha is the means of
regulating man’s journey through life.
I find myself
traveling in a world of secular medical ethics. Many in the secular world have
continually told me that there is little role for the religious voice in
medical ethics. We who represent a Faith-tradition guided by a Torah of
instruction given to us by the Creator of the Universe have a responsibilty to
ignore such requests and be ambassaders for Torah truths. Indeed, foremost
among the credentials of Judaism is the exclusive witnessing of the most
momentous event in the history of mankind: Almighty God's revelation at Sinai.
It was there established for all time that His Word is the only source for a
moral universe. We were, after all, the originators, the pioneers of moral law.
Whatever other Faiths - certainly Monotheistic Faiths - have to say, they have
in one form or another derived from us, albeit often with grave distortion. The
Torah is the source of absolute truth, which alone can serve to guide man and
for the Torah-true Jew the resolution of medical ethics issues must be viewed
through the lens of halacha, not through personal predilection as molded by
These life and death
medical decisions are highly fact-sensitive and Rabbinic authorities together
with the physicians in each case, must make a careful evaluation of a
multiplicity of factors.
The Torah says that when
Hashem finished creating the world, He examined His creation, realized that
death was to be a feature in it, for so He had decided, and He declared that
the creation was tov me'od, very good. And yet, in our society,
death is very often perceived as an evil which should be postponed for as long
as possible, and our medical professionals work to defeat death. The Jewish
attitude on death has often been described as “death-defying” because we
emphasize the sanctity of life; the need to preserve life even when it entails
violating religious prohibitions.
Although it is true that
Judaism is somewhat death-defying, this is only partially true as can be
illustrated by an interesting comment made by Rav Dovid Ibn Zimra.
He discusses the question as to how Adom could follow Chava's advice to sin
after he had been treated so well by Hashem, and he gives a fascinating answer:
When Hashem told Adom not to eat from the eitz ha-da’as tov v’ra – the
Tree of Knowledge, good and evil, he threatened the punishment of death. This
says, Radbaz, referred to an essential death, not a natural death. Adom
realized that his natural death was inevitable for there was no reason for him
to have thought himself immortal? He knew that there was an eitz ha-chaim
in the garden but he did not know where it was. The snake’s argument to Chava,
which she conveyed to her husband, was that by eating of the eitz ha-da’as
they could be like Hashem; eternal, understanding the difference between good
and evil. Adom believed that if he ate from the this tree he would gain the
information as to where the eitz ha-chaim was. He could then eat from it
and serve Hashem eternally like the angels. He reasoned that it would be
satisfactory to transgress one sin and then repent, since in the final
analysis, he would better be able to serve Hashem if he was immortal.
To seek immortality, as
Adom did, may strike us as being a pious act, but it was rejected outright by
Hashem. If He had wanted us to be deathless like the angels, He would have
created us that way.
Most of us would like to
die a quiet, dignified death. Anyone who works in a hospital knows that this
reasonable wish is almost never fulfilled. The last rites of respirators,
dialysis machines, nasogastric and gastrostomy tubes along with cardiopulmonary
resuscitation and the nth round of chemotherapy may have their place, but they
have changed death into a mechanized spectacle in which no sane person would
like to be the main actor.
difficulties surrounding these issues arise from the tension between the
obligation to save life and avoid the prohibition of r’tzicha, murder,
while simultaneously not allowing human suffering. As
life’s only certainty, death is never more than a heartbeat away. Decisions
about the end of life, such as whether to pursue aggressive care or withhold or
withdraw life-sustaining treatments, require consideration of clinical factors
in the context of other values.
Within the halachic
tradition, the statement of a defendant is given unqualified authority even
when contrary to his self-interest. Judgment is rendered against a person who
accepts liability even if his confession is contradicted by the testimony of
unimpeachable witnesses. This is so, however, only in dinei mamonos, monetary
matters. In criminal cases, the halachic laws of evidence say that not only can
an accused not be forced to testify against himself, but even should he
confess, his testimony is ignored. Rav Dovid Ibn Zimra
explains a fundamental principle of Torah ethics by explaining why in matters
where corporal or capital punishment can be meted out one’s testimony is
ignored. In monetary matters there is no concern since a person may do with his
money as he wishes. Self-incrimination that might lead to corporal or capital
punishment is not allowed because “man’s life is not his possession, but the
possession of the Almighty.” Since man lacks proprietary rights over his body
he may not do anything to harm himself.
While it certainly true
that every moment of life is intrinsically valuable and that preservation of
life, even for a moment, is important enough to violate all the mitzvos, save
three, this not to say that life must be preserved in any and all circumstances.
Patients near the end of life who may be suffering intractable pain are
entitled to refuse treatment that is clearly medically futile or entails great
suffering. Intractable pain without hope of recovery is far too burdensome to
demand using modern medicine to prolong the dying process and may very well be
beyond the Torah’s license of v’rapo yi’rapei.
While the physician is
uniquely qualified to diagnose illness and to access the probable prognosis and
avenues of treatment, the decision to treat or not to treat is a value
judgment, not a medical decision and for observant Jews involves consultation
with Halachic experts.
Let me make some comments
about palliative medicine, CPR vs. DNR and artificial nutrition and hydration.
The Study to Understand
Prognosis and Preferences for Outcomes and Risks of Treatment (“SUPPORT”),
an empirical study conducted over a four-year period that involved 9,105 adult
patients suffering from life-threatening illnesses and five university
hospitals from around the country, determined that half of the study-patients
who were conscious in their final days of life suffered severe pain. While
palliation can and should always be an integral part of the entire spectrum of
patient care, it stands alone as the care for the patient who has been
diagnosed with an irreversibly deteriorating or terminal condition and
for whom curative treatment is no longer the goal of care.
There are many
misconceptions of the role that palliative care should play in a treatment
plan. Because of its association with end-of-life care, palliative treatment is
often viewed as just that. While many physicians have begun to recognize the
need for the administration of palliative care throughout all stages of a
painful medical condition, many are still of the belief that palliation is a
recognition of failure – that it is an alternative, rather than a complement,
to aggressive curative treatment.
The end stages of chronic,
progressive diseases bring a host of difficult symptoms and causes of suffering.
There are disease-mediated symptoms, such as pain, dyspnea, fatigue, and loss
of mobility, and there are the accompanying emotional states, such as
depression, anxiety, and a sense of uselessness. Of the many symptoms
experienced by those at the end of life, pain is one of the most common and
most feared. Pain is often under-treated, but with careful assessment and a
comprehensive plan of care that addresses the various aspects of the patient's
needs, pain can be controlled in the vast majority of cases.
All the members of a
palliative care team play important roles in comprehensive pain manage-ment. Both physicians' and nurses' roles begin with assessment and
continue throughout the development of a plan of care and its implement-tation. Clinical pharmacists, social workers, and chaplains can often
provide important essentials in helping patients optimize their quality of
life, heal relationships, complete unfinished business, and find peace as they
management can be accomplished through a variety of adjuvant therapies
including palliative radiotherapy, acupuncture, hypnosis, and, most commonly,
through the giving of drugs; in cases that involve severe pain, the
administration of opioids – pain medications, like morphine, derived from
opium, or synthesized to behave like opium derivatives.
Pain can usually be
defined as nociceptive or neuropathic. Patients in the terminal stage of an
illness may often experience different mechanisms of pain operating
simultaneously. It is important to differentiate among different types of pain
because the type of treatment is largely dictated by the pain mechanism and its
original source. Nociceptive pain is
typically the result of a musculoskeletal or visceral injury or disease and
includes somatic and visceral mechanisms. Neuropathic pain is
caused by lesions or physiologic changes in the nervous system, and it is
characterized by hypersensitivity either in the damaged area or in the
surrounding normal tissue.
There is significant
evidence that inadequate pain relief hastens death by increasing physiologic
stress, potentially diminishing immunocompetence, reducing mobility, increasing
proclivities toward pneumonia and thromboembolism, and increasing the work of
breathing and myocardial oxygen requirements. Pain may lead to spiritual
despondency and significant decrease in emotional well-being because the
individual's quality of life is impaired.
cites the verse “And he shall surely cause him to be healed” as the
authority establishing permission to engage in the practice of medicine. Rambam
quotes “and you shall restore it to him” as the source of this
permission and obligation. Ramban says that in addition to
treating illness, the obligation of the physician to treat a suffering patient
is part of the mitzvah of “and you shall love your neighbor as yourself.”
Rav Dovid ibn Zimra writes that one is
obligated to come to the assistance of an individual in distress due to being
weighed down by a burden because of the obligation to restore “the loss of his
body” as well as the commandment “you shall not stand idly by the blood of your
fellow.” Relief of pain and suffering is thus mandated not only by the
commandment to restore that which has been lost but also by the admonition not
to “stand idly by the blood of your fellow.”
Given the above, there
exists an affirmative obligation to utilize opioid analgesics and other
necessary medication in an attempt to relieve a patient’s pain and suffering.
Judaism believes that everything in creation was designed for a purpose. There
is every reason to accept that these types of drugs were given to mankind for
the specific purpose of controlling pain and discomfort.
Since halacha is concerned
about the danger of actively hastening a person’s death, many ethically-minded
physicians are worried that using opioid analgesics may do just that. But the
medical literature has demonstrated that patients receiving chronic opioid
therapy for the relief of pain develop tolerance to the respiratory depressant
effects of these medications within a few days of initiating therapy.
Furthermore, studies demonstrate that when patients are on chronic opioid
analgesics for pain, dosage increases of 50% or more are needed to treat
breathlessness, another common symptom near the end of life. Additionally, such
patients, when given opioids to treat their breathlessness, have improvement in
symptoms and do not experience respiratory compromise or arrest.
Increasing the dose of morphine in the last week of life because of increased
pain does not shorten patient survival.
physician education have led to a phenomenon known as opiophobia – excessive
concern about the addictive potential and side effects of narcotics. From early
in their medical training, physicians are taught that narcotics cause
respiratory depression, cardiovascular collapse and depressed levels of
consciousness. This is completely accurate. However, it is necessary to
differentiate those who turn to morphine for pain relief from those who do so
for recreational purposes. The likelihood of these side effects occurring when
morphine is used for the relief of pain is low, and when these side effects do
manifest, they are often easy to control. In contrast to pain-free morphine
users, a patient with cancer pain can tolerate enormous doses of morphine
without a negative effect on respiratory effort. Therefore, there is no evidence that treating patients with the necessary
therapeutic doses of opioid analgesic to relieve pain results in the hastening
of death, and Jewish law fully supports appropriate treatment for the relief of
pain without concern for respiratory compromise. Having been involved with this
issue for many years and speaking with experts in palliative medicine, I have
never heard of a single case of a death of a patient as a result of pain
palliation – unless the death was intended or the medication not titrated
The rule with regard to
how much money a person must expend in order to avoid transgression is that a
person is obligated to expend 20% of his net worth, but not more, in order to
fulfill, or to avoid transgressing, a Mitzvas Aseh but is obligated to
expend even kol mamono - his entire fortune in order to avoid transgressing
a Lo Ta’aseh.
Many Poskim are of the opinion that a person is not obligated to use kol mamono
- his entire fortune to preserve life. A
person in intractable pain would likely be willing surrender his entire fortune
in order to rid himself of pain. Since a person need not spend more than his
entire fortune in order to preserve his life, he need not accept pain either.
As recorded in Sefer Daniel, Nevuchadnetzar of Babylonia constructed a golden
statue and gave Shadrach (Chanania), Maishach (Mishael) and Avaid (Azariah) an
ultimatum: bow to it or be thrown into a fiery furnace. The Talmud
declares that had they been subjected to torture rather than immediate death,
they would have succumbed. Shitah Mekubetzes quotes an anonymous source who
says that there is no obligation to sacrifice more than one's life and since
sustained torture (and intractable pain) represents a sacrifice greater than
martyrdom, no requirement exists to do so.
It is fundamental to our
understanding of the role of mankind that we utilize the “laws of medicine” (refu’ah
biduka u’minusa) for the benefit of mankind.
(This is true on Shabbos as well where pikuach nefesh, life-threatening
situations allow and mandate overriding otherwise prohibited activities. Such
permission exists only with regard to known therapeutic efficacy based on
“natural law” not the supernatural or the miraculous).Intractable pain without hope of cure is a
reason for non-treatment even when treatment is easily available. The benefits
to be achieved are not worth the risk since the price to be paid is an
unacceptable pain-filled life. As Rav Moshe Sternbuch
succinctly says: “We do not find any obligation for a person in
intractable pain to remain so even though there will be no improvement in his
condition.” Of course, if a person chooses to continue a treatment that
prolongs his pain, he is entitled the full support of the health-care providers
taking care of him.
* * * * * * * * * *
resuscitation, originally developed to help people who experience a cardiac
arrest from heart attack, drowning or electrocution, has become the universal
standard of practice.
There have been many
developments in the understanding of CPR (Cardiopulmonary resuscitation) since
it was first described as a beneficial and life-saving treatment for cardiac
arrest more than 40 years ago. It is only in the last decade or so that the
poor outcomes of CPR in certain patient populations have been recognized. This
has resulted in the acceptance of the DNR order, which, as an advance
directive, allows patients or families to forgo future attempts at CPR. This
process is now embedded in the concept of respecting patient autonomy by
allowing competent individuals or their surrogates to refuse the potentially
lifesaving therapy of CPR.
resuscitation, when successful, restores heart beat and breathing. It is
assumed that by restoring cardiac and pulmonary function it may be possible to
prevent what would otherwise be imminent death. The process assumes that the underlying
condition that precipitated the arrest is potentially reversible; otherwise the
activity would be clinically futile. In the appropriate situation, in which the
cardiac arrest itself is an aberration in cardiac electrophysiological function
or part of a self-limiting condition (such as an acute myocardial infarction),
CPR may return the heart to a self-sustainable rhythm and cardiac output,
without irreversible damage to other vital organs.
In the geriatric long-term
care population, the heart stoppage itself is often the final common pathway to
death following the lethal deterioration of other organ systems. The heart
rhythm and cardiac output is usually not capable of being permanently restored.
In such situations, CPR serves no clinical purpose.
The success of CPR depends
on the patient’s overall medical condition. Age alone does not determine
whether CPR will be successful, although illnesses and frailties that go along
with age often make CPR less successful. When patients are seriously ill or terminally
ill, CPR may not work or may only work partially, leaving the patient
brain-damaged or in a worse medical state than before the heart stopped. The
patient may be alive, but will be connected to a ventilator or be left with
neurological damage as a result of the time that has lapsed without blood
supply to the brain.
Many people have an
exaggerated perception regarding the success of CPR. The medical literature
suggests that, in general, CPR as a procedure is not very successful.
It is reported that only about 15% of all patients who receive CPR survive to
hospital discharge, with the rate of survival varying by location, from a high
of 39% for a selected group of cardiac patients who have sustained a witnessed
arrest in a monitored setting, to a survival rate of less than 1% for patients
who have an out-of-hospital and/or unwitnessed arrest.
Because chronically ill elderly patients who require CPR have a less than 5%
chance of surviving to hospital discharge, one can infer an even lower success
in terminally ill patients, many of whom are in more advanced stages of the
same chronic illnesses.
CPR is often harmful,
increasing pain and suffering in the few terminally ill patients who might
survive the procedure. Autopsy studies have demonstrated significant traumatic
injury following CPR, including rib and sternal fractures, mediastinal
hematomas, aspiration pneumonia, epicardial hemorrhage, and other injuries to
various cardiac and respiratory structures in the chest. An as indicated above,
patients who survive CPR often are left with severe and irreversible neurologic
deficits as well.
Assessing all the
evidence, CPR is not beneficial for patients who are near the end-of-life and
may be harmful. From a halachic perspective therefore, CPR may be withheld from
or refused by Jewish patients who are terminally ill or at the end of life
where agreement exists that there is no clinical value to the procedure.
* * * * * * * *
Feeding an incompetent,
demented geriatric patient is a common challenge that raises complex questions
on a daily basis. Since eating is such a basic component of life, losing the
ability to do so is a major blow to one’s integrity. The result of this
inability is a combination of medical problems such as malnutrition and aspiration,
as well as psychological problems. The decision to stop nutritional support is
almost inconceivable. When deglutition is abnormal, one loses the ability to
swallow, tube feeding is needed and several options exist: nasogastric tube is
the simplest to insert, but may be uncomfortable for the patient; it is easily
removed, but it may be associated with increased risk of aspiration. More
invasive techniques include the insertion of a gastric or a jejunal feeding
tube. The main advantage of these is the ease of use coupled with the relative
comfort of the patient. With the introduction of percutaneous endoscopic
gastrostomy (PEG), the insertion of a gastric tube without the need for a
surgical procedure became a very attractive option to provide feeding when the
oral route is no longer effective.
In Cruzan v. Director,
Missouri Department of Health, the U.S. Supreme court
ruled that nutrition and hydration were medical interventions and as such could
be withdrawn. Jewish medical ethics does not make distinctions between
"natural" and "artificial". Rambam
writes that the Almighty provides for all the needs of mankind. He causes man
to seek bread for food and in a similar manner He allows for the discovery of
medicines and technology so as to benefit mankind. Hydration and nutritional
support are thus ruled by most Poskim to be basic care rather then medical
interventions. A mitzi’us question, however exists as it relates to
end-of-life treatment. As opposed to stroke and PVS patients, hydration and
nutritional support for patients near the end of life raises significant
medical questions as to whether or not these forms of care are indeed
beneficial and whether or not there is risk of harm. I would like to
specifically mention the case of patients suffering dementia and Alzheimer’s
Dementia is a fatal
neurological disorder involving progressive loss of memory, judgment, language,
and other aspects of cognition, and results in death within a decade of
diagnosis. In its most advanced stage, the affected individual loses the
capacity to communicate or to help with personal care and suffers from severe
Several distinct factors
conspire to create nutritional problems among demented patients. Those in the
end stages of dementia are unable to eat for various reasons such as
indifference to food, refusal of food, or failure to manage the food bolus
properly once it is in the mouth. Demented patients who stop eating become
malnourished rapidly. It is very common to see such individuals recommended for
artificial nutrition and hydration. This is done with the justification that it
improves nutrition, maintains skin integrity by enhanced protein intake,
prevents aspiration pneumonia, minimizes suffering, improves functional status,
and extends life. However, the literature does not support these claims.
Indeed, mortality among hospitalized patients during the first month following
PEG insertion is high, ranging from 20% to 60%.
In a study reported in
the Journal of the Israel Medical
despite the vast clinical evidence that there is no benefit in performing
PEG in demented older patients, most of the referring physicians in the study
recommended PEG because they believed it would prevent aspiration and improve
quality of life. The majority of gastroenterologists, however, did not believe
this to be true.
Review of the medical
literature examining the benefits of artificial nutritional support by feeding
tube (either via a nasogastric tube or a gastrostomy tube) in patients with
advanced dementia (who may or may not be terminally ill) has shown:
No reduction in
risk of aspiration pneumonia.
No improvement in
clinical markers of nutrition.
No improvement in
No improvement in,
or prevention of, decubitus ulcers.
No reduction in
No improvement in
functional status or slowing of decline.
No improvement in
On a practical level – halacha
l’ma’aseh – patients who are terminally ill should be provided food and
fluid, but physicians have a responsibility to make sure that the food and
fluid provided (or the method by which they are provided) do not cause the
patient harm and/or discomfort. If a competent patient refuses nutrition or
hydration after attempts have been made to convince him or her to accept the
supportive care, the patient’s wishes must be respected.
In situations where the physician believes that the food or fluid is of no
benefit and/or harmful to a patient near the end of life, such as in those with
dementia, the specific circumstances of the patient should be discussed with a
Rav knowledgeable in this subject, because there may be situations where even
the provision of artificial nutritional support and hydration can be avoided.
The initiation of artificial hydration and nutrition should certainly not occur
if it is determined that the patient is a gosses.
the literature quoted with respect to artificial feeding of the demented
patient is, for the most part, far from conclusive and is often misleading.Let me
make a few preliminary points:
patient can live without nutrition or hydration, so that a decision not to feed
a patient or to remove the only source of nutrition is a death sentence, with
all of its consequences.
it is possible to feed a patient orally, even with much investment of time and
effort, this is preferable to tube or enteral feeding. And, as pointed out by
my colleague Alan Jotkowitz (1), such time- and effort- consuming feeding by a
child of a patient is part of the requirement of kibbud av va'em
has not to my knowledge ever been published a randomized control study in which
patients who were candidates for possible tube feeding were divided into two
groups, one tube fed and one not, comparing the two groups . Thus the generalizations
repeated over and over again by individuals like Finucane and Gillick, decrying
enteral feeding in terminal dementia, are not supported by adequate evidence.
Criticism of their conclusions has been published by several authors, including
Finucane's articles, in which he reviewed the literature betwwen 1996 and 1999,
are quoted over and over again, and are regarded as definitive, I will analyse
briefly his interpretation of some of the quoted data and indicate the serious
(6) et al attempted to study 150 patients who had percutaneous endoscopic
gastrostomy (PEG) feedings performed .They write that among patients surviving
60 days or more" at least 70% had no significant improvement in
functional, nutritional, or subjective health status". Finucane wrote an
editorial (7) commenting on the article, and he states "mortality rates
were very high". But the high death rates were probably unrelated to the
PEG, because a large percentage of the patients selected for PEG died even
before they could be included in the study.These were very sick patients to
begin with. Finucane writes further, "only a minority of patients showed
any measurable improvement. Functional status, serum albumin, and weight were
better at follow-up in very few patients" But the actual data in the paper
showed that 30% had a significant improvement in serum albumin, and only 5% had
a deterioration in serum albumin. Is 30% considere "very few"? But
more important, PEG maintained nutritional and functional status in the
overwhelming majority of the patients, in essence keeping them alive.The value
of prolonging life itself is given very little attention in the discussion, in
contrast to its major importance in the Jewish tradition. Were these patients
not to have been fed at all they certainly would have progressed rapidly to
describes the "horrible mortality" of PEG tube feeding and comments
pejoratively that a "surgical procedure with these mortality figures would
probably not be done more than 100,00 times a year" He further suggests
that families be told, "If the PEG is placed there is a very high chance
that he/she will die soon". This, to my mind, is grossly misleading,
because the population in whom these procedures were done were desperately ill
before the PEG placement, and in all likelihood they did not die because of the
PEG, but rather with a PEG, and perhaps in spite of a PEG.
are several reports in the literature which clearly contradict the dire
prospects described by Finucane and by Gillick. Lindemann from Germany (8) reports that more than half his demented patients in whom PEG had been placed
lived longer than six months.He suggests that one should consder placing the
PEG at an earlier stage in the dementia. Shapiro and Friedmann(9) describe
their own experience with demented patients in several nursing homes in Jerusalem. They report that 43% o00f the patients were still alive after 2 years and 31%
were alive 3 years after PEG insertion. Their experience coincides with the
data reported by Peck et al (10), that the terminal stage of dementia may be
prolonged for months or even years if supportive care such as artificial
nutrition is provided. Similarly van Dijk and Sonnenblick(3) tell of their
extensive experience in which such patients survive for years.
course PEG has complications, as does any procedure, and in each case there
needs to be a careful evaluation of the potential benefits versus the problems
of any course of therapy. But good ethics must be based on correct facts, and
unfortunately the literature on the subject has been seriously biased, leading
to conclusions which are clinically as well as ethically unsound, certainly as
evaluated from a halachic point of view.
honored and delighted that Professor Shimon Glick took the time to comment on
an aspect of my article. Dr. Glick is an outstanding physician and one of the
best spokesmen the Torah world has for our eternal values. He is a role model
of what a Jewish physician ought to be – a ben torah of high caliber and one
who throughout his long and illustrious career, made a daily Kiddush Shem
must, however, take exception to his critique. As a Rav, I am fully aware that
like all areas of halacha, life and death decisions of which I wrote are highly
fact-sensitive and Poskim must make a careful evaluation. Psak halacha is to
the Talmud what engineering is to mathematics. If the raw data is inaccurate,
the bridge will collapse. If the raw data is accurate but the conclusions drawn
are in error, then the greatest mathematician will have labored in vain,
because the engineer has misinterpreted his instructions. I believe that the
data I quoted is accurate and falls within the scope of chochma ba-goyim
ta’amin – and can thus be relied upon in reaching a halachic ruling.
reiterate again that there is little question that in almost all situations the
halacha requires the use of artificial nutrition and hydration and the fact
that society terms these modalities as “artificial” has no impact in Jewish
thought or law. I also fully agree that removing nutrition/hydration would be
looked upon as an act of ritzicha (murder) under the p’sik reisha v’lo yamus
rule. However, in the patient population of which I wrote – those suffering
from end-stage Alzheimers and other dementias – I am convinced that initial
placement of a PEG once they lose the ability to swallow is as medically contraindicated
as the introduction of fluids in a patient for whom fluids may cause pulmonary
edema without definite beneficial results. In order for there to be an
obligation to provide nutrition via a PEG, the assumptions of benefit and
minimal risk must be met. It is this point that I believe has been shown to be
scientifically acurate both from my review of the literature, conversations
with experts in both geriatrics and gastroenterolgy, as well as personal
observation of many years dealing with this sub-set of patients.
from the sources I have already quoted let me note the following: “Tube feeding
in the Demented Elderly with Severe Disabilities”, Israel Medical Association
Journal, 8:870-874 (2006); To PEG or not to PEG? Feeding the Incompetent Patient,
Ibid. 9:881-882 (2007); Long Term Feeding Tube Placement in Elderly Patients
(Booklet published by Mitchell, Tetroe, O’Connor, Ottawa Hospital, 2008);
my original comment on Rabbi Kaye's article there was published a Cochrane
document about enteral feeding in advanced dementia (1). They retrieved some
452 articles, but found not one single randomized controlled trial. They were
unable to do a meta-analysis because of the poor quality of the reports.
Ultimately they discussed only 7 papers, of which 6 discussed mortality,and
only 3 used exclusively PEG. The numbers in most of the studies were quite
small. Their conclusion was that" there is insufficient evidence to
suggest that tube feeding is beneficial in patients with advanced dementia.
Data are lacking on the adverse effects of this intervention". They are
also critical even of each of the 7 papers included in their analysis, and
indicate the need for "better designed studies" to "provide more
robust evidence". The kind of studies needed are proposed in the following
article by Professor Steinberg. Unfortunately what has occurred is that the
poor data from patients with "advanced dementia" have not only been
widely quoted, but then extended in many articles to patients with dementia in
general. If one waits until the stage of severe deterioration the benefits of
the procedure are indeed diminished and the side effects increased. One needs
to make early diagnoses of declining intake and poor nutrition; in such
situations PEG can have long-term life preserving effects.