By: Dr. Barbara A. Olevitch, Ph.D., a clinical psychologist and author of Life is a Treasure: The Jewish Way of Coping with Illness.
Dr. Allen Lempel, speaking at the Conference of Synagogue Rabbonim at the 88th Annual Convention of Agudath Israel of America, said, “If you have the opportunity to speak to physicians, you will hear that when we make a recommendation for a feeding tube, oftentimes it’s a battle now. The nurses have already spoken to the family about end of life issues. They have already told them ‘Feeding tubes don’t help.’ Other physicians have already said, ‘Feeding tubes don’t help.’ You’re actually at a disadvantage. When we go and speak to patients, they’ve already been told that ‘Feeding tubes don’t help.’”
When a patient can, for some reason, no longer swallow food, why wouldn’t a feeding tube help? It goes against common sense. It also goes against the wisdom of experienced physicians. As Dr. Lempel says, “That goes against, of course, everything that we know. We see patients all the time who reach an end point, who do do better on feeding tubes.”
What is the source of this widespread belief that “feeding tubes don’t help?”
The article that everybody points to as proof that feeding tubes don’t help did not actually prove this at all.
In 1999, Finucane and his colleagues published an article in the Journal of the American Medical Association. In this article, the authors looked through the research literature at a lot of studies that had been done comparing patients on feeding tubes with patients who were being hand fed.
In all of the studies, the patients who were not on feeding tubes were still eating. Patients who couldn’t eat were excluded from the study.
Their study showed that feeding tubes were not superior to eating! Now who ever thought that they would be superior to eating?
Then, their conclusion that they had “identified no direct data to support tube feeding” was widely publicized by a number of other authors until finally it was seemingly forgotten that all of the patients in the Finucane study could still eat. The conclusion that there was “no direct data to support tube feeding” was taken out of context and elevated to a general principle.
This idea that “feeding tubes don’t help” has become an official policy
The Hospice and Palliative Nurses Association put out a Position Statement on May 21, 2007 saying, “studies show that tube feeding does not appear to prolong life in most patients with life-limiting, progressive diseases . . . .” Nurses are trained to give this information routinely to families.
Another article in the Journal of the American Medical Association 2003 put this negative conclusion into words that have been widely quoted, that feeding tubes have “no demonstrable health benefits.”
The sentence “Feeding tubes have no demonstrable health benefits” gives a powerful false impression. It seems to be saying that feeding tubes have “no health benefits.” But the only way to make this sentence true is to put the emphasis on the word “demonstrable.” In the research world, a medicine has “demonstrable” benefits if its benefits can be proven in a research study published in a medical journal. But the benefits of feeding tubes for patients who really need them can never be demonstrated in a research study, because to deprive half of the subjects of food and fluids would be totally unethical. Therefore feeding tubes have no demonstrable benefits. But of course they save lives and we all know it.
Unbelievably, health care counselors are referring to this “finding” that “feeding tubes have no demonstrable benefits” to encourage families to withhold or withdraw food and fluids from patients.
Other absurdities in discussions about feeding tubes
It is really quite absurd that the opponents of feeding tubes use two contradictory arguments. First, they claim that the patients wouldn’t want to be kept alive. Then they claim that the feeding tubes don’t keep them alive. If this were truly the case – that feeding tubes don’t keep people alive – there would be no need for the campaign to try to get more people to sign advance directives declining feeding tubes.
In this Position Statement by the Hospice and Palliative Nurses Association, the provision of food is given a technical name, “artifical nutrition and hydration,” abbreviated ANH. Nurses are given a rather condescending view of families who want feeding tubes. They are told that families deprived of their “fundamental caregiving activity” of giving food and fluids “may fear that the patient will suffer as she or he ‘starves’ to death or dies of dehydration. Therefore, families and other caregivers need to be presented with accurate information about the burdens and benefits of ANH.”
As an example of the way in which these “burdens and benefits” are being presented to families, read carefully a very sly statement by Ira Byock, writing in the American Journal of Hospice and Palliative Care in 1995 regarding giving information on the risks of dehydration, “among the terminally ill, the risks of uncorrected malnutrition and dehydration are few. (In this circumstance, death is not properly regarded as a risk, since it is a principal expected outcome.)”
He feels that in a risk/benefit analysis presented to families, the risk of death from dehydration need not be mentioned because it is not a risk – it is a certainty!
Given that the benefits of food and fluids are so obvious in most cases, why are health care personnel even talking about them in such a way as to imply that their benefits would need to be proven in research studies?
There used to be a big distinction between what was called medical treatment and what was simply called “humane care” such as food, fluids, and oxygen. But now this distinction is in danger of disappearing. A famous U.S. Supreme Court decision in 1990 regarding a patient named Nancy Beth Cruzan made it possible to discontinue food and fluids if evidence was provided that this was the wish of the patient.
Since the Cruzan case, in America, medically provided food and fluids are in the same category as medical treatment in the sense that they can both be refused. However, putting them in the same category as medical treatment in the sense that their value has to be proven in a published research study would be ridiculous. So when the health care counselors say in an authoritative way that the benefits of feeding tubes have not been proven, implying that therefore they should not be used, the family should realize that this “logic” doesn’t really make sense.
Rabbi Mordechai Biser, speaking along with Dr. Lempel at the conference of Synagogue Rabbonim in 2010, told the audience about a case where a woman wanted a feeding tube for her mother, but the hospital, citing studies about how feeding tubes can cause infections, etc., was refusing. So Rabbi Biser had a talk with the hospital’s counselor.
“I don’t understand these studies,” Rabbi Biser said. “In other words, a feeding tube could be potentially harmful. But if you don’t feed the patient, she’s going to die within a week or two. So what’s the harm of putting in the feeding tube?”
After they repeated their concerns, he repeated his response, “But for sure, she’ll be dead in two weeks . . .without a feeding tube.”
He succeeded in that particular case. The Rav of the community was involved. They found another doctor and another hospital, and a year or two later, “she was still alive.”