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    Friday, December 17, 2004

    Reader Mail: The battle between McDonald's and the crusading Cleveland Clinic cardiologists brought this email about the consequences of having a fast food restaurant in a hospital:

    We had the same problem in the cath lab at the WLA VA Medical Center. It was as if they vented the Burger King hood directly into the cath lab. Every morning at 10 AM the odor of greasy hamburgers was piped directly into the lab.

    The irony was that a couple of the cardiologists thought that the Burger King food was the most edible/safe in the cafeteria - since the grill got the meat up to a high enough temperature to kill any potential E. coli, and the steam table food was always suspect.

    On a more serious note, a reader had this to say about end-of-life issues:

    I needed to make a point about the letter sent to you by a reader about her relative with end-stage alzheimers and the decision to continue feeding/hydrating. It is very clear to me that the nursing administrator had a agenda and sold her point. I quote, "Then an interesting thing happened, she thanked me on behalf of the staff. They are the ones that must carry out these orders. They are the ones that hear the dying person's moans and watch as they starve to death and suffer from not having fluids." Most hospice data would indicate that in a demented patient dehydration is an "easy" death, not associated with suffering. Moaning and crying is common in demented patients unrelated to their nutritional status. Most have no anatomic difficulty swallowing but become anorexic, exhibiting no appetite or thirst. Unlike stroke patients that have difficulty swallowing though usuallyl feeling hunger and thirst, Alzheimer's patients just stop eating and drinking. Based on only what is in the letter (and of course I realize that there may be more to it) the nursing administrator essentially lied to this patient's family because she had her own opinion about the ethics of initiation and withdrawal of enteral nutrition in this situation.

    What it comes down to is a choice — which should be based on the patient's known (in the best case) or inferred wishes. Whether to "suffer" (debatable) starvation and dehydration or to undergo a painful invasive procedure at least once ( feeding tubes whether nasal or percutaneous clog, become displaced, and fracture on a regular basis) for the benefit of extended life which for most end-stage Alzheimer's patients consists of incontinence, inability to perceive pleasure (or pain perhaps), a bedridden state, pressure ulcers, skin tears and a lingering death from recurrent infection. Yes as a surgeon I can too "sell" a patient on my own opinion when I'm asked to place a surgical feeding tube in a patient such as this one. I take pride in not doing so and alowing the family to make an informed decision based on the best information I can offer.

    Yes of course the nurses take "point" on the carrying out of most orders. They also have to take care of the withering patient, losing all elements of personality, laying in stool, with recurrent episodes of pneumonia and UTI. I don't think for a minute that that is any easier.


    posted by Sydney on 12/17/2004 06:54:00 AM 0 comments


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