Court rules in favour of GMC's guidance on withholding treatment
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7512.309-a (Published 04 August 2005) Cite this as: BMJ 2005;331:309
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Yes, it was our hospital that made the application to withdraw treatment
from Tony Bland. (Airedale NHS Trust v Bland [1993]1 All ER821
HL). Dr Au-Yeung may like to know that survivals of more than 20 years
have been recorded in PVS, but none of these unfortunate people ever
recovered consciousness, their existence was clearly worth nothing to
them, though it might have had meaning and value for others. Before
technology enabled us to keep their bodies alive such people died much
more quickly. The major technological input is in intensive care after the
brain injury. AN&H plays a minor part, but that lesser technology, plus
skilled nursing and antibiotics is what can keep a PVS victim alive for
years.
That is why the descriptions of PVS are so recent, see Jennett &
Plum, Lancet 1972; 1: 734-7.
Spoon feeding carries no risk of perforation of a viscus, major
abdominal sepsis, nor bleeding, rather different from PEG or even
nasogastric feeding. But someone in PVS can not be spoon fed, for they
cannot swallow. Medical treatment is keeping their body living but not
restoring their mind to life, they can not experience anything nor value
anything, this is a life worth not living.
I can not understand Dr Au-Yeung's unease with allowing death, rather
than preventing it, in PVS. What is he afraid of?
For my part I can conceive of no reason to want my lifeless brain to be
kept in a living but useless body for year after year, if I should be so
unfortunate as to suffer such a severe brain injury.
His lovely daughter is growing and thriving and has a future of value,
not so the empty shell of the ex-person in PVS.
Mr & Mrs Bland told me that their son died at Hillsborough Football
ground not in our hospital, and that sums it up for me.
Competing interests:
None declared
Competing interests: No competing interests
The ethical issues surrounding the withdrawal of the artificial
nutrition and hydration (ANH) have been discussed in details in different
settings. We are all aware of Teri Schiavo case and recently the Leslie
Burke case has been the centre of debate. I can see another angle to this
issue, which I find rather concerning: media's attention. In the initial
phase when the court ruled in favour of Mr Burke there was a good coverage
of the story in the media and the news including interviewing Mr Burke.
The appeal judgement (favouring the General Medical Council) did not
receive the same coverage. It is not even moentioned in Channel 4's
website (BBC has mentioned it once). I do not see the appeal court's
decision as a victory for the medical profession and I am sure the doctors
caring for Mr Burke are doing their best to help this gentleman. What I
see is the exploitation of the doctor-patient relationship by the media.
It seems in the public discourse of the relationship between doctors and
patients, media play by their own rules (publishing what sells more).
The relationship between medicine and media has always been a
turbullent one. I believe the medical profession should be more assertive
in responding to media's bias against it.
Competing interests:
None declared
Competing interests: No competing interests
Dr Howe's response is tinged by the problem that Airedale is the
health authority providing the legal precedent of Bland. As a doctor, I
would like to think independently, regardless of what the law or current
medical fashion propose. The Schiavo case amply illustrates that the
current medical culture has ignored its Hippocratic roots and are willing
to withdraw the basic necessities of life, when the medical establishment
feel that it is a life that is deemed not worth living. After all, I hope
that Dr Howe would not deny me the opportunity to state the obvious, which
is that if you or I or anyone else for that matter, is denied nutrition or
hydration, we will succumb in due course, regardless of our previous state
of health.
In the Schiavo case, Judge Greer had actually issued a supplementary
order, after the one to remove the nasogastric tube, to forbid Nutririon
and Hydration by Natural Means. As a doctor, I feel extremely uneasy about
this turn of events. For those who argue that the Persistent Vegetative
State (PVS) is a Terminal Disease, let me pose you a question: how do you
reconcile the the fact that Terri Schiavo, a PVS patient, survived more
than the six months demanded of the Terminal Disease criteria? Even Tony
Bland survived with the PVS diagnosis for over 6 months.
As an anaesthetist who has a minor practice in Intensive Care, I
would beg to differ from Dr Howe's point of view on tube feeding. Yet
Artifical Nutrition and Hydration (ANH) could well be a misnomer as this
covers far too wide a range of modalities of feeding and watering. Despite
our differences, I would agree with Dr Howe that misuse of language can
be a problem in this case. Surely tube feeding through a well established
nasogastic or gastrostomy tube is just a tiny step up from spoon feeding,
which is not too far removed from feeding an infant from a bottle. At the
other extreme would be TPN in someone without enough gut to survive, but
who may be prone to fluid overload from renal impairment. There is more
than ample reason to separate the two.
Just as it is important to separate withdrawal of futile therapy from
euthanasia, so here I plead for tube feeding to be separated from other
modalities of ANH. Maybe we can define ourselves out of a veritable
quagmire.
Competing interests:
Father of a lovely six month old baby girl, and someone who would never consider feeding her by bottle as anything other than the fulfilment of a basic paternal duty and the satisfaction of her fundamental human right
Competing interests: No competing interests
Why do commentators, judges and lawyers persist in talking about
dying
of thirst and starvation?
When medical Artificial Nutrition and Hydration (AN&H) is
withdrawn the
patient dies from renal failure and infection, usually within a few days,
depending on the fatal disease from which they are dying, and their
general condition. The IRA hunger strikers died more than sixty days
after they stopped eating, so starvation does not come near describing
the mode of dying when AN&H is withdrawn. Using the word is
emotional sloganising.
Thirst is a sensation, when AN&H is withdrawn the patient is
usually
unconscious or non-sentient in a vegetative state, and so can not
experience thirst. This is a horror word to scare the ignorant.
Let's get things clear when discussing the care of dying patients,
when
AN&H is withdrawn people do not die of thirst or starvation. The mode
of death is peaceful, and if necessary any possible pangs of hunger and
thirst can be assuaged by good palliative care.
Competing interests:
None declared
Competing interests: No competing interests
Re: misuse of language--withdrawal of tube feeding causes death
I think I have to agree to disagree with Dr James G Howe over tube
feeding. The Medical Examiner stated that Terri Schiavo died from
dehydration, confirming my suspicions that withdrawal of tube feeding
causes death.
Contrary to Dr Howe's assertion, I am totally at ease with allowing
death to intervene when medical interventions prove futile. Recently I had
to disagree with my colleagues in initiating aggressive ICU therapy for
significant haemoptysis in PVS. Luckily the thoracic surgeon at the tertiary referral centre did
not share in this madness and declined to consider surgery after
assessment and investigation.
Maybe the patients I know of are fortunate, none of those on long
term tube feeding had developed the complications described by Dr Howe. My
friend (a gastroenterology Senior Lecturer at a London teaching hospital)
also agrees with me that continuing to feed via a functioning tube is
basic care and ordinary means.
I also do not argue for nutrition and hydration for all cases. I have
the misfortune to anaesthetise a neonate for surgeons to delineate the
extent of aganglionosis of his gut. It turned out that he only had nerve
cells as far as the mid-jejunal area, leaving him insufficient gut to
survive. I did not advocate TPN for this baby, given that I understood
that TPN at that time can result in fatal liver failure in the neonate and
the infant. One is faced with the unenviable prospect of starving the baby
to death to avoid feeding the baby to death, or vice versa.
Competing interests:
None declared
Competing interests: No competing interests