by Between Life
Inotropes also carry risks. In certain situations you can suffer a heart attack while on an inotrope. Furthermore, these medications can pitch the heart into dangerous, life-threatening rhythms.
Vasopressors have risks too. When we endure profound shock, constriction of our small arteries with pressors can actually damage our organs, even when measured blood pressure is normal.4 The high doses of pressors necessary to increase blood flow to the heart and brain can paradoxically restrict blood to our limbs, such that our hands and feet blacken, die, and require amputation. This process can also occur in the intestines, leading to bowel perforation that requires emergency surgery, as well as in the liver and kidneys, causing their failure.
The gentleman at the beginning of this chapter developed this very kind of progressive organ failure. Although pressors maintained pressure within his large arteries, the blood flow to his organs was insufficient. His blood pressure appeared normal, which is why his loved ones strained to understand his decline.
Near the end of life, shock often becomes refractory; in other words, increasing doses of pressors yield no response. In refractory shock, doctors may increase doses of pressors to astronomical levels, with little change in blood pressure. At this stage, further interventions to stave off death are futile.
Fearfully and Wonderfully Made
For those of us lingering at the bedside of a loved one in the throes of critical illness, the simplicity of numbers can offer a tempting anchor. Doses of medication go up, and things look worse. They decline, and hope takes flight within us.
Although in general, doses of pressors and inotropes correlate with illness severity, this is not always the case. Just as God sculpts us into unique, complex, mysterious, elegant beings in his image, so also he knits us together with an ornateness that our paltry technology can support but never duplicate. We are “fearfully and wonderfully made,” the workings of our blood vessels, hormones, cells, synapses, mind, passions, memories, and gifts “intricately woven” (see Ps. 139:13–16). ICU technology allows us a window into these exquisite workings, but just as we cannot distill our own complexity to a single word or trait, so also must we assess all facets of illness when we consider the nearness of heaven. Medications are just one piece of the puzzle, and especially when they have potential to hurt, to cling to them and ignore other details skirts toward idolatry.
Above all, whether numbers unsettle us or embolden us, our hope resides not in the dosages meted out by pumps but rather in Christ. Only in him may we find peace and rest (Matt. 11:28).
Take-Home Points
Vasopressors and inotropes are powerful medications that support blood pressure and heart function.
Administration of these medications requires insertion of arterial and central venous lines. These catheters are ubiquitous in ICU care but confer risks of infection, clotting, and vessel injury.
In the ICU we can measure blood pressure within large arteries but cannot discern or control blood flow through the small vessels that supply organs. As a result, although we can adjust vasopressors to achieve a normal blood pressure, the extremities, intestines, kidneys, and liver may suffer permanent damage.
Inotropes also have limits, with high doses conferring risks of heart attack and fatal arrhythmia.
We may be tempted to use pressor and inotrope doses as a way to measure progress. However, these numbers represent single data points. Just as God made us in his image as complex and intricate beings, a solitary number cannot exclusively predict life or death.
7
Artificially Administered Nutrition
Few end-of-life issues rival artificially administered nutrition in public controversy. The tragic case of Terri Schiavo captured media attention in the early 2000s, as debates about whether to remove her feeding tube after fifteen years in a vegetative state went up the echelons of the judicial system, all the way to the Supreme Court.1 Tragic images of loved ones kissing her elicited emotional and polarizing responses from human rights advocates, the president of the United States, and even the Vatican.
While all end-of-life dilemmas incite conflict, our conscience recoils at the notion of withholding nutrition. When we cradle an infant and satisfy her cry for milk, our provision of food flows with tenderness. The equivalence of food with compassion persists into adulthood, manifested in holiday feasts, quiet everyday meals with family, and dinners over which we fall in love. Memories that shape us abound with overflowing tables.
In contrast, artificially administered nutrition bears little resemblance to these meals and traditions that sustain us. Artificial food arrives at the hospital as a beige liquid packaged in plastic bottles. Tubes and pumps replace candelight and place settings. From the doorway, artificially administered nutrition seems more akin to a medical intervention than to the human experience we all covet, and yet the thought of withholding such nourishment strikes us as subversive, even inhumane.
In many cases, withholding tube feeds does fly in the face of our biblical call to love one another (Matt. 22:39; John 13:34–35). A well-meaning and frightened son under my care once refused a temporary feeding tube for his mother, who had suffered a stroke, out of conviction that she would never want to be dependent on tubes and machines. Yet in her case, the tube was a temporary measure necessary for her recovery. After a lengthy and painful debate involving the ethics committee, she received the feeding tube and two months later had it removed when she could eat again.
Conversely, the tube is often ill-advised for a dying patient. The intestines shut down at the end of life. Force feeding as death nears creates painful cramping and bloating, and the tubes themselves are uncomfortable and fraught with complications. As our lives draw to a close, we may elect to simply feed ourselves as able, without artificial sources of nutrition. The Bible does not require us to lengthen our dying, and our view of the cross should coax us to loosen our grip on futile interventions.
At the Bedside
Every morning I would find her propped in a chair, facing a window to gaze at the sunrise as it spilled onto the Charles River. Sometimes she wouldn’t notice me as I entered; her mind was so intent on the flecks of gold dancing upon the water. Yet even as the early morning bathed her in its glow, she would cough, and her breathing would rattle.
“How are you doing?” I asked one morning.
She shrugged. She was trapped in a hospital at the end of life. Once she left the ICU, she would transition to hospice. Whether it was her sorrow or her own fragile breathing that stole her words, she spoke little.
I motioned to my own nose. “No more tube?” I asked.
She grimaced and shook her head. “No more,” she said.
“She took it out overnight,” her nurse, who had appeared behind us, interjected. “The team didn’t think it was right to push her about replacing it.”
I turned to the patient. “Food and drink might make you cough and make your breathing worse.”
“I know,” the patient answered. “I get it. But I can’t take it. I just want a popsicle. Or ice cream. Tube . . .” she gasped for breath, “tube is awful.”
“I’ll get you a popsicle,” I promised. She smiled wearily before returning her attention to the cascade of light upon the river.
When I returned with a popsicle and a container of ice cream, I found her son in the room, standing above her and glowering.
“You can’t eat, Mom,” he insisted. “It will make your breathing worse. You need the feeding tube.” He glimpsed the packages in my hands and scowled at me. “Doctor, what are you doing?”
“She asked me for a popsicle and some ice cream.”
“Are you serious?”
“She is.”
“No way. If she’s hungry, she needs the tube back in her nose. Her pulmonologist said if she eats, she could get pneumonia again.” I could see tears brimming in his mother’s eyes as she watched us. Worried our exchange would further upset her, I ushered her son out of her room.
“I c
an’t begin to imagine how upsetting this is for you,” I said in a hushed voice. “But she’s about to go on hospice. We need to focus on her comfort right now.”
“But how can she live on popsicles and ice cream? She’s going to starve to death. The cancer taking her is one thing, but I don’t think it’s right to starve her. She needs the tube.”
“She’s taken the tube out herself three times now and doesn’t want it replaced. It’s not a good solution for her.”
“Then what about placing one surgically?”
“That carries a greater risk of hurting her than the ice cream does.”
He chewed the side of his lip and stared at the ground as he shook his head. “I don’t know about this. I don’t like it. I need to talk to our priest; see what he thinks.”
When we returned to the room, she no longer explored the glimmering horizon. With her eyes cast downward, she wept softly and stared at the blank linoleum floor.
When Might We Need Artificially Administered Nutrition?
Numerous medical problems impair our ability to feed ourselves. Critical illness diminishes appetite, as anyone sick with the flu can attest. Feeding by mouth in the setting of mechanical ventilation, sedation, brain injury, and delirium either risks choking or is frankly impossible. Diseases of the gut, e.g., pancreatitis, bowel obstruction, poor blood flow to the intestine, diverticulitis, and intestinal bleeding often prohibit a normal diet. Furthermore, the procedures and tests so frequent among critically ill patients can interrupt nutrition delivery.
Aside from its weighty ethical significance, nutrition is essential for recovery.2 The stress of critical illness provokes our enfeebled bodies to break down muscle for energy, consuming their own mass.3 Additionally, poor nutrition weakens our bodies’ immune system, exposing us to dangerous infections. These effects lengthen our ICU stay, prolong our time on the ventilator, and speed death.4
To protect against these hazards, ICU doctors provide calories through a tube entering the gut or through a catheter in the veins. In the following pages, we will review these different types of nutrition to discern when they can help and when they might inflict undue suffering. Throughout, let us remember that our hope springs not from tubes but from the gospel.
Tube Feeds and Nasogastric (NG) Tubes
The simplest method of tube feed delivery, and often the first employed in the ICU, is a nasogastric (NG) tube. This plastic tube passes through the nose, down the throat, and into the stomach. Usually an NG tube is stiff and about a quarter of an inch in diameter, comparable to the dimensions of a large drinking straw. The wide caliber of the tube allows clinicians to remove stomach contents in the event of nausea by connecting the tube to a suction cannister on the wall. When risk of vomiting is low, a weighted, smaller, and more flexible tube can be more comfortable. In the setting of mechanical ventilation, physicians may insert the tube through the mouth, alongside the endotracheal tube, instead of through the nose.
The discomfort of an NG tube requires little explanation. Imagine a pencil up your nose, as well as a perpetual sore throat that worsens each time you talk or swallow. Unsurprisingly, those of us with delirium instinctively remove NG tubes, forcing nurses to restrain our arms to the bed. Nasogastric tubes can also irritate the nasal passages, leading to nosebleeds and sinusitis. Their placement carries a rare, but very serious, risk of malpositioning within the airways instead of the gastrointestinal tract, leading to life-threatening lung collapse (pneumothorax) or pneumonia.5 Finally, as a nasogastric tube keeps open the ring of muscle between the stomach and the esophagus, these tubes lead to regurgitation and inhalation of tube feeds in 25 to 40 percent of cases.6
Nurses connect a feeding tube to a pump that administers formula in preprogrammed volumes, usually continuously at a rate of one-third to one-half cup per hour. Tube feeds may trigger diarrhea, especially among the elderly and when medications are administered through the tubes.7 Physicians and hospital nutritionists add fiber to limit diarrhea, but patients may require a small tube placed in the rectum to control spillage and to prevent skin irritation and ulceration from loose stool.
Gastrostomy Tubes (G-Tubes)
If we require nutrition support for longer than four to six weeks, doctors may recommend surgical placement of a gastrostomy tube. Commonly referred to as a “G-tube” or “PEG” (for percutaneous endoscopic gastrostomy), this tube passes through the abdominal wall directly into the stomach. G-tubes provide more effective and consistent nutrition delivery than NG tubes, and there are fewer episodes of tube clogging.8 When implemented wisely, a G-tube provides nutrition critical to recovery when we cannot feed ourselves. Those of us afflicted with brain injury, debilitating stroke, advanced Parkinson’s disease, or long-term swallowing disorders, to name only a few diagnoses, may especially benefit from G-tube placement.
G-tube placement requires the skills of a surgeon, gastroenterologist, or interventional radiologist. The procedure itself carries risk of injury to the colon, small intestine, and liver, which occurs infrequently but can cause infection or bleeding that necessitates further surgery.9 Dislodgement of the tube within the first week of placement can also leak gastric acid and food into the abdominal cavity, triggering life-threatening infection and earning us a second trip to the operating room. Infection of the abdominal wall around the G-tube occurs in up to 30 percent of cases, requiring antibiotics at minimum and abscess drainage or widespread cutting away of infected tissue in the worst scenarios.10
Major complications occur infrequently with feeding tubes, but when they do, the ramifications can be catastrophic. I once cared for a teenage girl who survived multiple injuries from a car crash, only to die from leakage of stomach contents into her abdomen after her G-tube dislodged soon after placement. Another elderly and frail woman held on through major cardiac surgery but died from pneumonia when her feeding tube was inadvertently threaded into her lung.
In the hospital, no intervention is without risk. The key question, as we consider ICU care in the shadow of the cross, is whether the likely outcome justifies the risks.
Total Parenteral Nutrition (TPN)
Total parenteral nutrition, or TPN, provides nutrients and calories when our gastrointestinal tract is unusable. The high concentrations of salts and proteins in TPN can clot small veins, so TPN requires a central line. This indwelling line, as well as effects of TPN on the immune system, increases the incidence of infection and lengthens the ICU stay for patients receiving TPN.11 Studies suggest that these risks have decreased in recent years and may continue to do so as methods improve; however, current guidelines track away from this particular method except in cases where other options aren’t feasible.12
Does Feeding Help or Hurt?
As heavily as decisions about ventilators and resuscitation weigh upon us, ethics seem even murkier with artificially administered nutrition. Our Christian obligation to care for one another includes attention to hunger and thirst: “Then the King will say to those on his right, ‘Come, you who are blessed by my Father, inherit the kingdom prepared for you from the foundation of the world. For I was hungry and you gave me food, I was thirsty and you gave me drink” (Matt. 25:34–35). Feeding the hungry is a moral imperative as we minister to the vulnerable:
If a brother or sister is poorly clothed and lacking in daily food, and one of you says to them, “Go in peace, be warmed and filled,” without giving them the things needed for the body, what good is that?” So also faith by itself, if it does not have works, is dead. (James 2:15–17)
As Christ loved us, so must we feed the hungry among us.
Yet what if artificially administered nutrition, with its battery of pumps and tubing, worsens suffering or shortens life? How many times shall we replace a nasogastric tube when our husband with dementia, upset and panicked, wrenches it from his nose? At the end of life, as our bodies wither and the workings of our intestines grind to a stop, must we cram our stomachs with formulas that cause bloating, cramping, and diarrhea?
Although it cannot assuage heartache at the bedside, medical knowledge can offer guidance in a few scenarios. As the vignette at the beginning of this chapter suggests, artificially administered nutrition rarely helps at the end of life.13 Although we cringe at the thought of depriving loved ones of nourishment, tube feeds cause bloating, abdominal pain, nausea, vomiting, and diarrhea that actually worsen discomfort during our final days.14 Additionally, as the cardiovascular system and kidneys fail, the extra volume from tube feeds backs up into our lungs, causing coughing, shortness of breath, and a sensation of drowning.15 During our final days, when cure is no longer attainable, forced feeding through tubes hardly represents loving care.
We may worry about suffering from hunger and thirst at the end of life. Yet without functioning intestines, hunger occurs rarely, and feeding with tubes may only prolong our dying without providing any comfort. Simply wetting the mouth, which is a standard practice in palliative care, significantly abates thirst. If a loved one wishes for small amounts of food or liquid at the end of life so that she may enjoy taste and avoid thirst, we should provide these by mouth, with care and affection. What greater love can we show one another than to offer food and drink by hand? If unconsciousness precludes such hand feeding, we need not worry about suffering from hunger and thirst and should not risk nausea and vomiting with compulsory feeding.
End-stage dementia is another condition in which artificially administered nutrition threatens harm. Alzheimer’s and other diseases of cognitive decline complicate swallowing, generate apathy toward eating, and create dependence upon others for feeding. Although tube feeding may seem attractive in such scenarios, data suggest the contrary. In fact, research shows that G-tubes incur such significant harm and offer such scant benefit that both the American and Canadian geriatrics societies recommend against artificially administered nutrition in advanced dementia.16 Feeding by G-tube does not improve survival, augment nutritional status, avoid aspiration, or reduce the incidence of bed sores.17 People stricken with dementia frequently pull at and dislodge feeding tubes, necessitating emergency room visits and the use of restraints, which only further distress those already struggling with confusion.18 To nourish and care for loved ones suffering from dementia, the most compassionate approach is hand feeding for as long as possible, a tactic that encourages life-giving intimacy and social interaction in addition to providing nutrition.