Map of life expectancy at birth from Global Education Project.

Friday, December 08, 2006

For once, nature is kind

As we have often discussed here, the blessings of modern public health and medicine have brought with them the curse of longevity: more and more people who live long enough to enter the twilight zone of progressive dementia. Because I believe that, as my wise teacher Shulamit Reinharz said (more or less, I'm paraphrasing) the myth of the disembodied investigator undermines the very foundations of social science, I have also disclosed that my father is one who bears that curse, or more accurately it is my mother who suffers the most from his condition.

One of the most difficult problems facing family members of people with advanced dementia is how agressively to intervene to try to sustain their bodies. Frail, immobile demented people often eat less and less, to the point where it appears they must be starving, and so doctors and family members decide to insert a feeding tube. L. John Hoffer, in the new BMJ, relieves us of this impossible decision.

It turns out that as people enter the slow, terminal, decline their metabolic requirements also decline -- so much so that what appears to us to be a clearly inadequate diet is not inadequate after all. People in that state stop eating because they have no need to eat. Their BMI, obviously, may be very low by the standards of active people, but there is nothing wrong with that; and as long as their weight is stable, there is no need for concern.

Hoffer does point out that there may be specific reasons why people don't eat enough - their dentures don't fit right, or they just aren't being offered desirable food. Many years ago I happened to spend a night in a charity ward (yup, they used to have them) of a hospital in Philadelphia -- a long room with maybe a dozen beds. The man next to me weighed about 80 pounds, but he refused to eat, even though they kept pushing jello and pudding at him. When the nurse left, I asked him why he wouldn't eat. "The food is cold," he said. When the nurse came back, I passed this along. They then brought him a plate of baked chicken, which he devoured.

Hoffer concludes that tube feeding in nearly all cases is likely to do harm, and violates patient autonomy. Even severely demented people will eat if you put appetizing food in their mouths, and if their bodies actually require sustenance. Dementia is still a hard, sad, long road to travel but this conclusion helps a lot. Now let's hope the word gets out to every nursing home and hospice program on the planet.

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