I found this text very good and wish to share with you fellows :

In response to the many e-mails about end of life decisions, I would like
to put in my two cents worth as a geriatrician and a Parkinson's disease
specialist, with Dr. Lieberman's permission.  This has to do primarily
with decisions regarding feeding, although their are multiple decisions to
be made about one's life's end.

Those making the decision regarding feeding tubes face a huge, almost
innate feeling that if nothing else everyone must be fed.  This is noble,
but not always possible.  There are times when people simply cannot be fed
without consequences.  People with significant dysphagia, for example,
aspirate most of what they swallow.  This means that food and drink go
directly into their lungs.  Only a little gets into their stomach.  A
common way around this is to place a feeding tube, known by physicians as
a percutaneous endoscopic gastrostomy tube or PEG.

A PEG is a rubber tube that is placed by a surgeon or gastroenterologist.
The procedure is not easy, as it requires putting an endoscope into the
stomach via the mouth and esophagus.  This helps the physicians locate the
stomach in relation to the abdominal wall.  After this is done a trocar,
which is a pointed sharp instrument, is pushed through the abdominal wall
directly into the stomach.  A guide wire is threaded through this hole and
up the esophagus  and mouth to use to pull the rubber feeding tube down to
the stomach and out the abdominal wall.  The result is a rubber tube with
the long end hanging out of a person’s abdomen and the short end finding
itself in the persons stomach. Through this liquids can be poured directly
into the stomach for nutrition.

My point here is that this is not as easy a procedure as one might
imagine.  It also is no guarantee that a person will not aspirate.
Stomach contents can still reach the lungs via reflux, and a person’s oral
secretions can still be aspirated.  One can still get aspiration
pneumonia.  One can still die.  On top of this, persons with dementia may
not metabolize the food given via the PEG as well as they once did before
their disease, making the entire procedure futile.  In non-demented
patients, the quality of their lives is directly affected by the knowledge
of an artificial, rubber tube dangling from their belly wall.  It can be
very depressing.

Sometimes PEGs work to extend life, sometimes they do not.  The quality of
that extended life must be taken into account, also.  If the patient, when
he or she is with decisional capacity, decides to be tube fed if the time
comes, then that is their choice.  This must be an informed decision,
however, and must come from the patient, not from anyone else, as long as
the patient is able.

I was sorry to read about the son-in-law from out of town that came back
and wanted everything done.  I have seen this scenario on multiple
occasions and it only results in angst for all involved.  The very best
thing to do for everyone is to make these decisions before they are
necessary.  Healthy persons should discuss various scenarios with their
loved ones and their doctor(s) before a crisis presents.  Once a decision
is made it can, of course, be reversed by the person making it, so one
should not feel like it is etched in stone.  On the other hand, once a
person has expressed his or her wishes in this light, no one should make
the decision to treat that person otherwise.  To deny a person his or her
own choice of how to be treated at the last moments of life is cruel,
inhumane, and incredibly disrespectful of that person..

Lastly, death through lack of nutrition is rather peaceful.  If it helps
loved ones cope, it is good to know that when one lacks nutrition the body
reacts by releasing ketones and other substances that in effect
anesthetize the person.  There are no pains from lack of nutrition itself
in the dying patient.  The most useful analogy I have found is for one to
remember a time when one has the flu.  Then you only want to watch TV and
sleep, nothing else.  You are not lying in bed saying to yourself “I need
to be fed.  Where the heck is the food?!”  Instead, you don’t even think
about food.  It is usually the last thing on your mind.  The dying patient
who is not eating feels the same way.  It is a peaceful death, and who
among us would not wish for our death to be peaceful.  We must accept the
fact that we are all going to die.  A peaceful death is, frankly, what I
think we all strive for.  If you love the patient, and the patient is not
eating, do not force your wishes upon that person.  Do what he or she has
requested.  That is fair.  That is good.  That is, most of all,
respectful.

End of life decisions are a difficult subject at best.  I would encourage
everyone to be very open about these with loved ones and doctors.  Once
again, they are best discussed when all is going relatively well.  When a
crisis comes it is almost impossible to think clearly.  Talk about it now.

Dale R. Hamrick, MD
Senior Primary Care Practice
9 Richland Medical Park, Suite 230
Columbia, SC  29203

..............................
Cheers, Joao Carvalho
Salvador,BA,BR

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