Sunday, March 27, 2005

Neither 'Starvation' Nor the Suffering It Connotes Applies to Schiavo, Doctors Say

The New York Times

Neither 'Starvation' Nor the Suffering It Connotes Applies to Schiavo, Doctors Say

The battle over Terri Schiavo is about life and death, but it is also a war of words - and one of the words most at issue is "starvation."

Ms. Schiavo's parents have repeatedly used the word, as have politicians like the Senate majority leader, Bill Frist of Tennessee.

Commentators have compared Ms. Schiavo's situation to that of starving children in Africa and abandoned animals in shelters.

That kind of language disturbs Dr. Douglas Nelson, a geriatrician in Hickory, N.C. "That is a gross medical error," Dr. Nelson said.

He argues that when a feeding tube is removed, death is caused by dehydration, not loss of nutrition. And despite the emotionally charged language, many doctors say that patients in a persistent vegetative state, like Ms. Schiavo, feel no discomfort when the flow of nutrients through a feeding tube stops.

They contend that the provision of fluids and nutrition should not even be called "feeding." A statement from the American Academy of Neurology states that it should be considered a medical procedure "analogous to other forms of life-sustaining treatment, such as the use of a respirator."

The dispute is not about nitpicking, said Dr. Larry J. Sabato, director of the Center for Politics at the University of Virginia. Interest groups and politicians are adept at "coordinating the use of key words and phrases" that send a consistent message and frame the debate. Scientists and doctors, he said, "are totally unprepared to deal with it."

Language shapes the debate on all sides, said Dr. Kathleen Hall Jamieson, director of the Annenberg Public Policy Center at the University of Pennsylvania. Those who want to reinsert Ms. Schiavo's feeding tube, Dr. Jamieson said, use language "that increases your perception of her as a sentient human being, whose capacity to tell you that she wants to stay alive is limited only by the fact that she lacks the capacity to speak."

The language of the other side, she said, tends toward the clinical, and suggests "that the person who was there is no longer there." What could provide guidance through the "competing narratives," Dr. Jamieson said, is "what science is able to know."

But many who are involved in the debate question the ability of science to determine the truth in such issues.

Evoking concepts like starvation is especially powerful, said Dr. Sean Morrison, a professor of geriatrics and palliative care at Mount Sinai School of Medicine in New York, because "we are so familiar with what it feels like to be hungry" and have experienced the heartbreak of images from famine-ravaged regions.

But in fact, Dr. Morrison said, removing a feeding tube for a patient in a persistent vegetative state, which the courts have determined Ms. Schiavo is in, based on scientific evidence, is vastly different from a conscious person's being refused meals.

"No one is denying this woman food and water," Dr. Morrison said. People in a persistent vegetative state, he said, "have no knowledge of food."

"They don't recognize food," he continued. "If you put food in their mouth, it would sit there until they took a breath, and then that food would go down into the lungs."

Withdrawal of nutrition is a common method for ending life, and many terminally ill patients choose that course, Dr. Morrison said.

"I have never had a patient who has stopped eating and drinking who has expressed that they are hungry," he added.

Conscious patients report discomfort from dehydration, doctors say, so they combat symptoms with lip balms, humidifiers, and ice chips or mouth swabs to prevent dry mouth.

Once doctors stop providing the nutrient paste and fluids that flow through the feeding tube, death usually comes in about two weeks. There is no timetable for such a process, however; every patient is different, and there has been little research.

As the days pass, organs begin to shut down, starting with the kidneys. Toxins build up in the body, and the patient slips into what is known as a uremic coma. The balance of electrolytes like potassium and sodium is upset, disrupting the electrical system that drives muscles. The heart eventually stops.

In the case of Ms. Schiavo, experts say, the potential for discomfort is nonexistent because higher functions like consciousness and the ability to sense pain were destroyed 15 years ago when she suffered the loss of oxygen to her brain.

Dr. Joseph Fins, chief of the medical ethics division of New York-Presbyterian Hospital/Weill Cornell hospital, said that "the window of opportunity to be diagnosed as even minimally conscious" closes within three months of oxygen-deprivation brain damage.

Based on evidence accepted by the courts that Ms. Schiavo is in a persistent vegetative state and not in a more conscious state, Dr. Fins added, "the part of brain that allows one to suffer is not functioning."

And that, he said, "should be reassuring to people who are concerned."

originally published March 25, 2005