Implications of the Refusal of Tube Feeding

I do not usually agree with Margaret Tighe, but she is correct when she says that BWV will die of dehydration when her tube feeding is ceased. There will also be an element of starvation, depending on how long it takes for her to die. This is the significant issue that needs to be addressed in the wake of Justice Morris's decision in the Victorian Supreme Court.

The judge's decision was a pure legal decision as to whether artificial feeding, in this case by a PEG tube, was medical treatment or palliative care. His emphatic decision that it was medical treatment allows such treatment to be refused or withdrawn. He concluded his judgment by saying that the declaration "will enable the Public Advocate to decide, on behalf of BWV, whether to allow her to die with dignity."

There is no doubt that ceasing the tube feeding will allow BWV to end her state of forced feeding, that creates a life of indignity, of futility and with no quality at all. But will she die with dignity? Without fluid and nutrition, she will dehydrate and to a lesser extent starve until she dies, a process that Justice Morris acknowledged will take from one to three weeks. While her treatment may have been described as burdensome, her dying will be even more so. It is unconscionable to think that BWV would be allowed to suffer in this process, and although she is in a vegetative state, she is conscious; in my view, and certainly in her husband's view, she can experience pain. Hopefully, when the tube feeding is ceased, she will be granted "maximum relief from pain and suffering" as the preamble to the Medical Treatment Act requires. This effectively means that she should be put to sleep with adequate sedation, and kept asleep until she dies. There is no other way to ensure that she does not suffer during this macabre process of dying by imposed dehydration.

It is right to withdraw the tube feeding, Justice Morris indicating that the balance between her autonomy, or right of self determination, and the inviolability of her life (sanctity of life) was in favor of the former, and that her best interests were served by withdrawal. But is it in her best interests to then die by dehydration, even with sedation? Anyone who has witnessed such a process will know the anguish and distress that it causes to the family and carers, others can only imagine it. The RSPCA would be forthright in their condemnation of an animal owner who allowed such a process.

The medical profession has for decades removed artificial ventilators from patients in whom further treatment was futile, always with the agreement of the family. In the majority of instances, the decision to withdraw did not have a legal basis as the family was neither a legally appointed agent or guardian. Yet it has been accepted as 'legal' and never challenged. Justice Morris referred to the comparison between this situation and that of tube feeding, and made it clear that there was essentially no distinction as both were medical treatments that could be withdrawn. There is no doubt that there have been doctors and families who have withdrawn, or not placed, tubes in the past, without recourse to the courts. They have backed their judgment that it was the correct thing to do.

Why has there been this major difference between withdrawing ventilation and withdrawing hydration - both are life support systems? The difference lies in the emotional distinction between the usually quick death from removal of ventilation (a few minutes to a few hours) and the slow, macabre and grossly undignified death from dehydration, even with sedation, and the emotional symbolism of food and water. The Age editorial is right - this is not the same as euthanasia, and that is essentially because the process is totally lacking in dignity. It is simplistic to think of this as an issue simply of withdrawing of treatment, because the treatment is 'burdensome'. It is actually the life that is sustained by the treatment that is burdensome, is futile and without quality. It is the continuing life in this condition that is being rejected. BWV's death will ultimately be as a result of an action, taken at the request of her fully informed, rational family, with the intention of relieving her intolerable suffering, that will hasten her death - but it will not be dignified, and it is for this reason that it will not be an act of euthanasia.

The situation of BWV is not unique. A Professor of Nursing (Aged Care) has indicated that 8% of patients in a nursing home she is responsible for have PEG tubes, and another study showed that 137 out of 175 patients with PEG tubes in nursing homes were suffering from dementia. There are serious problems with the structure, administration and implementation of the Medical Treatment Act. It is time the Labor Government fulfilled it policy to set up an all party Parliamentary Inquiry into the Medical Treatment Act to address these issues.