To the Editor:
We were appalled by the July 1998 response (Vol. 24, No. 7) of Monica J. Cox, Gerontological Nurse Practitioner, to Dr. Kapp's critique of her article, "Nutrition and Hydration in Vulnerable Populations" published in the February 1998 issue of the Journal of Gerontological Nursing (Vol. 24, No. 2). How dreadful that the Creator who has decreed that there is "a time to be born and a time to die" [Ecclesiastes 3:2] would ordain such a death as described in Brophy v. New England Sinai Hospital for dying people since time began who have not had access to artificial nutrition and hydration!
In our experience as hospice nurses in Skilled Nursing Facilities, we have never witnessed a swollen, cracked tongue or symptoms of "burning of the bladder." We have witnessed patients suffering from vomiting, respiratory distress, and fevers of 107° because their tube feedings were continued as their bodies were shutting down.
The patient for whom Ms. Cox would provide artificial nutrition and hydration already has an "illness or injury." Daniel Callahan (1994) writes, "'Letting die' is only physically possible if there is some underlying disease that will serve as the cause of death" (p. 77). Artificial feeding withdrawn from any one of us would not cause death.
Loss of appetite and decreased intake is a normal, natural process. Comfort can be maintained with measures to keep the mouth clean and moist, repositioning, appropriate medications, and tender loving care to patients and families.
If we consider how we feel about food when we have the flu, we will understand that patients nearing the end of life are not suffering from starvation. It is not comfortable to eat or be fed when one is not hungry. Helen Nearing (1992) writes, "Death by fasting is a slow, gentle diminution of energies, peaceful, and natural" (p. 183). Our involvement in direct patient care in vulnerable nursing home populations has confirmed this finding repeatedly.
We have been at the bedsides of many patients as they were dying. Those who are most comfortable are the patients who have been permitted to decrease their intake of food and fluid.
Callahan, D. (1994). The troubled dream of life. New York: Simon & Schuster.
Nearing, H. (1992). Loving and leaving the good life. White River Junction, VT: Chelsea Green.
Erma Mae Perkins, RN, CRNH
Lorri Jacobs, RN
Barbara Cestero, RN
Jennifer Walter, RN
Sharon DeLorm, RN
Priscilla Lynn, RN
Leath DeRitter, RN, CRNH
Rush, New York
I certainly can understand why these nurses were appalled at my response to Marshall B. Kapp, JD, MPH, given the hospice philosophy of caring. While comfort for the dying is a noble cause in and of itself, to aid in hastening the death of a human being by dehydration is not of outstanding character. It is in fact taking away your patient's inherent time to die as planned by our Creator.
In my article, I presented both sides of the issue in withholding or withdrawing fluids and nutrition in vulnerable populations. This is more than hospice presents to patients and their families when these issues are discussed. Families have addressed me in their anguish after they have witnessed the death of their loved ones through dehydration. They question why hospice did not give them all the facts related to these end-of-life issues.
You have witnessed death through biased vision, for as human beings we perceive life events through our own world view. As hospice nurses entwined in a philosophy of death as you know it, you limit your depth of understanding of life itself.
Monica J. Cox, RN, CS, MSN,
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