2023-09-05 07:55:54
【Mingpao News】Editor’s Note: What is “comfort feeding”? Advanced patients are unwilling to eat, and the most common solution is to insert a nasogastric tube for feeding. But will the patient be comfortable with the long-term insertion of the tube for force-feeding? In addition to the extreme discomfort caused by nasogastric tube insertion, there is also the risk of death due to inadvertent force-feeding… For patients with advanced or dysphagia, another alternative can be considered, which is comfort feeding. There are more than ten or twenty applications and rules in this plan, but the key point is: don’t force it, and eat as much as you want according to the patient’s waking time and wishes. Let patients eat as they like, eat at any time, eat what they like, and eat with people they like…
Terminally ill patients are unwilling to take food for severe dehydration, comfortable feeding or nasogastric tube insertion?
Hearing about hunger and dehydration is generally miserable. But hunger and dehydration are not the same for dying people; they are neither hungry nor thirsty as bodily functions gradually shut down. After electrolyte imbalance, the index of consciousness will decrease, and the patient will fall into a hazy state, and the patient will fall into a coma, and eventually die peacefully in his sleep. So, generally there is not much pain.
“Doctor Liang, can you come to my house to see my mother? She hasn’t eaten for 4 days, and now she is in a daze and doesn’t respond to her screams. I’m really worried that she will starve to death. Can you see how to revive her as soon as possible?”
It was the daughter of the patient who called for an appointment. The patient was an old lady in her 80s. After answering the phone, I went to visit on the same day. The patient is in a coma and is believed to have not been eating normally for some time. Since the old lady was unconscious and severely dehydrated, I told my family that she was in critical condition, and if she was not sent to the hospital for treatment, her life might be in danger.
“No, doctor,” the daughter responded immediately. “My mother refuses to go to the hospital. After she was discharged from the hospital last time, she has said hundreds of times, “I will never go to the hospital again! Even if she dies, she must stay at home.” We are reluctant to leave my mother, can you revive her at home?”
Eating as you like—advanced patients who are unwilling to eat and refuse intubation feeding can try “comfort feeding”, that is, do not force them, and eat as much as they like according to the patient’s waking time and wishes. (Toa55@iStockphoto/ design picture, the model in the picture has nothing to do with the case mentioned in the text)
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Continued fasting or death. Interventional treatment is required to maintain life: hanging saline, inserting nasogastric tube
No one is 100% sure whether critically ill patients can be fully cured. But from the perspective of medical equipment, the hospital must be relatively complete. Treatment at home, with limited resources, we can only do our best. “Firstly, blood must be drawn for laboratory tests; secondly, patients must be rehydrated immediately, and salt water is necessary at this stage; thirdly, professional nursing services at home should be implemented as soon as possible, no matter for patients or caregivers, there are professional nurses Home care assistance is very important.”
The blood test report confirmed that the old lady was severely dehydrated, and we immediately arranged for an infusion at home. Under the infusion and drug treatment, the situation has been greatly improved in less than two weeks, and the person is fully awake and in good spirits. Although the family members were not relieved, they were also greatly relieved. The old lady can even walk from the bedroom to the hall, and when she sees me, she still has the spirit to chat with me. She said: “All my life, my favorite thing is to go to the African savannah to see animals. I have been to Kenya alone more than a dozen times. Every time the experience is different, lions, elephants, giraffes, hippos, white rhinos, Antelopes, zebras, wildebeests… There are countless groups of them. Seeing animals in real ecology, I will feel excited and satisfied. Every time I return, I will feel itchy, and I will never forget it.”
Speaking of the African savannah, I am also a fan; although not as hardcore as the old lady, I have already “entered the pit” and have a lot of photos taken in the African savannah in my mobile phone. In addition to animals, my collection is mainly birds. It was rare to have a “confidant”, so I immediately took out my mobile phone and shared it with the old lady. Although the mobile phone screen is small, we enjoy watching it. While tasting the old Pu’er, the old lady patiently judged each piece from the perspective of photography, light and darkness, and background. She said that the most amazing thing was the leaping attitude of the bird, and finally praised me as a “master of bird hunting”. I felt very elated and was amused by the old lady.
It seems that the old lady has passed this threshold. If she can continue to eat normally, she should be able to recover gradually. So, before leaving, I persuaded: “You must be cool! Continue to eat and drink more. After absorbing enough nutrients, your body will naturally recover.” The old lady’s daughter also said immediately: “Mom, you You must listen to the doctor, eat more and drink more. When you are healthy, we will go to Masai Mara, Kenya. Book a hotel and air ticket for October now, okay?”
The old lady nodded and said yes, and I left with peace of mind. Unexpectedly, less than 10 days later, the old lady’s daughter called again and said anxiously: “Doctor, grandma refused to eat again! She spit out every bite of nutritional milk; even if she poured it into her mouth, she turned her head and vomited it out. What? What to do? I’m afraid she will starve to death.”
Fasting is known to have a great impact on the body; continuous fasting will directly lead to death. People with anorexia nervosa will refuse to eat. Therefore, in order to save patients and maintain their lives, interventional treatments must be used, such as hanging saline, inserting nasogastric tubes, and even feeding with gastrostomy.
Prolonging the pain – hanging salt water, inserting the nose, stomach and throat, etc., may prolong the life of the dying elderly, but for them, it may also mean prolonging the pain. (alaskla@iStockphoto)
The wishes of the 80-year-old lady: Persevere in not being admitted to the hospital, not hanging salt water or inserting throat
However, this home consultation is different from the last time. The old lady was in a coma last time, but this time she is fully awake. In the last treatment, she could not express her opinion; this time we have to obtain her consent before giving treatment. Unexpectedly, after being asked, she firmly stated: she will not go to the hospital, do not insert her throat, do not hang salt water, do not take medicine, and do not accept any form of treatment. Her attitude was serious and decisive, and she asked us to promise to respect her wishes, and said: “Don’t forget the promise you made after I fell into a coma.”
That being the case, there really isn’t much that can be done. I had no choice but to persuade her to eat, took a cup of Pu’er tea and a small piece of cake, and invited her to eat with me. The old lady gave me enough face, took a sip of Pu’er tea, and took a small bite of cake. But she just kept it in her mouth and didn’t swallow it; after about 10 minutes, she spit out everything in her mouth. Everyone has nothing to do with her!
Patients with dysphagia can consider comfortable feeding instead of forced eating, and eating with people they like
I can only explain the application and rules of “comfort feeding” to her daughter. The most common solution for advanced patients who are unwilling to eat is intubation. But how can the patient be comfortable if the tube is inserted for a long time for force-feeding? As a result, they will resist the removal, and the doctors and nurses can only further restrain them, and the patients’ hands and even their feet are bound. In addition to causing extreme discomfort, inserting a nasogastric tube also has risks. Accidental force-feeding can lead to death. Therefore, for patients with dysphagia, another alternative that can be considered is comfort feeding. There are more than ten or twenty items in this plan, but the key point is: don’t force it, follow the patient’s waking time and wishes, eat as much as you want. Let patients eat as they like, eat at any time, eat what they like, and eat with people they like.
Family members and caregivers respect and do their best
“As caregivers, we just do our best.” I said to the old lady’s family. Five days later, I visited the old lady again, and my body was weaker, but my consciousness was still clear. The daughter said: “Mom lays in bed most of the time, and only occasionally sits up. We have tried our best to persuade her to eat, but she just refuses. The grandchildren and granddaughters also came back and took turns accompanying her to persuade her, but nothing worked. The first two days Tianlian’s mother’s old friend also came and talked with her for a long time, persuading her to eat, gain strength, and live happily. But her mother replied: She has lived enough and doesn’t want to live anymore. She wants to When she died naturally, she was sober and without any regrets. She also added that she would be cremated after death, and some of the ashes should be scattered on the grasslands of Masai, Kenya. If all goes well, she will be satisfied.”
I feel helpless to hear this. Since the patient has clearly expressed his wishes, the family members and caregivers can only respect them. Any forced intervention in medical treatment and treatment is against the patient’s wishes. At this time, the patient’s daughter said: “Doctor, we have accepted it now. Mom won’t eat anymore, and we won’t force her anymore. But we are most afraid of her hard work, and we don’t want her to starve to death. Can we help her not to work so hard?” “
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End-stage patients often lose the desire and ability to eat and are sent to the hospital for intubation or abdominal distension and vomiting
Most patients at the end stage lose their desire and ability to eat. If the family members can’t bear it and insist on sending the patient to the hospital to insert the throat, nutrients may be poured into the esophagus, but most of the digestion and absorption functions have declined, causing abdominal distension and vomiting, which will only bring more pain. Therefore, under the general principles of advanced care and palliative care, we will not force dying patients to eat. Ineffective medical treatment only prolongs the death process and adds to the suffering.
Three days later, the old lady passed away in her sleep at home, accompanied by her beloved, as she wished.
More than two weeks later, I received a text message on my mobile phone: “Thank you, Dr. Liang. Mom is leaving today.” There are two photos attached, one is a coffin with a Masai Safari yellow jeep printed on it, and the body is printed with Silhouettes of different animals with trees and grass. The other is the front of the jeep. On the left is a photo of an old lady with a bright smile. On the right is a blue-green globe with “*CHAMPION*” and “The Ultimate Safari” written in the middle; a large bunch of colors are placed on it The colorful flowers are really eye-catching and wonderful.
Aunt, have a good journey.
Text: Liang Wanfu
Editor: Chen Shu’an
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