Pondering the body's appetite controls

Why is it that many people who are very elderly and/or near death have no appetite? Some believe that the body's hormones and metabolism change dramatically with chronic illness and are a cause of a poor intake. Others believe that cogntive decline (inability to know it is time to each, lack of interest in food, etc) are the cause. But after years of working in long-term care with ill and elderly patients, I have come to believe that for many, a lack of appetite is a signal from the patient that they are ready to die. This signal might be a concious effort to stop eating to facilitate death. Or it might be subconcious. But it is very clear that many patients have no interest in food and actually refuse to eat or drink, turning their heads or clenching their teeth when a cup or spoon approaches their mouth.

Time after time I have witnessed well-meaning caregivers and family members of eldery and terminally ill patients try to encourage people to eat. Sometimes this encouragement turns to futile attempts to save a life. Upon occasion I have seen family members force food into a patient's mouth or trick a patient into eating, desperate to prevent their loved one from starving to death.

We (medical professionals, caregivers, and family members) need to begin to listen to signals and respect the rights of our patients and loved ones to refuse nourishment. Force-force feeding is disrespectful and could result in choking.

We need to be less afraid to let our elderly and terminally ill-loved ones choose not to eat and drink, and accept it as part of a natural part of the end of life.

Who chooses: the patient or her daughter?

Presently I am dealing with an issue of a fairly young woman (around 50) with end-stage MS who is not eating or drinking much. She can communicate using yes and no answers and has clearly told the staff at her nursing facility she does not want to be tube fed. However, her adult daughter is her guardian and she wants to save her mom at all costs. The patient emphatically does not want tube feeding but her daughter is planning to have a tube placed against her mother's wishes. The patient's daughter says it is her right as her mother's legal guardian to make that decision.

As a medical professional looking clinically at the situation, it is upsetting that this daughter is over-riding her mother's wishes. However, as a daughter, I understand her reluctance to let nature take its course, despite the fact that she has a terminal diagnosis.

This case raises lots of interesting "food for thought" for doctors, dietitians, nurses, and any of us who will face this type of decision at some point in their life.

The subject of end-of-life decisions is not comfortable for many people. Business Week just published an interesting commentary on the topic from the wife of a fairly young man named Terence Foley who died of cancer at age 67. Read the story of "Lessons Learned from a $618,616 Death at http://www.businessweek.com/mediacenter/podcasts/cover_stories/covercast_03_04_10.htm. In this difficult and revealing article, the author asks herself if the multiple attempts at saving her husband's life were worth it, and seems to conclude that they absolutely were, in costs both financial and emotional.

After several years of fighting cancer in every way possible, Mr. Foley was eventually transferred to hospice where he died as comfortable a death possible given the circumstances. Despite his illness, his last years were very full and he shard many important experiences with his family before he died.

If you have a loved one suffering from a debiliatating chronic disease, you should read this article.