16 Feb Nutrition & Hydration/Persistent Vegetative State (PVS) ? After studying the course materials located on Module 7: Lecture Materials & Resources page, answer the following: Cure
Nutrition & Hydration/Persistent Vegetative State (PVS)
After studying the course materials located on Module 7: Lecture Materials & Resources page, answer the following:
- Cure / care: compare and contrast.
- Basic care: Nutrition, hydration, shelter, human interaction.
- Are we morally obliged to this? Why? Example
- Swallow test, describe; when is it indicated?
- When is medically assisted N/H indicated?
- Briefly describe Enteral Nutrition (EN), including:
- NJ tube
- NG tube
- PEG
- Briefly describe Parenteral Nutrition (PN), including:
- a. Total parenteral nutrition
- b. Partial parenteral nutrition
- Briefly describe Enteral Nutrition (EN), including:
- Bioethical analysis of N/H; state the basic principle and briefly describe the two exceptions.
- Case Study: Terry Schiavo (EXCEL FILE on Module 7: Lecture Materials & Resources page). Provide a bioethical analysis of her case; should we continue with the PEG or not? Why yes or why not?
- Read and summarize ERD paragraphs #: 32, 33, 34, 56, 57, 58.
Submission Instructions:
- The paper is to be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
- If references are used, please cite properly according to the current APA style.
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WEEK 7: NUTRITION AND HYDRATION /PERSISTENT VEGETATIVE STATE (PVS)
Module 7
Watch:
https://www.youtube.com/watch?v=8yxIRjW9x7w&t=3437s BIO 603 3 24 18
ERD 32, 33, 34, 56, 57, 58
1. Cure / care: compare and contrast.
2. Basic care: Nutrition, hydration, shelter, human interaction.
a. Are we morally obliged to this? Why?
3. Swallow test, describe; when is it indicated?
4. When is medically assisted N/H indicated?
a. Briefly describe Enteral Nutrition (EN), including:
i. NJ tube
ii. NG tube
iii. PEG
b. Briefly describe Parenteral Nutrition (PN), including:
NUTRITION and HYDRATION
CURE / CARE
BASIC CARE:
• NUTRITION • HYDRATION • SHELTER • HUMAN INTERACTION
SWALLOW TEST (THICKENED FLUIDS)
MEDICALLY ASSISTED N/H
ENTERAL NUTRITION (EN) (GI TRACT)
NUTRITION / HYDRATION (N/H)
PARENTERAL NUTRITION (PN) (LINE; PORT)
ENTERAL NUTRITION (TUBE FEEDING):
• NASO-GASTRIC TUBE (NG TUBE) • NASO-JEJUNAL TUBE (NJ TUBE) • PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)
EXAMPLES OF
ENTERAL ACCESS
NPO = NOTHING PER ORAL (6-12 HRS)
PURPOSE:
• PREVENT ASPIRATION PNEUMONIA
• UNDERGO GENERAL ANESTHESIA
• WEAK SWALLOWING REFLEX
• GASTRO-INTESTINAL BLEEDING OR BLOCKAGE
PARENTERAL NUTRITION (INTRAVENOUS = IV):
• PARTIAL PARENTERAL NUTRITION (PPN) • TOTAL PARENTERAL NUTRITION (TPN)
VASCULAR ACCESS TO
PARENTERAL NUTRITION
(VENOUS CIRCULATION)
TPN solutions :
• Concentrated • can cause thrombosis of peripheral veins • central venous catheter usually required
TPN not used routinely in patients with an intact GI tract
disadvantages:
• It causes more complications • It does not preserve GI tract structure and function as well (PERISTALSIS) • It is more expensive
Indications
TPN may be the only feasible option for patients who do not have a functioning GI tract or who have disorders requiring complete bowel rest.
NUTRITION / HYDRATION
IN PRINCIPLE, ORDINARY CARE
MEDICALLY ASSISTED N/H
ENTERAL NUTRITION (EN) (GI TRACT)
NUTRITION / HYDRATION (N/H)
PARENTERAL NUTRITION (PN) (LINE; PORT)
PEG
ERD 56. A person has a moral obligation to use ordinary or proportionate means of preserving his or her life. Proportionate means are those that, in the judgment of the patient, offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community.
ERD 57. A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that, in the patient's judgment, do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.
ERD 58. There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient.
N/H, IN PRINCIPLE, ARE ORDINARY MEANS OF LIFE SUPPORT
2 EXCEPTIONS:
• WHEN N/H CAN NO LONGER BE ABSORBED OR ASSIMILATED
• WHEN, IN THE ESTIMATION OF THE DYING PATIENT,
N/H BECOMES AN EXCESSIVE BURDEN
CASE STUDY: TERRY (SCHINDLER) SCHIAVO
(1963 – 2005; AGED 41)
TERRI SCHIAVO TIMELINE
“QUALITY OF LIFE” (SUBJECTIVE)
VS
“SANCTITY OF LIFE” (OBJECTIVE)
SACRED QUALITY OF HUMAN LIFE
,
Sheet2
| 1963 | BORN | 3-Dec-63 |
| Theresa (Terri) Marie Schindler is born in Pennsylvania. | ||
| 10-Nov-84 | ||
| 1984 | MARRIED | Terri Schindler, 20, and Michael Schiavo, 21, are married at Our Lady of Good Counsel Church in Southhampton, Pennsylvania. The union is now among the "celebrity marriages" featured at About.com, a Website about marriage. |
| (20 Y/O) | 1986 | |
| The couple move to St. Petersburg, where Ms. Schiavo's parents had retired. | ||
| 25-Feb-90 | ||
| 1990 | COLLAPSE | Ms. Schiavo suffers cardiac arrest, apparently caused by a potassium imbalance and leading to brain damage due to lack of oxygen. She was taken to the Humana Northside Hospital and was later given a percutaneous endoscopic gastrostomy (PEG) to provide nutrition and hydration. Police report |
| PEG | 12-May-90 | |
| (26 Y/0) | Ms. Schiavo is discharged from the hospital and taken to the College Park skilled care and rehabilitation facility. | |
| 18-Jun-90 | ||
| Court appoints Michael Schiavo as guardian; Ms. Schiavo’s parents do not object. | ||
| 30-Jun-90 | ||
| Ms. Schiavo is transferred to Bayfront Hospital for further rehabilitation efforts. | ||
| Sep-90 | ||
| Ms. Schiavo’s family brings her home, but three weeks later they return her to the College Park facility because the family is "overwhelmed by Terri’s care needs.” | ||
| Nov-90 | ||
| Michael Schiavo takes Ms. Schiavo to California for experimental "brain stimulator” treatment, an experimental "thalamic stimulator implant” in her brain. | ||
| Jan-91 | ||
| The Schiavos return to Florida; Ms. Schiavo is moved to the Mediplex Rehabilitation Center in Brandon where she receives 24-hour care. | ||
| 19-Jul-91 | ||
| Ms. Schiavo is transferred to Sable Palms skilled care facility where she receives continuing neurological testing, and regular and aggressive speech/occupational therapy through 1994. | ||
| May-92 | ||
| Ms. Schiavo’s parents, Robert and Mary Schindler, and Michael Schiavo stop living together. | ||
| Aug-92 | ||
| 1992 | 1/4 M AWARD | Ms. Schiavo is awarded $250,000 in an out-of-court medical malpractice settlement with one of her physicians. |
| Nov-92 | ||
| 1992 | 1 M AWARD | The jury in the medical malpractice trial against another of Ms. Schiavo's physicians awards more than one million dollars. In the end, after attorneys’ fees and other expenses, Michael Schiavo received about $300,000 and about $750,000 was put in a trust fund specifically for Ms. Schiavo’s medical care. |
| (750Th TRUST) | 14-Feb-93 | |
| Michael Schiavo and the Schindlers have a falling-out over the course of therapy for Ms. Schiavo; Michael Schiavo claims that the Schindlers demand that he share the malpractice money with them. | ||
| 29-Jul-93 | ||
| Schindlers attempt to remove Michael Schiavo as Ms. Schiavo’s guardian; the court later dismisses the suit. | ||
| 1-Mar-94 | ||
| First guardian ad litem, John H. Pecarek, submits his report. He states that Michael Schiavo has acted appropriately and attentively toward Ms. Schiavo. | ||
| 6-May-97 | ||
| Michael Schiavo's attorney Deborah Bushnell writes to the Circuit Court to request that the Schindlers receive notice of all filings in the guardianship proceeding, in anticipation of a forthcoming request to withdraw Ms. Schiavo's PEG tube. | ||
| May-98 | ||
| ~1990 | INFIDELITY | Michael Schiavo was in a relationship with Jodi Centonze, and had fathered their first child. He said he chose not to divorce his wife and relinquish guardianship because he wanted to ensure her final wishes (not to be kept alive in a PVS) were carried out. |
| 1998 | MICHAEL | Michael Schiavo petitions the court to authorize the removal of Ms. Schiavo’s PEG tube; the Schindlers oppose, saying that she would want to remain alive. The court appoints Richard Pearse, Esq., to serve as the second guardian ad litem for Ms. Schiavo. |
| PET PEG OUT | 20-Dec-98 | |
| 1998 | TERRI | The second guardian ad litem, Richard Pearse, Esq., issues his report in which he concludes that Ms. Schiavo is in a persistent vegetative state with no chance of improvement and that Michael Schiavo’s decision-making may be influenced by the potential to inherit the remainder of Ms. Schiavo’s estate. |
| PVS OFFICIAL | January 24-27, 2000 | |
| Trial begins with Pinellas-Pasco County Circuit Court Judge George Greer presiding. | ||
| 2000 | JUDGE GREER | 11-Feb-00 |
| REMOVE PEG | Judge Greer rules that Ms. Schiavo would have chosen to have the PEG tube removed, and therefore he orders it removed, which, according to doctors, will cause her death in approximately 7 to 14 days. | |
| 2-Mar-00 | ||
| 2000 | SCHINDLERS | The Schindlers file a petition with Judge Greer to allow "swallowing” tests to be performed on Ms. Schiavo to determine if she can consume—or learn to consume—nutrients on her own. |
| PET SWALLOW | 7-Mar-00 | |
| 2000 | GREER | Judge Greer denies the Schindlers’ petition to perform "swallowing” tests on Ms. Schiavo. |
| DENIES SWALLOW | 24-Mar-00 | |
| 2000 | GREER | Judge Greer grants Michael Schiavo’s petition to limit visitation to Ms. Schiavo as well as to bar pictures. Judge Greer also stays his order until 30 days beyond the final exhaustion of all appeals by the Schindlers. |
| STAY PEG 30 DYS | Greer Stay and Order Limiting Visitation | |
| 24-Jan-01 | ||
| 2001 | 2DCA | Florida’s Second District Court of Appeal (2nd DCA) upholds Judge Greer’s ruling that permits the removal of Ms. Schiavo’s PEG tube. |
| REMOVE PEG | 22-Feb-01 | |
| 2001 | SCHINDLERS | The Schindler family’s motion for an Appellate Court rehearing is denied. |
| APPEAL | 12-Mar-01 | |
| 2001 | MICHAEL | Michael Schiavo petitions Judge Greer to lift his stay, issued March 24, 2000, in order to permit the removal of Ms. Shiavo’s PEG tube. |
| REMOVE STAY | 29-Mar-01 | |
| 2001 | GREER | Judge Greer denies Michael Schiavo’s motion to lift stay issued on March 24, 2000; Michael Schiavo can remove Ms. Schiavo’s PEG tube at 1 p.m. on April 20. |
| REMOVE PEG 1 APR | 10-Apr-01 | |
| The 2nd DCA denies the Schindlers’ motion to extend Judge Greer’s stay, which is scheduled to expire April 20, 2001. | ||
| 12-Apr-01 | ||
| 2001 | SCHINDLERS | The Schindlers file a motion requesting that Judge Greer recuse himself. |
| REMOVE GREER | The Schindlers petition the Florida Supreme Court to stay the removal of Ms. Schiavo’s PEG tube. | |
| 16-Apr-01 | ||
| 2001 | GREER | Judge Greer denies the Schindlers’ motion to recuse himself. |
| REMOVAL DENIED | 18-Apr-01 | |
| 2001 | FL SUPREME | The Florida Supreme Court chooses not to review the decision of the 2nd DCA. |
| REFUSE REVIEW 2DCA | In re Schiavo, 789 So. 2d 248 (Fla. 2001). Case No.: SC01-559 | |
| 20-Apr-01 | ||
| 2001 | FED CT JD LAZZARA | Federal District Court Judge Richard Lazzara grants the Schindlers a stay until April 23, 2001, to exhaust all their possible appeals. |
| PEG STAY 4/23/01 | 23-Apr-01 | |
| 2001 | SUPREME CT KENNEDY | Justice Anthony M. Kennedy of the United States Supreme Court refuses to stay the case for a review by that Court. |
| REFUSE STAY | 24-Apr-01 | |
| 4/23/01 | PEG 1 REMOVED | By order of trial court Judge Greer, and upon issuance of a 2nd DCA mandate, Ms. Schiavo’s PEG tube is removed |
| 26-Apr-01 | ||
| 4/26/01 | SCHINDLERS | The Schindlers file an emergency motion with Judge Greer for relief from judgment based upon new evidence, which includes a claim that a former girlfriend of Michael Schiavo will testify that he lied about Ms. Schiavo’s wishes; Judge Greer dismisses the motion as untimely. Also on this date, the Schindlers file a new civil suit that claims that Michael Schiavo perjured himself when he testified that Ms. Schiavo had stated an aversion to remaining on life support. Pending this new civil trial, Circuit Court Judge Frank Quesada orders Ms. Schiavo’s PEG tube to be reinserted. |
| 4/26/01 | JD QUESADA | |
| REINSERT PEG 1 | ||
| 4/30/01 | MICHAEL | 30-Apr-01 |
| APPEALS | Michael Schiavo files an emergency motion with the 2nd DCA to allow the removal of Ms. Schiavo’s PEG tube. | |
| 9-May-01 | ||
| The 2nd DCA announces a date for the hearing of oral arguments regarding Michael Schiavo’s motion of April 30, 2001. | ||
| 11-Jul-01 | ||
| 7/11/01 | 2DCA | The 2nd DCA remands the case back to Judge Greer. (1) The 2nd DCA informs the Schindlers that they must address both their desire to have new evidence heard and their perjury claim against Michael Schiavo within the original guardianship proceeding; further, the Schindlers are instructed to file a new motion for relief from judgment in the guardianship proceeding. (2) The 2nd DCA instructs Judge Greer to weigh the Schinders’ new evidence in making a new determination of what Ms. Schiavo would have wanted. (3) The 2nd DCA denies Michael Schiavo’s request to discontinue the PEG tube. |
| CASE BACK TO GREER | 7-Aug-01 | |
| After the 2nd DCA remands the case back to Judge Greer, he again finds that Michael Schiavo may remove Ms. Schiavo’s PEG tube on August 28. | ||
| 10-Aug-01 | ||
| AUG/10/01 | GREER | Judge Greer denies the Schindlers' motion (1) to have their own doctors examine Ms. Schiavo, (2) to remove Michael Schiavo as her guardian, and (3) to disqualify himself from the proceedings. |
| REMOVE PEG 29 AUG | 17-Aug-01 | |
| AUG/17/01 | GREER | Judge Greer delays the removal of Ms. Schiavo's PEG tube until October 9 in order to allow the Schindlers time to appeal. |
| PEG STAY OCT/9/01 | 3-Oct-01 | |
| OCT/3/01 | 2DCA | The 2nd DCA delays the removal of the PEG tube indefinitely. |
| PEG STAY INDEF | 17-Oct-01 | |
| OCT/17/01 | 2DCA | The 2nd DCA rules that 5 doctors should examine Ms. Schiavo to determine if she can improve with new medical treatment. The Schindlers and Michael Schiavo are to choose 2 doctors each, and the court is to appoint a doctor. The appeals court also affirms Greer’s denial of the motion to disqualify himself |
| RULE 5 MD EXAM | 1-Nov-01 | |
| The 2nd DCA denies Michael Schiavo’s motion to rehear the case. | ||
| 14-Dec-01 | ||
| DEC/14/01 | MICHAEL | Michael Schiavo petitions the Florida Supreme Court to stay the October 17, 2001, ruling of the 2nd DCA. He states that he and the Schindlers will attempt to mediate the dispute in lieu of further litigation. |
| PET FL SUPREME CT | Michael Schiavo’s Notice of Appeal to the Florida Supreme Court | |
| 19-Dec-01 | ||
| Attorneys meet with a mediator to determine which tests doctors should run on Ms. Schiavo. | ||
| 10-Jan-02 | ||
| JAN/10/02 | FL SUPREME | State Supreme Court stays all legal proceedings pending mediation; it orders attorneys to report on the status of mediation in sixty days. |
| STAY ALL TILL MED | 13-Feb-02 | |
| FEB/13/02 | MED FAILS | Mediation between the Schindlers and Michael Schiavo fails. |
| 14-Mar-02 | ||
| The Florida Supreme Court denies Michael Schiavo’s petition to review the 2nd DCA’s ruling allowing 5 doctors to examine Ms. Schiavo. | ||
