PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of jmedethJournal of Medical EthicsVisit this articleSubmit a manuscriptReceive email alertsContact usBMJ
 
J Med Ethics. 1998 February; 24(1): 44–48.
PMCID: PMC1377431

Autonomy and paternalism in geriatric medicine. The Jewish ethical approach to issues of feeding terminally ill patients, and to cardiopulmonary resuscitation.

Abstract

Respecting and encouraging autonomy in the elderly is basic to the practice of geriatrics. In this paper, we examine the practice of cardiopulmonary resuscitation (CPR) and "artificial" feeding in a geriatric unit in a general hospital subscribing to jewish orthodox religious principles, in which the sanctity of life is a fundamental ethical guideline. The literature on the administration of food and water in terminal stages of illness, including dementia, still shows division of opinion on the morality of withdrawing nutrition. We uphold the principle that as long as feeding by naso-gastric (N-G) or percutaneous endoscopic gastrostomy (PEG) does not constitute undue danger or arouse serious opposition it should be given, without causing suffering to the patient. This is part of basic care, and the doctor has no mandate to withdraw this. The question of CPR still shows much discrepancy regarding elderly patients' wishes, and doctors' opinions about its worthwhileness, although up to 10 percent survive. Our geriatric patients rarely discuss the subject, but it is openly ventilated with families who ask about it, who are then involved in the decision-making, and the decision about CPR or "do-not-resuscitate" (DNR) is based on clinical and prognostic considerations.

Full text

Full text is available as a scanned copy of the original print version. Get a printable copy (PDF file) of the complete article (963K), or click on a page image below to browse page by page. Links to PubMed are also available for Selected References.

Selected References

These references are in PubMed. This may not be the complete list of references from this article.
  • Gillon R. Medical ethics: four principles plus attention to scope. BMJ. 1994 Jul 16;309(6948):184–188. [PMC free article] [PubMed]
  • Schostak RZ. Jewish ethical guidelines for resuscitation and artificial nutrition and hydration of the dying elderly. J Med Ethics. 1994 Jun;20(2):93–100. [PMC free article] [PubMed]
  • Dresser RS, Boisaubin EV., Jr Ethics, law, and nutritional support. Arch Intern Med. 1985 Jan;145(1):122–124. [PubMed]
  • Paris JJ. When burdens of feeding outweigh benefits. Hastings Cent Rep. 1986 Feb;16(1):30–32. [PubMed]
  • Meilaender G. On removing food and water: against the stream. Hastings Cent Rep. 1984 Dec;14(6):11–13. [PubMed]
  • The ethics of artificial feeding. N Engl J Med. 1988 Aug 4;319(5):306–307. [PubMed]
  • Thomasma DC. Reflections on the offspring's ethical role in decisions for incompetent patients: a response to Sonnenblick, Friedlander, and Steinberg. J Am Geriatr Soc. 1993 Jun;41(6):684–686. [PubMed]
  • O'Mahony D, McIntyre AS. Artificial feeding for elderly patients after stroke. Age Ageing. 1995 Nov;24(6):533–535. [PubMed]
  • Sheiman SL. Tube feeding the demented nursing home resident. J Am Geriatr Soc. 1996 Oct;44(10):1268–1270. [PubMed]
  • Ackerman TF. The moral implications of medical uncertainty: tube feeding demented patients. J Am Geriatr Soc. 1996 Oct;44(10):1265–1267. [PubMed]
  • Rosner F. Why nutrition and hydration should not be withheld from patients. Chest. 1993 Dec;104(6):1892–1896. [PubMed]
  • Slomka J. What do apple pie and motherhood have to do with feeding tubes and caring for the patient? Arch Intern Med. 1995 Jun 26;155(12):1258–1263. [PubMed]
  • Craig GM. On withholding artificial hydration and nutrition from terminally ill sedated patients. The debate continues. J Med Ethics. 1996 Jun;22(3):147–153. [PMC free article] [PubMed]
  • Glick SM. Unlimited human autonomy - a cultural bias? N Engl J Med. 1997 Mar 27;336(13):954–956. [PubMed]
  • Derr PG. Why food and fluids can never be denied. Hastings Cent Rep. 1986 Feb;16(1):28–30. [PubMed]
  • Callahan D. Necessity, futility, and the good society. J Am Geriatr Soc. 1994 Aug;42(8):866–867. [PubMed]
  • Quill TE, Bennett NM. The effects of a hospital policy and state legislation on resuscitation orders for geriatric patients. Arch Intern Med. 1992 Mar;152(3):569–572. [PubMed]
  • Paris BE, Carrion VG, Meditch JS, Jr, Capello CF, Mulvihill MN. Roadblocks to do-not-resuscitate orders. A study in policy implementation. Arch Intern Med. 1993 Jul 26;153(14):1689–1695. [PubMed]
  • Tulsky JA, Chesney MA, Lo B. See one, do one, teach one? House staff experience discussing do-not-resuscitate orders. Arch Intern Med. 1996 Jun 24;156(12):1285–1289. [PubMed]
  • Shmerling RH, Bedell SE, Lilienfeld A, Delbanco TL. Discussing cardiopulmonary resuscitation: a study of elderly outpatients. J Gen Intern Med. 1988 Jul-Aug;3(4):317–321. [PubMed]
  • Havlir D, Brown L, Rousseau GK. Do not resuscitate discussions in a hospital-based home care program. J Am Geriatr Soc. 1989 Jan;37(1):52–54. [PubMed]
  • Morgan R, King D, Prajapati C, Rowe J. Views of elderly patients and their relatives on cardiopulmonary resuscitation. BMJ. 1994 Jun 25;308(6945):1677–1678. [PMC free article] [PubMed]
  • Bruce-Jones P, Roberts H, Bowker L, Cooney V. Resuscitating the elderly: what do the patients want? J Med Ethics. 1996 Jun;22(3):154–159. [PMC free article] [PubMed]
  • Pollack S. Detours on the road to autonomy. A critique of the New York State do-not-resuscitate law. Arch Intern Med. 1996 Jul 8;156(13):1369–1371. [PubMed]
  • Torian LV, Davidson EJ, Fillit HM, Fulop G, Sell LL. Decisions for and against resuscitation in an acute geriatric medicine unit serving the frail elderly. Arch Intern Med. 1992 Mar;152(3):561–565. [PubMed]
  • Hill ME, MacQuillan G, Forsyth M, Heath DA. Cardiopulmonary resuscitation: who makes the decision? BMJ. 1994 Jun 25;308(6945):1677–1677. [PMC free article] [PubMed]
  • Rosner F, Kark PR, Bennett AJ, Buscaglia A, Cassell EJ, Farnsworth PB, Halpern AL, Henry JB, Landolt AB, Loeb L, et al. Medical futility. Committee on Bioethical Issues of the Medical Society of the State of New York. N Y State J Med. 1992 Nov;92(11):485–488. [PubMed]
  • Miller DL, Gorbien MJ, Simbartl LA, Jahnigen DW. Factors influencing physicians in recommending in-hospital cardiopulmonary resuscitation. Arch Intern Med. 1993 Sep 13;153(17):1999–2003. [PubMed]
  • Heffner JE, Barbieri C, Casey K. Procedure-specific do-not-resuscitate orders. Effect on communication of treatment limitations. Arch Intern Med. 1996 Apr 8;156(7):793–797. [PubMed]
  • Dautzenberg PL, Broekman TC, Hooyer C, Schonwetter RS, Duursma SA. Review: patient-related predictors of cardiopulmonary resuscitation of hospitalized patients. Age Ageing. 1993 Nov;22(6):464–475. [PubMed]
  • Murphy DJ, Burrows D, Santilli S, Kemp AW, Tenner S, Kreling B, Teno J. The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation. N Engl J Med. 1994 Feb 24;330(8):545–549. [PubMed]
  • Rosenfeld KE, Wenger NS, Phillips RS, Connors AF, Dawson NV, Layde P, Califf RM, Liu H, Lynn J, Oye RK. Factors associated with change in resuscitation preference of seriously ill patients. The SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Arch Intern Med. 1996 Jul 22;156(14):1558–1564. [PubMed]
  • Tresch D, Heudebert G, Kutty K, Ohlert J, VanBeek K, Masi A. Cardiopulmonary resuscitation in elderly patients hospitalized in the 1990s: a favorable outcome. J Am Geriatr Soc. 1994 Feb;42(2):137–141. [PubMed]
  • Rosenberg M, Wang C, Hoffman-Wilde S, Hickam D, Hickham D corrected to Hickam D] Results of cardiopulmonary resuscitation. Failure to predict survival in two community hospitals. Arch Intern Med. 1993 Jun 14;153(11):1370–1375. [PubMed]
  • Boyd K, Teres D, Rapoport J, Lemeshow S. The relationship between age and the use of DNR orders in critical care patients. Evidence for age discrimination. Arch Intern Med. 1996 Sep 9;156(16):1821–1826. [PubMed]
  • Ghusn HF, Teasdale TA, Pepe PE, Ginger VF. Older nursing home residents have a cardiac arrest survival rate similar to that of older persons living in the community. J Am Geriatr Soc. 1995 May;43(5):520–527. [PubMed]
  • Solomon DH. The US and the UK. An ocean apart? J Am Geriatr Soc. 1990 Mar;38(3):259–260. [PubMed]
  • Williams R. The 'do not resuscitate' decision: guidelines for policy in the adult. J R Coll Physicians Lond. 1993 Apr;27(2):139–140. [PubMed]
  • Rango N. The nursing home resident with dementia. Clinical care, ethics, and policy implications. Ann Intern Med. 1985 Jun;102(6):835–841. [PubMed]
  • Sonnenblick M, Rosin A. Do not resuscitate--decision making. Isr J Med Sci. 1994 Sep;30(9):720–725. [PubMed]

Articles from Journal of Medical Ethics are provided here courtesy of BMJ Group