More information on death by starvation. It does not appear to be painful . . .
Little Known About Starvation Death
By David Brown
Washington Post Staff Writer
Wednesday, March 23, 2005; Page A05
Unless a court orders that her feeding tube be reinserted, Terri Schiavo will probably die in the next three weeks of a fatal heart rhythm brought on by the chemical imbalances that arise from extreme dehydration, according to several experts on end-of-life medical care.
But, they are quick to add, that is just a guess.
Very little is known about the timing and mechanism of death when food and water are withheld from people with severe brain damage who are otherwise in fairly good health. Not many people have that experience. Studying their deaths is an extremely low priority.
"I usually tell families not to expect that it will necessarily be very quick," said Joanne Lynn, a researcher at Rand Corp. and an expert on care of the terminally ill. In her experience, patients who forgo even water can live as long as 21 days, although most die in seven to 10. But there is no large series of cases on which to base predictions because "nobody has actually sat down and studied this."
With advanced dehydration, the functioning of many vital organs -- heart, brain, kidneys, lungs -- worsens. But it is difficult to say which is first to fail, tipping a person irreversibly toward death, said Porter Storey, a leader of the American Academy of Hospice and Palliative Medicine who was the medical director of a hospice in Houston for 18 years.
"Their breathing slows down, and then their next breath doesn't come," he said yesterday. "Does that mean the brain, which sends a signal to the lungs, goes first? Or does it mean the lungs failed? We do not precisely know why people die, and it is not something that can be answered by scientific experiment."
Each day the body produces waste (such as acid, potassium and a nitrogen-containing compound called urea) that must be excreted in urine to prevent it from accumulating to toxic levels. To do that, the kidneys require a minimum volume of water, which they extract from the blood, in which to dissolve those substances.
When dehydration becomes severe, the kidneys essentially run out of water to make urine. As production of urine falls, the concentration of toxins rises.
The effect on organs is varied and profound. Ammonia-like substances have a sedating effect on the brain. High concentrations of potassium alter the heartbeat and eventually stop it -- which is the mechanism of the injection used for execution.
Whatever the mechanism of death, experts are virtually unanimous in saying it does not appear to be painful.
"You go into a uremic coma. You go into a stuporous state, and you stay that way until you die," said William A. Knaus, who co-directed the intensive care unit at George Washington University Medical Center for 20 years and is now at the University of Virginia. "There is absolutely no indication that the body reacts to this with stress."
Storey said that in his hospice practice he has "sat at the bedside of thousands of patients as they died, and many of them could tell me how they were feeling when they had gone weeks without eating and drinking." What they told him, he said, was that they did not feel bad at all. Their chief discomfort was a dry mouth. That could be relieved by sips of water or by swabbing the mouth with a water-soaked sponge.
Exactly what hastens death and what makes it more or less tolerable is largely unknown.
Lynn, a geriatrics specialist in suburban Maryland who also serves in the organization Americans for Better Care of the Dying, said end-of-life care is full of beliefs and practices untested by research.
For example, doctors do not know what the best form of sedation is for people suffocating from respiratory failure. Most physicians believe that liberal use of morphine hastens death. But it may not. People who receive it may actually survive longer.
"Nobody has studied it because nobody cares. There is not a National Institute of Advanced Illness," she said.
Part of the resistance comes from a belief that the dying should be beyond the reach of medical experimentation.
Storey said he once proposed a clinical trial to determine whether giving hospice patients intravenous fluids made them more comfortable. One group would be assigned to get the fluids while another would take only the fluids they wanted by mouth. Storey was then going to survey them about how they felt.
Hospices, however, generally frown on IV lines as invasive devices best left behind when a cure is no longer possible. Storey said the review committee at his institution rejected his protocol, saying it was unethical.
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