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March 23, 2007

100 Hours of Starvation

Topics: Remembering Terri

Two years ago today, as her family unsuccessfully petitioned a federal appelate court, Terri Schiavo was been without sustenance for over 100 hours and was likely experiencing the effects of starvation described by St. Louis neurologist William Burke.

A conscious [cognitively disabled] person would feel it just as you or I would. They will go into seizures. Their skin cracks, their tongue cracks, their lips crack. They may have nosebleeds because of the drying of the mucus membranes, and heaving and vomiting might ensue because of the drying out of the stomach lining. They feel the pangs of hunger and thirst. Imagine going one day without a glass of water! Death by dehydration takes ten to fourteen days. It is an extremely agonizing death.
Noting Terri's 100 hours of suffering, Andy McCarthy of The Corner wrote,
Of course, the physical needs of the body are not limited to food and water. There is also air. But no judge, even in Florida, would ever have had the nerve in Terri's case to permit "the medical procedure that opponents refer to as asphyxiation." Too crude. Too quick. Too obviously murder of a vulnerable innocent. Brazen, instant savagery might wake us from our slumber. For the culture of death, better that we sleep.
Nobody should have to endure a government ordered doctor enduced death via starvation/dehydration. Terri's family is doing something about it - fighting for the rights of the disabled through the Terri Schindler-Schiavo Foundation.

Posted by tim at March 23, 2007 12:30 AM


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Dr. Cranford on Dehydration:

After seven to nine days [from commencing dehydration] they begin to lose all fluids in the body, a lot of fluids in the body. And their blood pressure starts to go down. When their blood pressure goes down, their heart rate goes up.... Their respiration may increase and then ... the blood is shunted to the central part of the body from the periphery of the body. So, that usually two to three days prior to death, sometimes four days, the hands and the feet become extremely cold. They become mottled. That is you look at the hands and they have a bluish appearance. And the mouth dries a great deal, and the eyes dry a great deal and other parts of the body become mottled. And that is because the blood is now so low in the system it's shunted to the heart and other visceral organs and away from the periphery of the body ...

Kate Adamson on Dehydration:

O'Reilly: When they took the feeding tube out, what went through your mind?

Adamson: When the feeding tube was turned off for eight days, I thought I was going insane. I was screaming out in my mind,"Don't you know I need to eat?" And even up until that point, I had been having a bagful of Ensure as my nourishment that was going through the feeding tube. At that point, it sounded pretty good. I just wanted something. The fact that I had nothing, the hunger pains overrode every thought I had.

O'Reilly: So you were feeling pain when they removed your tube?

Adamson: Yes. Oh, absolutely. Absolutely. To say that -- especially when Michael [Schiavo] on national TV mentioned last week that it's a pretty painless thing to have the feeding tube removed -- it is the exact opposite. It was sheer torture, Bill.

O'Reilly: It's just amazing.

Adamson: Sheer torture ...

Judge Lynch (Paul Brophy case) on dehydration:

The removal of a nutrition and hydration tube, wrote Judge Lynch of the Massachusetts Supreme Judicial Court, would likely create some or all of the following effects before death.

The mouth would dry out and become caked or coated with thick material.
The lips would become parched and cracked.
The tongue would swell, and might crack.
The eyes would recede back into their orbits and the cheeks would become hollow.
The lining of the nose might crack and cause the nose to bleed.
The skin would hang loose on the body and become dry and scaly.
The urine would become highly concentrated, leading to burning of the bladder.
The lining of the stomach would dry out and the sufferer would experience dry heaves and vomiting.
The body temperature would become very high.
The brain cells would dry out, causing convulsions.
The respiratory tract would dry out, and the thick secretions that would
result could plug the lungs and cause death.
At some point within five days to three weeks the major organs, including the lungs, heart, and brain, would give out and the patient would die.

Terri's Exit Protocol:

Exit Protocolxxxxxxxxxxxx00038
Patient Care Notesxxxxxxxxxxxxx The Hospice
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xOf The Florida Suncoast
Date
4/19/01xxxxxxxxxxxxxClinical Pharmacy
xxxxxxxxxxxxxxRe: Medication review and symptom management
Pt. is a 37 yo woman in a vegetative state with no apparent signs of distress. Enteral tube-feeding to be discontinued on 4/20/01.
Current Medications:
1. antacid suspension 1-2 tablespoons prn [prn ="as needed"]
2. Naproxen suspension 375 mg Q8* prn menstrual cramps.[Q8* prn ="every 8 hours as needed". Naproxen is a pain-relieving and anti-inflamatory drug.]
3. Vitamin liquid daily.
Upon discontinuation of enteral feeding the following signs/symptoms may or may not occur. The following is a brief list of symptoms for which to monitor and recommended interventions.
1. d/c ["discontinue"] antacid. d/c Naproxen suspension.
2. d/c Vitamin liquid
3. Monitor symptoms of pain/discomfort. If noted, medicate with Naproxen rectal suppository 375 mg Q8* prn.
Wait a minute! George Felos, Michael Schiavo, and all the other advocates of feeding-tube removal have been saying repeatedly that dying by denial of nutrition & hydration is "peaceful" and "painless". They've both said so in interviews and press conferences, such as on Larry King Live. So if dying by denial of nutrition and hydration is, as Michael said,"painless and probably the most natural way to die", then why is medication needed for pain and discomfort?
4. Signs of compromised skin integrity -- continue vigilant skin care, provide moistener to lips, consult wound-care specialist if needed.
As the body dehydrates, the skin loses its tone and dries out. Left untreated, this will lead to cracking and bleeding. The lips are even more sensitive in this respect."Vigilant skin care" is the liberal use of lotions and moisteners to mask these symptoms. The lips must be continually swabbed with special moisteners, and have lip balm applied to them. In the last stages, though, in spite of such measures, skin breakdown often occurs. Because of the body's debilitated state, normal healing mechanisms do not function. Hence the need to consult wound-care specialists to deal with ulcers and open sores.
5. Signs of dehydration
(A) dry lips, mouth. Swab saliva substitute inside mouth prn.(see next page)
After a few days without water, the body stops producing saliva, necessitating the use of a "saliva substitute" to avoid ulceration in the mouth, and a characteristic foul odor on the patient's breath. The cessation of salivation also leads to other complications which appear in the "pulmonary" section.

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxx00039

Patient Care Notesxxxxxxxxxxxxx The Hospice
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xOf The Florida Suncoast

Date

4/19/01xxxxxxxxxClinical Pharmacy Note -- continued

xxxxxxxxxxxxxSigns of dehydration -- continued

(B) decreased urinary output - no change in care plan.

While there may be "no change in care plan", one of the effects of dehydration is incontinence. The patient's diapers or "chux" pads will need to be changed more frequently, until such output ceases entirely.

6. Pulmonary
(A) Inability to clear secretions - reposition and swab mouth, consider scopolamine patch behind ear every 3 days.

Dehydration causes the natural mucus secretions of the mouth, nose, and throat to thicken, as the body struggles to protect these delicate membranes. The lack of saliva exacerbates this problem, preventing the normal swallowing of these secretions. These thick deposits can interfere with breathing. The use of the scopolamine patch promotes drying of these secretions, which prevents their build-up, but hastens the breakdown of the tissues.(B) dyspnea ["difficulty in breathing"]-- nebulize low dose 2-5 mg morphine sulfate Q4* prn.

In the last stages of dehydration/starvation, the patient's breathing will become difficult and labored. He or she may even begin gasping for breath, as even the lungs' ability to effect transfer of gases is compromised. Morphine nebulized into a fine spray relaxes bronchial passages and relieves these symptoms. However, because of the resultant decrease in respiratory efficiency, this may hasten death.

7. Multifocal myoclonus or terminal agitation (sometimes caused by electrolyte imbalance). Consider diazepam rectal administration 5-10 mg. May repeat in 4 hours if not resolved then daily - twice daily as needed.

Myoclonus is twitching or spasm of the muscles. Multifocal means "occurring in many different parts of the body". This is usually the result of imbalance in electrolytes, the chemicals, such as salt, potassium, and calcium, which make your bodies internal electrical "batteries" work. Nerve impulses and muscle contractions are governed by electro-chemical reactions utilizing these chemicals. Dehydration causes these chemicals to be out of balance, interfering with normal nerve and muscle function. This can result in nerves and muscles "firing off" uncontrollably, causing spasm. The patient will writhe and become extremely agitated. If you have ever had muscle cramps resulting from strenuous exercise (especially when you have sweat profusely), you have some idea what this feels like. Imagine having this happen all over your body, repeatedly. Diazepam (more commonly known as Valium) is a muscle relaxant

8. Grand Mal seizure, which is highly unlikely given current conditions and lack of contributing factors (meds). Recommend diazepam 15 mg rectally as indicated in seizure management orders.

In the final stages of starvation and dehydration, the same electrolyte imbalances which can cause muscle spasm can also lead to uncontrolled firing of neurons in the brain, according to a similar mechanism. This results in seizures.

Thank you for the opportunity to collaborate regarding this patient's care.

I would observe, in conclusion, that most of the "treatments" described in this Exit Protocol are in fact not directed at easing the patient's true condition, but in masking the symptoms of dying by starvation and dehydration. These treatments are designed to create the appearance of a peaceful "slipping away", when nothing of the sort is happening. The medications hide the fact that the patient undergoes a lengthy and painful deterioration, in which his/her body wastes away cruelly. Remember this the next time you hear or read someone say that Terri should be "allowed" to die.

Posted by: James at April 1, 2007 10:07 PM