LETTER: Decision-Making in Acute Critical Illness

To the Editor:

We read with interest the discussion on decision-making in acute critical illness by Rabbi Judah Goldberg, M.D., and the rabbinic postscript by Rabbis Hershel Schachter and Mordechai Willig (TRADITION, Winter 2021).

We heartily agree with Dr. Goldberg that patients and their caretakers are the best judges of the patients’ current level of pain and willingness to try or to forgo various means of alleviating it. We also concur that reducing suffering is critically important. 

We humbly suggest, however, that emerging evidence requires us to think differently about the effects of hydration, nutrition, and oxygen at the end of life. Instead of relieving suffering, withholding these basic necessities may in fact result in a more uncomfortable end-of-life experience by causing both emotional suffering triggered by powerful biological drives and physical pain.

We have investigated the medical research supporting the hospice claim that dying without medically assisted fluids is more comfortable than having the dehydration relieved. Not only is this claim not supported by evidence [1, 2], there is robust evidence from converging sources – clinical research and basic neuroscience – that the opposite is true [3, 4]. 

Clinical research found that medically assisted hydration significantly reduced sedation, hallucinations, muscle twitches (myoclonus), and fatigue [5]. Additionally, supplemental hydration significantly ameliorated pain, depression, anxiety, and nausea. Providing hydration not only measurably reduced suffering, it actually improved patients’ comfort, dignity, and quality of life. 

Drives for food, and water could only be rigorously studied very recently by virtue of advances in technology and genetics. This research, performed on mice, has revealed circuits in the brain dedicated to inducing an emotionally aversive state, i.e., suffering, when activated by thirst and hunger [6]. The circuits activate the cortex of the brain, the location of cognitive activity, which, small in mice, is large in humans.

We are not qualified to comment on the halakhic issues surrounding end-of-life decision-making. Rather, given that the guiding principle outlined by Rabbis Schachter and Willig is the imperative of being sensitive to the patient’s suffering, we should certainly not contribute to that suffering in an attempt to relieve it. This emerging evidence suggests that in most circumstances, we should continue to provide hydration, nutrition, and oxygen for the very same motive outlined by the authors – to relieve the patient’s suffering and allow for a comfortable and peaceful end of life.

Rabbi Daniel Rose is the rabbi of Bnai Jacob Shaarei Zion Congregation and the former director of Jewish Hospice Services for Seasons Hospice of Maryland. 

Nancy Weisman, Ph.D., is a clinical psychologist in private practice in Bethesda, Maryland.

References

1. Good P, Richard R, Symis W, Marsh SJ, Stephens J. Medically assisted hydration for adult palliative care patients. Cochrane Data Systematic Reviews. 2014;(4):CD006273.; doi:10.1992/14651858.
2. Weisman N. The need for informed consent for denial of artificial hydration in hospice and palliative medicine. American Journal of Hospice and Palliative Medicine. 2020; doi 10.1177|1049909120951081.
3. Weisman N. The neuroscience of drives for food, water, and salt. New England Journal of Medicine. 2019;380(18):e33. Doi:10.1056/NEJMc1902946
4. Lowell BB. The neuroscience of drives for food, water, and salt. New England Journal of Medicine. 2019;380(18);e33. doi:10.1056/NEJMc1902946 
5. Bruera E, Hui D, Dalal S, et al. Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial. Journal of Clinical Oncology. 2013;31:111-118.
6. Lowell, BB. The new neuroscience of drives for food, water, and salt. New England Journal of Medicine. 2019;380(5):459-471.