Tube feedings and persistent vegetative state patients: ordinary or extraordinary means?

This article looks at the late John Paul II's allocution on artificial nutrition and hydration (ANH) and the implications his statement will have on the ordinary-extraordinary care distinction. The purpose of this article is threefold: first, to examine the medical condition of a persistent vegetative state (PVS); second, to examine and analyze the Catholic Church's tradition on the ordinary-extraordinary means distinction; and third, to analyze the ethics behind the pope's recent allocution in regards to PVS patients as a matter of conscience. Rather than providing clarification, I argue that the papal allocution has raised many difficult questions. People in situations where decisions must be made about withdrawal or continued ANH are in need of guidance. Moreover, additional analysis is needed to determine whether the papal allocution is in conflict with the traditional Catholic medical ethics understanding of the ordinary-extraordinary care distinction.     

The burdens-benefits ratio consideration for medical administration of nutrition and hydration to persons in the persistent vegetative state.

In this article, Harvey notes the initial confusion about the statement made by the pope concerning artificial nutrition and hydration on patients suffering persistent vegetative states (PVS) due to misunderstanding through the translation of the pope's words. He clarifies and assesses what was meant by the statement. He also discusses the problems of terminology concerned with the subject of PVS. Harvey concludes that the papal allocution was in line with traditional Catholic bioethics, and that while maintaining the life of a patient is favorable, in particular cases this presumption wanes when it is clear that this treatment modality would be futile or very burdensome.     

Nutrition and hydration: an analysis of the recent papal statement in the light of the Roman Catholic bioethical tradition.

This article discusses the unexpectedly firm stance professed by John Paul II on the provision of artificial nutrition and hydration to patients who are in a persistent vegetative state, and it implications on previously held standards of judging medical treatments. The traditional ordinary/extraordinary care distinction is assessed in light of complexities of the recent allocution as well as its impact on Catholic individuals and in Catholic health care facilities. Shannon concludes that the papal allocution infers that the average Catholic patient is incapable of making proper judgments about their own care. Shannon sees the preservation of life at all costs as at least highly troubling, if not as a radical move against the Catholic medical ethics tradition.     

Stopping nutrition and hydration technologies: a conflict between traditional Catholic ethics and church authority.

This article focuses on the troubling effects of the secular values of individual freedom and autonomy and their impact on laws regarding suicide and euthanasia. The author argues that in an increasingly secularized culture, death and dying are losing their meaning and are not thought of within a moral framework. The debate regarding the provision of artificial nutrition and hydration is critically considered in light of the history of Catholic morality as well as within the modern healthcare context, and finally with new insight from the recent statements made by the late pope. Drane argues that the pope's insistence on providing artificial nutrition and hydration despite irreversible persistent vegetative states in unconvincing.     

The impact of Roman Catholic moral theology on end-of-life care under the Texas Advance Directives Act.

This essay reviews the Roman Catholic moral tradition surrounding treatments at the end of life together with the challenges presented to that tradition by the Texas Advance Directives Act. The impact on Catholic health care facilities and physicians, and the way in which the moral tradition should be applied under this statute, particularly with reference to the provision dealing with conflicts over end-of-life treatments, will be critically assessed. I will argue, based on the traditional treatment of end-of-life issues, that Catholic physicians and institutions should appeal to the conflict resolution process of the Advance Directives Act only under a limited number of circumstances. The implications, under the Texas statute, of varied interpretations of Pope John Paul II's recent allocution on artificial feeding and hydration in the persistent vegetative state will also be considered.     

Religion and United States Physicians’ Opinions and Self-Predicted Practices Concerning Artificial Nutrition and Hydration

This study surveyed 1,156 practicing US physicians to examine the relationship between physicians’ religious characteristics and their approaches to artificial nutrition and hydration (ANH). Forty percent of physicians believed that unless a patient is imminently dying, the patient should always receive nutrition and fluids; 75 % believed that it is ethically permissible for doctors to withdraw ANH. The least religious physicians were less likely to oppose withholding or withdrawing ANH. Compared to non-evangelical Protestant physicians, Jews and Muslims were significantly more likely to oppose withholding ANH, and Muslims were significantly more likely to oppose withdrawing ANH.     

Development of an institutional policy on artificial hydration and nutrition

The issues involved in deciding whether to use artificial methods of delivering hydration and nutrition are often very difficult for patients, families, and health care providers. Once private and personal matters, these decisions now frequently involve the judicial system. Five years ago, Hospice of Washington recognized the need for a written policy and wrote the one published here. Its goal is to respect individual preferences and family concerns while addressing the nutrition and hydration needs of dying patients. The policy sets parameters on the issue, provides basic information, and encourages crafting the most fitting resolution to each situation.     

Persistent Vegetative State: A Presumption to Treat

The article briefly analyzes the concept of a person, arguing that personhood does not coincide with the actual enjoyment of certain intellectual capacities, but is coextensive with the embodiment of a human individual. Since in PVS patients we can observe a human individual functioning as a whole, we must conclude that these patients are still human persons, even if in a condition of extreme impairment. It is then argued that some forms of minimal treatment may not be futile for these patients; they may constitute a form of respect for their human dignity and benefit these patients, even if they are not aware of that. Moreover, it is important to consider the symbolic significance of care: while many believe that PVS is a kind of imprisonment, for others providing food and fluids is the only way to testify our proximity to these persons. The best policy would be to provide, as a general rule, artificial nutrition and hydration to PVS patients: this treatment could be withdrawn, after a period of observation and reflection by the family and proxies, on the basis of the proxies' objection to the continuation or of the patient's advance directives specifically referring to this situation.     

Withdrawing life-sustaining medical treatment--a physician's personal reflection

The decision to withhold or withdraw artificially provided hydration and nutrition is one which evolves over time and must be made jointly by the medical team and the patient's family. Although withholding nutrition can be argued to be ethical and appropriate for certain clinical scenarios, it is still a decision which can be difficult to make and, because of different social and legal issues, can be difficult to carry out. This is the story of one physician's journey as he worked with the mother and father of a young child who suffered a severe neurological injury and was left in a persistent vegetative state.     

Using strategic psychotherapy: A case study of chronic PTSD after a terrorist attack

This article describes a case of chronic post traumatic stress disorder (PTSD). The patient came to psychotherapy three years after he was injured in a terrorist attack. He was in a state of dysfunction. The article elaborates on theoretical issues, the choice of strategic model of psychotherapy, the various phases of the therapeutic process and the specific difficulties that such a case presents.     

African indigenous games: Using Bame Nsamenang’s Africentric thoughts to reflect on our heritage,pedagogy, and practice in a global village

As we go global and begin to make early childhood practices universal, certain aspects of communities remain fixed in deep realms of their everyday living and can only be accessed by those who believe in it. Believing in it requires having faith in a practice that will always be better than what others bring as “best practice”. This is because that aspect is what defines who you are and changing it amounts to removing a piece of you with the intention of replacing it with an “artificial part”. This may be the case with African indigenous games that have been played in various settings to define the Africanness of given communities. The values that these games bring to the Africans as they try to hold on to what belongs to them, is discussed in this paper. Bame Nsamenang used such thoughts to propel the Africentrism philosophy to direct thoughts into values that are African in nature, even when there are no clear boundaries of African in Africa. This article focuses on Nsamenang’s Africentric arguments in line with promotion of African indigenous games as a heritage, pedagogy, and a practice.     

When we were comrades together: a note on the language of assessment

From a psychoanalytic perspective, the assessor is seen as more than a gatherer of data; he or she is viewed as a source of information independent of the tests as well as a potential vehicle of change. To effect these functions, the assessor needs to pay close attention to the language he or she uses in interaction with the patient. In this article, I present a case and then discuss it in terms of the role of language in the assessor-patient relationship: specifically, how the language used facilitated the establishing of a working alliance, the promoting of a meaningful dialogue, and eventually led to a deeper understanding of the patient.     

When We Were Comrades Together: A Note on the Language of Assessment

From a psychoanalytic perspective, the assessor is seen as more than a gatherer of data; he or she is viewed as a source of information independent of the tests as well as a potential vehicle of change. To effect these functions, the assessor needs to pay close attention to the language he or she uses in interaction with the patient. In this article, I present a case and then discuss it in terms of the role of language in the assessor-patient relationship: specifically, how the language used facilitated the establishing of a working alliance, the promoting of a meaningful dialogue, and eventually led to a deeper understanding of the patient.     

A discussion of some moral issues in nutrition and feeding

In this essay we review a number of values and conflicts involved in human nutrition in order to clarify the sources of resistance to accepting a pump-fed patient on the part of nursing home nurses. The case illustrates the complexities of our feelings and values in the area of intrusion showing the need for continued reflection upon and revision of our intuitive reactions. The case also displays conflict resolution.     

The Other Game: A Journey into the World of Warcraft

ABSTRACT

Many people today live out significant aspects of their internal lives online, in a digital world. Rather than analyze these worlds as mere metaphors for real life, it has become increasingly important for psychotherapists to be willing to participate in these worlds as they are described during the clinical hour. It is necessary to work within a paradox: An online fantasy world takes away from living life in the outer world; the world online offers the safety necessary to help the patient approach living his life in any world. This article explores a case in which I learn to work within the parameters of an online gaming experience—World of Warcraft?—to help a patient integrate split-off aspects of himself as he develops the capacity to own his desires. In this case, the game functioned as an “Eden project” (Hollis, 1998, p. 33), an earnest, if severely constricted, search for paradise lost. This article illustrates what was found—not Eden, but true Otherness.     

Questioning the Presumption of Naturalism in the Social Sciences: A Case Study

An important consensus has occurred across the social sciences: The best philosophy for guiding knowledge advancement omits any substantive reference to an active transcendent being. This philosophy of naturalism is so prevalent that social science disciplines renowned for examining research philosophies, such as anthropology, overlook naturalism. This article describes an anthropological case in point: E. E. Evans-Pritchard’s study of the Azande people. Evans-Pritchard is noted for his thoughtful and thorough cultural studies, and the Azande are noted for their unorthodox, non-naturalistic beliefs. We describe the interaction of this anthropologist and culture and find that he presumes a reified naturalism, which dramatically affects his understanding and treatment of this non-naturalistic culture. We then proffer several lessons and implications for pastoral psychology and psychotherapy that follow from our case study.     

Integrative Therapy in Cases of Pregnancy Following Infertility

This article describes, through several case studies, the use of an integrative therapeutic approach with women who achieved pregnancy after long periods of infertility. Our therapeutic approach includes both verbal and no verbal interventions (relaxation, holding, etc.,) which draws upon the therapist's maternal skills. Our approach includes a focus on both the transference and the real relation with the therapist. The therapist needs to help the patient work though the extensive range of feelings toward the fetus (anger, fear, ambivalence, etc.) that the patient developed while struggling to become pregnant.     

From Knowing to Discovering: Some Suggestions for Work with Anorexic Patients

ABSTRACT

In this article I offer some technical suggestions for psychoanalytic work with anorexic patients. Although focused on an outpatient setting, certain parts of the article will also have utility for inpatient work. As an outpatient therapist working with an anorexic patient, especially in the acute stages of the illness, there are case management demands that need immediate attention. The setting up the particular frame is required to augment the therapeutic work. The most urgent pressure felt by the clinician is the precariousness of the patient’s physical health. This can be experienced as if there is a gun to the head of the therapist. This deathly force must be carefully and constantly grappled with, and particularly so in the most symptomatic stages of the illness. The clinician must work with a patient who might die at any time, yet an anorexic patient cannot be managed the way a suicidal patient would be. The question of technique in this situation is a complex one. Above all, the patient must be met where s/he is. Notwithstanding the uniqueness of each patient there are some specific themes that often arise in the acute stage of the illness. Certain technical suggestions are offered.     

Commentary on "Sedation before ventilator withdrawal

In any important article in the field of clinical ethics, the focus should not be on the specific case example, but rather on the issues it presents for thought and discussion. Barbara Springer Edwards and Winston M. Ueno achieve this end admirably. They present a terminally ill patient who requested termination of ventilator support, despite the overwhelming odds that he would die as a result. The authors ask whether or not the physician acted appropriately in accommodating the patient's wish and in sedating him to decrease suffering in his last moments. They present compelling arguments that sedation was warranted in this case. They also note correctly that competent patients have the right to refuse treatment. However, in addition to the question of sedation, this case raises other important issues, specifically those related to pain management and depression in the terminally ill....     

Treating an HIV/AIDS Patient’s PTSD and Medication Nonadherence With Cognitive-Behavioral Therapy: A Principle-Based Approach

HIV/AIDS patients with medication adherence problems are vulnerable to developing drug resistance, immune system degradation, and opportunistic infections. Poor adherence to antiretroviral medication regimens can be aggravated by psychiatric problems, including depression and posttraumatic stress disorder. This article presents the case study of a patient with HIV/AIDS who was unable to adhere to his antiretroviral medication regimen primarily because of PTSD and depressive symptoms resulting from a sexual assault that had caused his seroconversion. Exposure-based cognitive-behavioral therapy was instrumental in helping the patient overcome his PTSD and depressive symptoms so that he could tolerate his HIV medications. The patient’s symptom relief was evidenced by improved scores on the Impact of Event Scale and Beck Depression Inventory. The article discusses the importance of accurate assessment, therapist flexibility, and principle-based treatment versus strict adherence to manual-based protocols.