End-of-life care.

Many good points were presented in the editorial, "Allowing to Die II" (April 23). Perhaps a few additional points will help those who may some day be confronted with this situation, either as providers, patients, or family members. First, there was an implication in the editorial that discontinuing a feeding tube is somehow different from not starting a feeding tube. There is no difference between withdrawing and withholding any intervention. We should never start an intervention, whether antibiotics, assisted ventilation, or feeding tubes, that we are not willing to discontinue. Second, the term Persistent Vegetative State (PVS) cannot be applied before three or six months, depending on the cause of the brain damage. Both PVS and dementia represent changes in brain structure and function. Neither diagnosis is easy. Finally, PVS patients are, in fact, dying. The condition is irreversible; the brain cannot recover.

Traditionally, Catholic theologians have considered physiology as well as theology in their writings on end-of-life care. That kind of nuance was markedly absent from the pope's recent statement. John Paul II's call for "awakening centers" contradicts medical realities. While we often wish for a cure for our severely ill or injured patients, we know this is often impossible.

There has already been harm done by the pope's statement. People have changed their advance directives. Family members are demanding tube feedings for dying patients, "because the pope says we have to." To have a family member die is almost universally difficult. The recent Vatican statement increases these burdens inappropriately and unnecessarily.

MIMI MAHON

Bryn Mawr, Pa.

The writer is an advanced practice nurse in palliative care and ethics and a senior fellow at the University of Pennsylvania Center for Bioethics.