Saturday, November 9, 2013

How it Feels to Force-Feed

June 2013

The intubation of prisoners on hunger strike at Guantanamo Bay, the use of force-feeding to stifle dissent, took on a disturbing clarity for me in the process of becoming a registered nurse. I had to ask myself how a nurse, in the context of the prison system, could agree to perform an act of torture.

The procedure itself, typically used when a patient is unable to swallow or otherwise maintain adequate oral nutrition, is a familiar one. Supplies are gathered and laid out. The patient or prisoner is positioned at an angle of at least 45 degrees to avoid aspiration of the feeding contents. Physical or chemical restraints may be ordered to prevent self-harm resulting from resistance to the procedure. A flexible plastic nasogastric tube is held and measured from the tip of the nose to the earlobe, from the earlobe to the xyphoid process, to approximate the distance from the nostril to the stomach. The tip of the nasogastric tube is lubricated and inserted through the nare, guided through the nose to the back of the throat. The patient or prisoner may cough and gag when the tube reaches the epiglottis and should be instructed to tuck his chin down toward his chest and swallow to guide the tube into the esophagus. When the tube has been inserted to the measured point and secured to the nose, placement in the stomach must be verified by x-ray. The most accurate bedside technique to verify placement is the extraction of gastric secretions by syringe and testing to confirm an acidic pH. Liquid nutrients are then delivered directly to the stomach by force of gravity. The tube is flushed with 30 cc 's water or normal saline to ensure complete delivery of the feeding contents. The tape is removed from the nose and the patient or prisoner is instructed to hold her breath as the tube is removed.

Violence is not innate in any person, and a nurse does not independently decide that performing torture is compatible with her role. To some, the violation of a prisoner's autonomy and bodily integrity may be justified by concluding that the breach is necessary for the protection of the prisoner's life. In no other context is it considered justifiable to force-feed a patient who will not consent to eat, whether or not it is necessary for the preservation of life. I believe another force is at work here. In treating patients under a privatized medical system organized by profit, nurses are regularly asked to place speed of production over quality of care. Performing all necessary procedures in a timely manner on a floor with a low nurse-to-patient ratio may require that a nurse treat each patient as a set of necessary tasks to be completed and documented. Guidelines for the use of restraint and the acquisition of consent are set in state Nurse Practice Acts and clarified in a facility's Policy and Procedure Manual. This provides a baseline of ethical practice, but it may also distance nurses from daily engagement with ethical reasoning. Selective dehumanization of prisoners or patients is more conceivable in this context.

The insertion of a tube through the narrow nasal passages, along the length of the esophagus and into the stomach is uncomfortable at best, and by circumstance, technique, or a patient’s condition, painful and terrifying. The ease of the procedure is determined largely by the patient's cooperation; positioning of the head and forceful swallowing guide the nasogastric tube into place. In 1914, Djuna Barnes underwent the procedure, then used on hunger-striking suffragists, as a journalistic experiment: "All of life's problems had now been reduced to one simple act-- to swallow or to choke." I cannot claim understanding of how it feels to be tortured for having performed a medical procedure on myself in the safety of my apartment. I have no means of identification with a prisoner held in indefinite detention, denied confidential counsel, stripped of consent. In performing the procedure of nasogastric tube feeding on myself, I did not attempt to understand the impossible contradiction of being forcibly fed by my own hand, but rather, sought a relationship with the experience of a nurse acting as a torturer.

"Limits surely there are to the subservience even of those who must sternly execute the law." --Djuna Barnes