Allen Sandler (2009) argued appropriately about the need to be cautious before concluding that the sudden onset of lethargy, lack of responsiveness, noncommunication, and refusal to eat or drink in a severely intellectually disabled person signals a terminal illness that justifies transfer to hospice. I am concerned, however, that he believed the intervention required in this scenario was the placement of a gastrostomy tube (I assume that he means a percutaneous endoscopic gastrostomy [PEG] tube.) He correctly noted that clinicians must make a distinction between the futile and possibly unwelcome (by the patient) use of gastrostomy tube feedings at the end of life and the use of PEG feedings to restore caloric balance in persons with a chronic disability whose food refusal is not related to the process of dying.

To illustrate his point, Sandler (2009) described the case of a 49-year-old...

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