Terminal nutrition: framing the debate for the withdrawal of nutritional support in terminally ill patients

The ethics of withholding/withdrawing nutrition in the newborn

The provision of nutrition and hydration to newborn infants is considered fundamental care. For premature and critically ill newborns, similar considerations generally hold true. Nutrition may be provided for these infants using assisted measures such as parenteral nutrition or tube feedings. However, for some newborn infants the provision of medically assisted nutrition may be a more complicated issue. In particular, the goals of nutrition need to be clearly elaborated for newborns with lethal conditions or for whom appropriately administered intensive care is unsuccessful in sustaining life. These infants may benefit from palliative measures of care and a limitation or withdrawal of burdensome or nonbeneficial interventions. This article explores issues pertinent to deciding and communicating the appropriate withdrawal of medically assisted nutrition and implementing palliative comfort measures.

Evidence-based approach to management of fever in patients with end-stage dementia

Alzheimer's dementia and related dementias are incurable illnesses for which curative treatment currently does not exist, and the efficacy of remittive treatment is extremely limited. Persons with advanced dementia commonly develop fever and are at high risk for death. We preformed a systematic review of outcome following fever in patients with advanced Alzheimer's dementia and developed evidence-based recommendations for the treatment of fever in this population of patients. We use a case example to illustrate our discussion.

Could lack of clarity in written advance directives contribute to their ineffectiveness? A study of the content of written advance directives

Since 1991, advance directives have failed to have a significant impact on end of life care. One reason is that despite widespread interest in these documents, few individuals have chosen to issue advance directives. Another reason reported in several studies is that the conditions under which the patient intended the directives to apply are unclear as are some of the treatments requested or declined. The purpose of this study was to describe instructions commonly included in written advance directives concerning the conditions under which the directives should apply and the treatments that are requested or declined. Five hundred consecutive closed medical records were reviewed from the medical and surgical departments of an urban hospital. These records produced 40 (8%) advance directive documents. Patient instructions indicating when the directives should take effect and which treatments should be declined or provided were summarized. Nurses and other health professionals can use this information to assist in patients in making their advance directives as clear as possible and to make patients more aware of the potential limitations of these types of written instructions.

Update on anorexia and cachexia

Declining physical, emotional, and social function as a result of anorexia and cachexia are considerable contributors to discomfort for cancer patients and their families, and they impair the patient's ability to express optimal physical and psychosocial potential as long as possible. This decline no longer has to be accepted as an indispensable sequel to advanced cancer, just as pain is no longer considered to be unavoidable. A routine screening for anorexia and cachexia and associated symptoms is necessary, as is a careful, comprehensive assessment, because the condition is not always obvious. Decisions about anorexia and cachexia treatment are guided by prioritizing the different, concurrent physical, psychosocial, and existential problems and by considering the natural course of the cancer and the effects of antineoplastic therapies. Reversible causes for anorexia and cachexia need to be identified and treated, if appropriate. Nutritional interventions are often indicated; patients with a predominant starvation component and without inflammation may profit the most. New pharmacologic therapies for primary anorexia and cachexia syndrome are expected to enter clinical practice soon; however, until then, treatment with corticosteroids, progestins, or prokinetics may be indicated for some patients. To understand a multicausal syndrome, multimodal and interdisciplinary therapy is required. Specialist palliative care services can be helpful to provide, hand-in-hand with the disease specialists [172], assessment and management of psychophysical symptoms and sociospiritual needs of patients during the course of the illness and at the end of life [173]. Research efforts aim to better characterize subgroups of patients suffering from secondary causes of anorexia and cachexia and to elucidate the mechanisms involved in the primary anorexia and cachexia syndrome. Increasingly individualized treatments are expected with combination treatments that involve different mechanisms including nutrition.

Position of the American Dietetic Association: ethical and legal issues in nutrition, hydration, and feeding

It is the position of the American Dietetic Association that the development of clinical and ethical criteria for the nutrition and hydration of persons through the life span should be established by members of the health care team. Registered dietitians should work collaboratively to make nutrition, hydration, and feeding recommendations in individual cases. Registered dietitians have an active role in determining the nutrition and hydration requirements for individuals throughout the life span. When patients choose to forgo artificial nutrition and hydration, or when patients lack decision-making capacity, and others must decide whether or not to provide artificial nutrition and hydration, the registered dietitian has an active and responsible professional role in the ethical deliberation around that decision. There is strong clinical, ethical, and legal support both for and against the administration of food and water when issues arise regarding what is or is not wanted by the patient and what is or is not warranted by empirical clinical evidence. When a conflict arises, the decision to administer or withhold nutrition and hydration requires ethical deliberation. The registered dietitian's understanding of nutrition and hydration within the context of nutritional requirements and cultural, social, psychological, and spiritual needs provides an essential basis for ethical deliberation on issues of nutrition and hydration.