Artificial nutrition and hydration at the end of life

Ethical Implications of Nutrition Therapy at the End of Life

PURPOSE OF REVIEW

Provide an evidence-based resource to inform ethically sound recommendations regarding end of life nutrition therapy.

RECENT FINDINGS

• Some patients with a reasonable performance status can temporarily benefit from medically administered nutrition and hydration(MANH) at the end of life. • MANH is contraindicated in advanced dementia. • MANH eventually becomes nonbeneficial or harmful in terms of survival, function, and comfort for all patients at end of life. • Shared decision-making is a practice based on relational autonomy, and the ethical gold standard in end of life decisions. A treatment should be offered if there is expectation of benefit, but clinicians are not obligated to offer non-beneficial treatments. A decision to proceed or not should be based on the patient's values and preferences, a discussion of all potential outcomes, prognosis for given outcomes taking into consideration disease trajectory and functional status, and physician guidance provided in the form of a recommendation.

The Difficult Decision Not to Prescribe Artificial Nutrition by Health Professionals and Family: Bioethical Aspects

Introduction

Bioethics and nutrition are essential issues in end of life, advanced dementia, life-sustaining therapies, permanent vegetative status, and unacceptably minimal quality of life. Even though artificially administered nutrition (AAN), for this type of health condition, does not improve quality of life and extension of life, and there is evidence of complications (pulmonary and gastrointestinal), it has been used frequently. It had been easier considering cardiopulmonary resuscitation as an ineffective treatment than AAN for a healthy team and/or family. For this reason, many times, this issue has been forgotten.

Objectives

This study aimed to discuss bioethical principles and AAN in the involved patients.

Discussion

The AAN has been an essential source of ethical concern and controversy. There is a conceptual doubt about AAN be or not be a medical treatment. It would be a form of nourishment, which constitutes primary care. These principles should be used to guide the decision-making of healthcare professionals in collaboration with patients and their surrogates.

Conclusions

This difficult decision about whether or not to prescribe AAN in patients with a poor prognosis and without benefits should be based on discussions with the bioethics committee, encouraging the use of advanced directives, education, and support for the patient, family, and health team, in addition to the establishment of effective protocols on the subject. All of this would benefit the most important person in this process, the patient.

Decision Making of Artificial Nutrition and Hydration for Cancer Patients at Terminal Stage-A Systematic Review of the Views From Patients, Families, and Healthcare Professionals

BACKGROUND

Decision making on nutrition and hydration for cancer patients during terminal stage cause critical impacts toward patient's comfort and living quality. The management of nutrition is the main dilemma that arises in these final situations and has been the subject of intense debate over the last few decades.

AIM

To find the views of patients, families, and healthcare professionals related to how decisions are made when cancer patients are at terminal stage.

DESIGN

This systematic review used PRISMA strategy to search and used Critical Appraisal Skills Programme checklist to evaluate the papers.

DATA SOURCES

All English papers through August 2020 that contained the view of the decision making at artificial nutrition and hydration with cancer patients, families, and healthcare professionals at terminal stage were included. Selected studies were independently reviewed, and data collaboratively synthesized into core themes.

RESULTS

Most of the terminal stage cancer patients and their families initially started the decision-making process when facing the reduction of oral intake. There are two primary considerations of patients and families, one is for prolonging patients life, and the other is to maintain their life quality. The voices of patients were influential, but not determinative; families usually had influence, but seldom make the final recommendation by themselves; healthcare professionals frequently face the dilemma about their decision.

CONCLUSION

The decision of nutritional support was dynamic; the interaction between patients and families frequently be hesitated to protect the rights of life, unnecessarily prolonging lifetime. Therefore, a better understanding of the views on nutritional support and processing the clinical guideline of decision making for healthcare professional is necessary.

Palliative and end-of-life care for people living with dementia in rural areas: A scoping review

Background and objectives

People living with dementia deserve to experience the benefits of receiving palliative care and end-of-life services and supports, yet they often do not receive this care compared to those with other terminal diseases. People living with dementia in rural areas often face additional challenges to accessing such care. The purpose of this scoping review was to systematically review and synthesize the literature on palliative and end-of-life care for people with dementia living in rural areas, and to identify and describe key findings and gaps in the literature.

Methods

A collaborative research team approach was used in an iterative process across all stages of this review. Systematic, comprehensive searches were conducted across ten databases and eight targeted websites for relevant peer-reviewed, original research and other less formal literature, published in English, which yielded a total of 4476 results. After duplicate removal, screening, and review, 24 items were included for synthesis.

Results

All items were described and illustrated by frequency distribution, findings were grouped thematically, and five key themes emerged, including: 1) Knowledge about dementia, 2) Availability, accessibility, and utilization of palliative and end-of-life care services and supports, 3) Decision-making about care, the value of a person-centered approach and collaborative support, 4) Perspectives on artificial nutrition, hydration, and comfort care, and 5) Quality of life and death. The main gap identified was literature pertaining to rural populations, especially from locations other than the United States. The influence of rurality on relevant findings was mixed across rural-urban comparison studies, as was the effect of sex and gender across the literature.

Conclusions

Several areas were highlighted including the importance of increasing knowledge about dementia, having early conversations about advanced care and treatment options, providing a person-centered approach, and the potential for using technology to address rural access issues. These findings can be used to inform future research and policy and the development of services, supports, and strategies for rural people living with dementia. Further research is recommended.

Artificial hydration at the end of life: balancing benefits and risks in the absence of conclusive evidence

There is a lack of clear evidence regarding the benefits and harm of artificial hydration at the end of life. Trial findings are conflicting and inconclusive, offering little basis for recommendations. As a result, the advantages and disadvantages of artificial hydration remain largely anecdotal, and decisions about its use, withholding or withdrawal are often based on opinion rather than evidence. In certain circumstances, some patients who are dying might derive benefit from artificial hydration in terms of reducing specific symptoms, such as delirium. This article explores the central questions pertaining to artificial hydration at the end of life by undertaking a critical exploration of the relevant literature.

Strategies for home nutritional support in dementia care and its relevance in low-middle-income countries

Older people suffering from dementia are prone to develop malnutrition. Ensuring adequate nutrition among such patients has always been a challenge for the carers due to the pathological and chronic nature of the disease. In this article, the author tries to analyze the use of five different strategies in providing adequate nutrition for such patients in their own homes by the carers using a narrative literature review method. The strategies include nutrition screening and assessment, training and education program for the caregiver, mealtime environment and routine modification, provision of nutritional supplements, and role of artificial nutrition and hydration (ANH). An attempt was made to critically engage the readers while exploring the feasibility and challenges involved in implementing such strategies in resource-poor settings like low-middle-income countries. The article concludes that the first four strategies should be used in tandem to prevent the risk of malnutrition. It does not recommend ANH and concludes that it does not bring in any added benefit and may worsen the quality of life.

Tube Feeding in Individuals with Advanced Dementia: A Review of Its Burdens and Perceived Benefits

Background

Dementia remains a growing concern for societies globally, particularly as people now live longer. About 90% of individuals with advanced dementia suffer from eating problems that lead to general health decline and ultimately impacts upon the physical, psychological, and economic wellbeing of the individuals, caregivers, and the wider society.

Objective

To evaluate the burdens and perceived benefits of tube feeding in individuals with advanced dementia.

Design

Narrative review.

Methods

Computerized databases, including PubMed, Embase, Medline, CINAHL, PsycInfo, and Google Scholar were searched from 2000 to 2019 to identify research papers, originally written in or translated into English language, which investigated oral versus tube feeding outcome in individuals with advanced dementia.

Results

Over 400 articles were retrieved. After quality assessment and careful review of the identified articles, only those that met the inclusion criteria were included for review.

Conclusion

Tube feeding neither stops dementia disease progression nor prevents imminent death. Each decision for feeding tube placement in individuals with advanced dementia should be made on a case-by-case basis and involve a multidisciplinary team comprising experienced physicians, nurses, family surrogates, and the relevant allied health professionals. Careful considerations of the benefit-harm ratio should be discussed and checked with surrogate families if they would be consistent with the wishes of the demented person. Further research is required to establish whether tube feeding of individuals with advanced dementia provides more burdens than benefits or vice-versa and evaluate the impacts on quality of life and survival.

ESPEN guideline on ethical aspects of artificial nutrition and hydration

BACKGROUND

The worldwide debate over the use of artificial nutrition and hydration remains controversial although the scientific and medical facts are unequivocal. Artificial nutrition and hydration are a medical intervention, requiring an indication, a therapeutic goal and the will (consent) of the competent patient.

METHODS

The guideline was developed by an international multidisciplinary working group based on the main aspects of the Guideline on "Ethical and Legal Aspects of Artificial Nutrition" published 2013 by the German Society for Nutritional Medicine (DGEM) after conducting a review of specific current literature. The text was extended and introduced a broader view in particular on the impact of culture and religion. The results were discussed at the ESPEN Congress in Lisbon 2015 and accepted in an online survey among ESPEN members.

RESULTS

The ESPEN Guideline on Ethical Aspects of Artificial Nutrition and Hydration is focused on the adult patient and provides a critical summary for physicians and caregivers. Special consideration is given to end of life issues and palliative medicine; to dementia and to specific situations like nursing care or the intensive care unit. The respect for autonomy is an important focus of the guideline as well as the careful wording to be used in the communication with patients and families. The other principles of Bioethics like beneficence, non-maleficence and justice are presented in the context of artificial nutrition and hydration. In this respect the withholding and withdrawing of artificial nutrition and/or hydration is discussed. Due to increasingly multicultural societies and the need for awareness of different values and beliefs an elaborated chapter is dedicated to cultural and religious issues and nutrition. Last but not least topics like voluntary refusal of nutrition and fluids, and forced feeding of competent persons (persons on hunger strike) is included in the guideline.

A descriptive study of nasogastric tube feeding among geriatric inpatients in Malaysia: utilization, complications, and caregiver opinions

The strong emphasis on feeding in Asian cultures may influence decisions for nasogastric (NG) tube feeding in geriatric inpatients. We evaluated the utility, complications, and opinions of caregivers toward NG tube feeding in an acute geriatric ward in a teaching hospital in Kuala Lumpur. Consecutive patients aged 65 years and older receiving NG tube feeding were included. Sociodemographic, clinical, and laboratory indices were recorded. Opinion on NG tube feeding were evaluated through face-to-face interviews with caregivers, recruited through convenience sampling. Of 432 patients admitted, 96 (22%), age ± standard deviation = 80.8 ± 7.4 years, received NG tube feeding. The complication and mortality rates were 69% and 38%, respectively. Diabetes (odds ratio [95% confidence interval] = 3.34 [1.07, 10.44], aspiration pneumonia (8.15 [2.43, 27.24]), impaired consciousness (3.13 [1.05, 9.36]), and albumin ≤26 g/dl (4.43 [1.46, 13.44]) were independent predictors of mortality. Other relatives were more likely than spouses (23.5 [3.59, 154.2]) and caregivers with tertiary education more likely than those with no formal education ( 18 [1.23, 262.7]) to agree to NG feeding. Sixty-four percent of caregivers felt NG tube feeding was appropriate at the end of life, mostly due to the fear of starvation. NG tube feeding is widely used in our setting, despite high complication and mortality rates, with likely influences from cultural emphasis on feeding.

Nutritional Vulnerability in Older Adults: A Continuum of Concerns

A nutritionally vulnerable older adult has a reduced physical reserve that limits the ability to mount a vigorous recovery in the face of an acute health threat or stressor. Often this vulnerability contributes to more medical complications, longer hospital stays, and increased likelihood of nursing home admission. We have characterized in this review the etiology of nutritional vulnerability across the continuum of the community, hospital, and long term care settings. Frail older adults may become less vulnerable with strong, consistent, and individualized nutritional care. Interventions for the vulnerable older adult must take their nutritional needs into account to optimize resiliency in the face of the acute and/or chronic health challenges they will surely face in their life course.

Ethical problems related to intravenous fluids in nursing homes

Background:

Intravenous fluids and/or antibiotics are applied to only a limited extent in Norwegian nursing homes, and the patients are often sent to hospital in these situations. A transfer and a stay in hospital may be unnecessary strains for frail older patients. Given this background, a collaborative research project was initiated in a Norwegian county in 2009. A teaching programme was developed, which aimed to strengthen the awareness of ethics, assessments and practical procedures related to intravenous fluid and/or antibiotics among healthcare professionals.

Objectives:

This qualitative study aimed to increase our knowledge of the ethical problems experienced by nursing home nurses in situations related to the administration of intravenous fluids and/or antibiotics.

Research design:

An exploratory design was used, and five focus group interviews were conducted with 26 registered nurses. A hermeneutic analytic approach was applied.

Ethical considerations:

This study was reported to the Norwegian Social Science Data Services in May 2010. The Regional Committee for Medical and Health Research Ethics approved the collaborative research project.

Findings:

The analysis showed that the nurses experienced difficult decision-making situations, which were interpreted as external pressure and internal pressure. External pressure emerged in interactions with patients and relatives. Organizational factors were also interpreted as external pressure. Internal pressure was interpreted as the nurses’ experience of feeling inadequate in situations where it was difficult to protect the dignity of patients.

Discussion:

These findings correspond with international studies, which show that ethical problems often arise during decision-making situations.

Conclusion:

In agreement with the definition of an ethical problem, we found that the nurses experienced uncertainty and disagreements about how situations should be managed. External and internal pressures related to intravenous fluids and/or antibiotics in nursing homes have not been reported in previous studies. Thus, these findings merit further exploration.

Buddhist ethics and end-of-life care decisions

Buddhism has grown in the United States in the past 50 years. Immigrants come following long traditions. American converts are more eclectic. The first Buddhist precept prohibiting harm to living things, the virtue of compassion, and the goal of a peaceful death provide guidance for ethical decision making regarding organ donation, withholding and withdrawing life-sustaining treatment, voluntary cessation of eating, physician aid in dying, and euthanasia. Concepts and views from three Buddhist traditions and views of master practitioners are presented. Case examples illustrate some of the differences within Buddhism. Suggestions for social workers are provided.

Comfort Measures Only

Despite how frequently we say “comfort measures only” (CMO) in the hospital setting, review of the medical literature yields poor representation and definition of the term. Through a survey in our hospital center, we aimed at understanding what doctors understand as CMO. A total of 176 physicians responded to the survey. We asked them about the moment in the patient care timeline when to use it and what degree of respiratory support, laboratory draws, antibiotic therapy, level of care, and code status should be a part of it. Disparities in responses were the norm, and common defining characteristics were the exception.