Ethical Issues in Artificial Nutrition and Hydration

Enhancing the decision-making process when considering artificial nutrition in advanced dementia care

Background:

Nutritional problems often manifest during late-stage dementia, and some families may request to instigate artificial nutrition and hydration (ANH) therapies. In the US, an estimated one-third of nursing home patients with a severe cognitive impairment have artificial feeding tubes inserted. Fear that a relative could experience extreme hunger or thirst if they are not mechanically fed tends to be the main driver behind family's requests to implement artificial or enteral feeding methods. In contrast, artificial hydration is rarely given to older people with dementia in the UK and this practice of non-intervention tends to apply across all healthcare and hospice type environments.

Aim:

This literature review aims to evaluate the evidence to support the use and non-use of ANH.

Method:

A literature review was undertaken to examine the evidence around ANH for patients with dementia to offer support to families or carers contemplating feeding choices.

Conclusion:

This paper challenges the implementation of invasive ANH worldwide. It highlights how resorting to ANH does not necessarily lead to improvements in comfort, survival or wound healing. The risk of aspiration does not appear to significantly alter either.

Home parenteral nutrition for patients with intestinal failure due to advanced cancer

Patients who experience intestinal failure as a result of advanced malignancy can be supported with parenteral nutrition in their own home (HPN). This article describes how to identify which cancer patients would benefit from this therapy and how to ensure it is safely and correctly administered in the home setting.

Hospital Malnutrition Related to Fasting and Underfeeding: Is It an Ethical Issue?

Hospital malnutrition is a relevant clinical issue present in about 50% of patients that is associated with increased morbidity, mortality, and cost of care. Because of the relation of malnutrition with chronic and acute inflammatory processes secondary to disease, nutrition therapy is considered an important medical treatment. However, there is little discussion about the impact of another critical issue related to hospital malnutrition, that is, lack of appropriate food or nutrition therapy given to the patients. Unnecessary fasting practices and the use of inappropriate nutrition prescriptions result in underfeeding that can be a related or direct cause of hospital malnutrition, independent of disease or inflammatory state. Suboptimal prescription of oral, enteral, and parenteral nutrition should be analyzed and discussed from an ethical perspective since this practice has the potential to harm patients. In addition, absence or inadequate provision of nutrition may present barriers for improved patient outcomes and could be prevented by simply recognizing lack of knowledge, skills, or experience in nutrition and entrusting nutrition prescription to interdisciplinary teams with clinicians well prepared in nutrition sciences. This article reviews potential barriers to the prevention or treatment of hospital malnutrition and proposes specific actions that can help clinicians to overcome and implement optimal nutrition not just as medical therapy but also as a basic comfort care that may help patients nutritionally, clinically, physically, and emotionally.

Bridging the Continuum: Nutrition Support in Palliative and Hospice Care

Clinicians and patients in today's technically focused healthcare environment are often faced with decisions of what should be done vs what could be done. The decision to provide or not provide nutrition support during palliative care and hospice care requires an understanding of and respect for patient wishes, an appreciation for the expectations of the patient and family, and open and effective communication. There can be confusion and disagreement concerning what nutrition therapies should be continued and which ones stopped. These decisions can be facilitated by answering the question: When do the burdens of nutrition support outweigh the benefit to the patient? The patient, family members, and healthcare providers should openly discuss and agree upon the goals of nutrition support during palliative care and hospice care.

Enteral nutrition in end of life care: the Jewish Halachic ethics

Providing versus foregoing enteral nutrition is a central issue in end-of-life care, affecting patients, families, nurses, and other health professionals. The aim of this article is to examine Jewish ethical perspectives on nourishing the dying and to analyze their implications for nursing practice, education, and research. Jewish ethics is based on religious law, called Halacha. Many Halachic scholars perceive withholding nourishment in end of life, even enterally, as hastening death. This reflects the divide they perceive between allowing a fatal disease to naturally run its course until an individual's vitality (life force or viability) is lost versus withholding nourishment for the vitality that still remains. The latter they maintain introduces a new cause of death. Nevertheless, coercing an individual to accept enteral nourishment is generally considered undignified and counterproductive. A minority of Halachic scholars classify withholding enteral nutrition as refraining from prolonging life, permitted under certain circumstances, especially in situations where nutritional problems flow directly from a fatal pathology. In the very final stages of dying, moreover, there is a general consensus that enteral nourishment may be withheld, providing that this reflects the dying individuals' wishes. In the event of enteral nourishment becoming a source of overwhelming discomfort, two Halachic ethical mandates would come into conflict: sustaining life by providing nourishment and alleviating suffering. As in all moral conflicts, these would have to be resolved in practice. This article presents the issue of enteral nourishment as it unfolds in Halacha in comparison to secular and other religious perspectives. It is meant to serve as a foundation for nurses to reflect on their own practice and to explore the implications for nursing practice, education, and research. In a world that remains broadly religious, it is important to sensitize health practitioners to the similarities and differences among religions and between secular and religious approaches to ethical issues.

Nutrition, older people and the end of life

Older patients are at increased risk of malnutrition, resulting in higher mortality and morbidity. It is important to address nutritional need early in order to prevent or mitigate these adverse outcomes. Decisions about nutrition and hydration for older people presenting with acute illness or evolving multiple long-term conditions present great difficulty to all involved. Clinicians are more likely to encounter such situations as the population of older people with frailty syndromes expands. The clinical evidence base to guide such decisions is sparse and largely unhelpful. Clinicians must recognise their role in these difficult decisions. In addition to familiarity with the clinical evidence base, they must be fully informed of the legal, professional and moral context of the decisions with which they are faced. Responsible clinicians have a professional duty to elicit, understand and weigh the views of their patient, and where necessary their representatives. This can only be undertaken through a process of facilitated patient choice utilising the available legal and professional decision-making frameworks. Any decision relating to clinically assisted nutrition and/or hydration in a frail older person who is considered to be nearing the end of their life must also include explicit consideration of the needs of that individual for formalised palliative care.

Hydration in advanced cancer: can bioelectrical impedance analysis improve the evidence base? A systematic review of the literature

CONTEXT

Decisions surrounding the administration of clinically assisted hydration to patients dying of cancer can be challenging because of the limited understanding of hydration in advanced cancer and a lack of evidence to guide health care professionals. Bioelectrical impedance analysis (BIA) has been used to assess hydration in various patient groupings, but evidence for its use in advanced cancer is limited.

OBJECTIVES

To critically appraise existing methods of hydration status assessment in advanced cancer and review the potential for BIA to assess hydration in advanced cancer.

METHODS

Searches were carried out in four electronic databases. A hand search of selected peer-reviewed journals and conference abstracts also was conducted. Studies reporting (de)hydration assessment (physical examination, biochemical measures, symptom assessment, and BIA) in patients with advanced cancer were included.

RESULTS

The results highlight how clinical examination and biochemical tests are standard methods of assessing hydration, but limitations exist with these methods in advanced cancer. Furthermore, there is disagreement over the evidence for some commonly associated symptoms with dehydration in cancer. Although there are limitations with using BIA alone to assess hydration in advanced cancer, analysis of BIA raw measurements through the method of bioelectrical impedance vector analysis may have a role in this population.

CONCLUSION

The benefits and burdens of providing clinically assisted hydration to patients dying of cancer are unclear. Bioelectrical impedance vector analysis shows promise as a hydration assessment tool but requires further study in advanced cancer. Innovative methodologies for research are required to add to the evidence base and ultimately improve the care for the dying.

Challenges to improving end of life care of people with advanced dementia in the UK

The end of life care received by patients with advanced dementia and their carers is of increasing importance as the incidence of dementia is set to rise in the next 30 years. Currently, inappropriate admissions to hospital are common in the UK and patients are less likely to be referred to palliative care services, receive less pain control but undergo more invasive interventions compared to their cognitively intact counterparts. Patients and families are seldom informed of the terminal nature of dementia and advance care planning discussions are rare. The aim of this study was to improve the understanding of end of life care needs for this patient group and their carers, and to use this information to devise an intervention to improve care. Qualitative data were obtained from relatives of 20 patients with advanced dementia admitted to an inner London teaching hospital acute National Health Service (NHS) Trust and 21 health care professionals involved in their care. Framework analysis was used to analyse the transcripts. The results showed that participants’ understanding of dementia and its likely progress was poor. Provision of information regarding the future was rare despite high information needs. Attitudes regarding end of life care were often driven by the participant’s illness awareness. These attitudes served to guide the decision making process and appear to be a major barrier to the provision of more appropriate care. Implications for patient care are discussed and suggestions for future interventions are made.

From means to ends: artificial nutrition and hydration

The withdrawal, withholding, or implementation of life-sustaining treatments such as artificial nutrition and hydration challenge nurses on a daily basis. To meet these challenges, nurses need the composite skills of moral and ethical discernment, practical wisdom and a knowledge base that justifies reasoning and actions that support patient and family decision making. Nurses' moral knowledge develops through experiential learning, didactic learning, and deliberation of ethical principles that merge with moral intuition, ethical codes, and moral theories. Only when a nurse becomes skilled and confident in gathering empiric and ethical knowledge can he or she fully act as a moral agent in assisting families faced with making highly emotional decisions regarding the provision, withholding, or withdrawal of artificial nutrition and hydration.

The artificial nutrition debate: still an issue... after all these years

Debate over withdrawal or withholding of artificial nutrition appeared a distant discussion until the furor over the Schiavo case and a Papal Allocation reignited this ethical dilemma. The purpose of this article is to provide a review of the bioethical opinion regarding artificial nutrition, as published in the Hastings Center Report from 1971 until 2007. A clinical and religious history of the evolution and use of artificial nutrition prefaces the review containing common themes and categories framed within a chronology of bioethical and legal events. Finally, an interpretative philosophical discussion is offered on the resurgence of the ethical dilemma concerning withdrawal or withholding of artificial nutrition. Through a combination of classic content analysis and grounded theory, 8 inductively derived categories emerged from a sample of 63 articles/letters with a primary focus on artificial nutrition, enteral nutrition or parenteral nutrition. These categories included illness/treatment trajectory, personhood, family, provider, cost, religion, legal, and ethics and morality. In more than 35 years, surprisingly little has changed with regard to withdrawal or withholding of artificial nutrition. As the Schiavo case revealed, despite a sense in bioethics of a firm consensus about handling the withdrawal of food and water, many are still searching for answers to this dilemma.

Tube feeding in advanced dementia: the metabolic perspective

Problems with the procedure do not fully explain its ineffectiveness