The Use of Advance Care Planning to Guide Decisions About Artificial Nutrition and Hydration

Effects of Visual Aids for End-of-Life Care on Decisional Capacity of People With Dementia

Purpose This study evaluated the decision-making capacity of persons with mild and moderate dementia on end-of-life care when using visual aids. A secondary purpose was to learn whether the judges naive to the experimental conditions would rate participants' decisional abilities as better when augmented by visual aids, thereby validating the behavioral changes due to the use of these external support. Method Twenty older adults with mild and moderate dementia demonstrated Understanding, Expressing a Choice, Reasoning, and Appreciation of 2 medical vignettes under 2 counterbalanced conditions: verbal alone or verbal with visual aids. Transcripts were analyzed and scored to measure decisional skills. Twelve judges rated participants' decisional abilities using a 7-point Likert scale. Results Participants demonstrated significantly better overall decisional capacity in Understanding, Reasoning, and Appreciation when supported by visual aids during the decision-making process. No significant differences between conditions were found in Expressing a Choice, the decisional skill Logical Sequence under Reasoning, and Acknowledgment under Appreciation. Overall, the judges' ratings validated these outcomes; the judges' ratings reflected greater agreement in the visual condition than in the verbal condition. Conclusions Findings indicated that visual aids (a) improved the decision-making capacity of individuals with dementia in comprehending medical information, employing supportive reasons, and relating this information to his or her own situation and (b) contain the potential for judges who majored or are majoring in speech-language pathology to reach a stronger consensus when determining the decision-making capacity of individuals with dementia.

Ethical Issues in Artificial Nutrition and Hydration

From the time of Hippocrates, approximately 2500 years ago, medical ethics has been seen as an essential complement to medical science in pursuit of the healing art of medicine. This is no less true today, not only for physicians but also for other essential professionals involved in patient care, including clinical nutrition support practitioners. One aspect of medical ethics that the clinical nutritionist must face involves decisions to provide, withhold, or withdraw artificial nutrition and hydration. Such a decision is not only technical but often has a strong moral component as well. Although it is the physician who writes any such order, the clinical nutritionist as fellow professional should be a part not only of the scientific aspects of the order but of the moral discourse leading to such an order and may certainly be involved in counseling physicians, other healthcare providers, patients, and families alike. This paper is intended to give the clinical nutritionist a familiarity with the discipline of medical ethics and its proper relationship to medical science, politics, and law. This review will then offer a more specific analysis of the ethical aspects of decisions to initiate, withhold, or withdraw artificial nutrition and hydration (ANH) and offer particular commentary on the ethically significant pronouncements of Pope John Paul II in March of 2004 related to vegetative patients and artificial or "assisted" nutrition and hydration.

Tube Feeding Patients With Dementia

As the population ages, the incidence of dementia increases. All types of dementia, whether they are reversible or irreversible, lead to loss of intellectual function and judgment, memory impairment, and personality changes. The skills to feed oneself, use eating utensils, and consume items recognized as food, thereby maintaining nutrition status, may be lost as dementia progresses. Reports indicate that nutrition status may be maintained when patients are hand fed, but this is labor intensive and therefore expensive. Feeding via a percutaneous endoscopic gastrostomy tube is often chosen as an acceptable alternative. Research indicates that there is little benefit in this population when aggressive nutrition support is instituted. Providing tube feeding to patients with dementia does not necessarily extend life, increase weight, or reduce the incidence of pressure ulcers or aspiration. There are many legal and ethical issues involved in the decision to place a feeding tube in demented patients. The primary issue in patients with dementia may be autonomy and the right of an individual to decide whether or not a tube should be placed at all. Legally, there is clear precedent that the courts see the insertion of a feeding tube as extraordinary care that the patient has the right to refuse. However, much of case law is derived from cases of patients who were in a persistent vegetative state. Advance directives help to determine what the patient would want for himself. Considering all the options before the patient can no longer make decisions is the most desirable course.

A Quick Guide to Ethical Theory in Healthcare: Solving Ethical Dilemmas in Nutrition Support Situations

Ethical dilemmas can be challenging for the nutrition support clinician who is accustomed to evidence-based practice. The emotional and personal nature of ethical decision making can present difficulties, and conflict can arise when people have different ethical perspectives. An understanding of ethical terms and ethical theories can be helpful in clarifying the source of this conflict. These may include prominent ethical theories such as moral relativism, utilitarianism, Kantian absolutism, Aristotle's virtue ethics and ethics of care, as well as the key ethical principles in healthcare (autonomy, beneficence, nonmaleficence, and justice). Adopting a step-by-step approach can simplify the process of resolving ethical problems.

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.

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.

[The development and validation of a standardised transfer sheet for care transitions between residential and acute care settings in Leuven, Belgium]

BACKGROUND

When elderly patients are transferred from a residential to an acute care setting, important information regarding their health care can be lost. Over the past years, the concept of advance care planning has also been given a more prominent place in the care for the elderly. However it remains a challenge to communicate the results achieved by this process when patients are referred to another health care setting. Developing a sound method for transferring information is a key element in the transitional care for the elderly patient.

OBJECTIVES

In collaboration with the residential and acute care settings in Leuven, Flemish Brabant, Belgium this study aimed to develop a validated, standardized transfer-sheet.

METHODS

After a literature search a topic list was generated to be used as the basis for a Delphi-procedure in which 16 experts from both the acute and the residential care settings participated. The transfer-sheet was then evaluated for content validity by an expert-panel (n = 9) from the acute and residential care settings. Face validity was assessed by two nurses and two doctors, randomly selected from the above settings.

RESULTS

All 44 subthemes in the transfer-sheet showed excellent content validity. The scale content validity universal agreement (S CVIUA) for the entire transfer-sheet was 0.68. The average scale content validity (S CVIAve) was 0.96. After a second and final Delphi-round a final transfer-sheet was constructed consisting of 8 themes and 50 sub-themes.

CONCLUSIONS

Based on these results standardized transfer-sheet was developed and validated.

Position of the academy of nutrition and dietetics: ethical and legal issues in feeding and hydration

It is the position of the Academy of Nutrition and Dietetics that individuals have the right to request or refuse nutrition and hydration as medical treatment. Registered dietitians (RDs) should work collaboratively as part of the interprofessional team to make recommendations on providing, withdrawing, or withholding nutrition and hydration in individual cases and serve as active members of institutional ethics committees. RDs have an active role in determining the nutrition and hydration requirements for individuals throughout the life span. When individuals choose to forgo any type of nutrition and hydration (natural or artificial), or when individuals lack decision-making capacity and others must decide whether or not to provide artificial nutrition and hydration, RDs have a professional role in the ethical deliberation around those decisions. Across the life span, there are multiple instances when nutrition and hydration issues create ethical dilemmas. 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 individual and what is or is not warranted by empirical clinical evidence. When a conflict arises, the decision requires ethical deliberation. RDs' understanding of nutrition and hydration within the context of nutritional requirements and cultural, social, psychological, and spiritual needs provide an essential basis for ethical deliberation. RDs, as health care team members, have the responsibility to promote use of advanced directives. RDs promote the rights of the individual and help the health care team implement appropriate therapy. This paper supports the "Practice Paper of the Academy of Nutrition and Dietetics: Ethical and Legal Issues of Feeding and Hydration" published on the Academy website at: www.eatright.org/positions.

Documentation and discussion of preferences for care among patients with advanced cancer

PURPOSE

We sought to describe the documentation, frequency, and timing of discussions about patient preferences for care and to examine patterns of palliative care and hospice use among patients with advanced cancer.

METHODS

We prospectively abstracted the medical records of 118 patients receiving care at a Veterans Administration (VA) facility from diagnosis of stage IV disease to 12 months postdiagnosis or death. We used univariate statistics to describe the type and frequency of documentation of patient preferences and palliative care/hospice referral. We calculated the time from diagnosis to the first documentation of preferences and the time from first documentation to death. We compared documentation of patient preferences between decedents and nondecedents using χ(2) tests.

RESULTS

The majority of patients (81%) had some documentation of their care preferences recorded, although decedents were significantly more likely to have had their preferences documented than nondecedents (96% v 60%; P < .000). Most (53%) patients did not have a formal advance directive documented in the medical record. The mean time from diagnosis to the first documentation of preferences was approximately 2 months. More than half of all patients (53%) and almost three-quarters of decedents (73%) had a palliative care consultation.

CONCLUSION

Despite high rates of preference documentation, there remains room for improvement. Providers may need to be helped to identify patients earlier in their trajectory for appropriate palliative care services, and future work should focus on developing useful alternatives to advance directives for adequately documenting patient preferences.

[Advance care planning and severe chronic diseases]

INTRODUCTION

Advanced care planning (ACP) helps in make decisions on the health problems of people who have lost the capacity for informed consent. It has proven particularly useful in addressing the end of life. The aim of this study was to determine the prevalence of ACP in patients with severe chronic diseases.

MATERIAL AND METHODS

Review of medical records of patients with dementia, amyotrophic lateral sclerosis, Parkinson's disease, chronic obstructive pulmonary disease or interstitial lung disease, heart failure, chronic kidney disease on dialysis and cancer, all in advanced stages. We collected data on living wills or registered prior decisions by the physician according to clinical planned.

RESULTS

A total of 135 patients were studied. There was a record of ACP in 22 patients (16.3%). In most of them it was planned not to start any vital treatment in the event of high risk of imminent death and lacking the ability to make decisions. Only two patients were had a legal living will.

CONCLUSION

The registration of ACP is relatively low, and this can affect decision-making in accordance with the personal values of patients when they do not have the capacity to exercise informed consent.

Advance directives in an intensive care unit: experiences and recommendations of critical care nurses and physicians

AIM OF STUDY

This study explored the experiences of critical care nurses and physicians with advance directives (ADs) in an intensive care unit (ICU) to identify the benefits and limitations of ADs and recommendations for improvement.

METHODS, SETTING, AND SUBJECTS

This descriptive study, obtained by ethnographic means, was implemented in a 22-bed adult medical-surgical ICU in a large community hospital in the Midwestern United States. Subjects included 14 critical care nurses, 7 attending, and 3 fellow critical care physicians. Subjects were interviewed informally and formally. Patient medical records were reviewed for ADs.

RESULTS AND CONCLUSIONS

Results supported numerous problems with ADs described previously and identified additional problems, including inability of ADs to prevent unwanted aggressive treatments outside of health care facilities, and patient reluctance to share ADs for fear of physicians "throwing in the towel" too early. Although most subjects described ADs as "useless," one helpful aspect was using ADs to shift perceptions of responsibility for end-of-life decision making and outcomes from the family/providers to the patient by reframing "pulling the plug" to "honoring patient wishes." Recommendations are described, including evolving the current emphasis of increasing completion of ADs to encourage patient-family discussions focused on quality of life to increase the likelihood of discussions occurring.

Lost in translation: the unintended consequences of advance directive law on clinical care

BACKGROUND

Advance directive law may compromise the clinical effectiveness of advance directives.

PURPOSE

To identify unintended legal consequences of advance directive law that may prevent patients from communicating end-of-life preferences.

DATA SOURCES

Advance directive legal statutes for all 50 U.S. states and the District of Columbia and English-language searches of LexisNexis, Westlaw, and MEDLINE from 1966 to August 2010.

STUDY SELECTION

Two independent reviewers selected 51 advance directive statutes and 20 articles. Three independent legal reviewers selected 105 legal proceedings.

DATA EXTRACTION

Two reviewers independently assessed data sources and used critical content analysis to determine legal barriers to the clinical effectiveness of advance directives. Disagreements were resolved by consensus.

DATA SYNTHESIS

Legal and content-related barriers included poor readability (that is, laws in all states were written above a 12th-grade reading level), health care agent or surrogate restrictions (for example, 40 states did not include same-sex or domestic partners as default surrogates), and execution requirements needed to make forms legally valid (for example, 35 states did not allow oral advance directives, and 48 states required witness signatures, a notary public, or both). Vulnerable populations most likely to be affected by these barriers included patients with limited literacy, limited English proficiency, or both who cannot read or execute advance directives; same-sex or domestic partners who may be without legally valid and trusted surrogates; and unbefriended, institutionalized, or homeless patients who may be without witnesses and suitable surrogates.

LIMITATION

Only appellate-level legal cases were available, which may have excluded relevant cases.

CONCLUSION

Unintended negative consequences of advance directive legal restrictions may prevent all patients, and particularly vulnerable patients, from making and communicating their end-of-life wishes and having them honored. These restrictions have rendered advance directives less clinically useful. Recommendations include improving readability, allowing oral advance directives, and eliminating witness or notary requirements.

PRIMARY FUNDING SOURCE

U.S. Department of Veterans Affairs and the Pfizer Foundation.

Dysphagia: implications for older people

This review opens with an outline definition of dysphagia, its causes, and why it is vital that people involved in the health care of older people should be aware of it. A brief consideration of prevalence is followed by an overview of assessment options. We conclude with a section on management.

An evaluation of nutrition support for terminal cancer patients at teaching hospitals in Korea

PURPOSE

We wanted to analyze the use of nutrition support for terminal cancer patients, the effect of discussing withdrawal of nutrition support and do-not-resuscitate (DNR) consent on the use of intravenous nutrition during the patient's last week of life and at the time of death.

MATERIALS AND METHODS

The study involved 362 patients with terminal cancer from four teaching hospitals, and they all died between January 1 2003 and December 31 2005. The basic demographic data, the use of intravenous nutrition during the patient's last week of life and at death, discussion of terminal nutrition withdrawal and DNR consent were evaluated.

RESULTS

In the week before death, the patients received artificial nutrition such as total parenteral nutrition (31%), intravenous albumin infusion (25%), and feeding tube placements (9%). A discussion concerning withdrawal of nutrition support was limited to 25 (7%) patients. DNR consent was obtained from 294 (81%) patients. None of the patients were directly involved in any of these decisions. The discussion about withdrawal of terminal nutrition and DNR consent with the patient's surrogates did not have any effect on reducing the use of parenteral nutrition.

CONCLUSION

The majority of patients dying of terminal cancer were still given potentially futile nutritional support. Modern clinical guidelines and ethical education about nutritional support at the end of life care is urgently needed in Korean medical practice to provide proper administration of terminal nutrition for end of life care.