Special challenges of withholding artificial nutrition and hydration

Artificial nutrition and hydration at the end of life

Considerable controversy surrounds the issue of care at the end of life (EOL) for older adults. Technological advances and the legal, ethical, clinical, religious, cultural, personal, and fiscal considerations in the provision of artificial hydration and nutrition support to older adults near death are presented in this comprehensive review.

Exercising restraint: Clinical, legal and ethical considerations for the patient with Alzheimer’s disease

The number of older people using emergency care is increasing steadily and older people account for over half of all emergency admissions. In the emergency setting, nurses caring for older people with Alzheimer's disease can be faced with many complex ethical and legal challenges. Moreover, challenges such as the use of physical restraint can precipitate conflict when the nurse is placed in the precarious position of doing good, respecting autonomy and avoiding paternalism. Although, there is no complete set of "rules" that can provide nurses with an answer to each dilemma, it is of significant value for nurses to have sound knowledge of ethical and legal positions in order to analyse the many complex situations that they may encounter.

Artificial hydration and nutrition in advanced Alzheimer's disease: facilitating family decision-making

BACKGROUND

As Alzheimer's disease progresses to its final stages of dementia and dysphagia, whereby patients can no longer swallow food and fluids, families suffer with difficult decisions regarding initiation of artificial hydration and nutrition.

AIMS AND OBJECTIVES

Through the use of a hypothetical family scenario, this theoretical article presents the ethical principals of beneficence and autonomy as a framework for use by nurses to hear and inform family decision-makers of the physiology of death in the advanced stages of Alzheimer's and examines the current literature related to benefits and burdens of artificial hydration and nutrition.

CONCLUSIONS

While a beneficial consideration, ethical principles are critiqued for their inability to provide an absolute answer and relieve family suffering in this clinical situation.

RELEVANCE TO CLINICAL PRACTICE

A nurse-lead consensus building process is proposed to guide family decision-making regarding artificial hydration and nutrition with advanced Alzheimer's disease.

Ethical challenges in end-of-life therapies in the elderly

With the increasing numbers of elderly in the population of all western countries and the increasing life expectancy at birth, many seniors spend the last period of their life with various afflictions that may require the need for long-term institutional care. During the last period of life, many seniors and their families face decisions that challenge ethical principles and may cause conflict among family members as well as healthcare professionals. The commonly used ethical principles of autonomy, beneficence, nonmaleficence and justice, although forming a useful foundation for the evaluation of decision-making dilemmas, alone cannot resolve many clinically challenging situations. Healthcare professionals must clearly understand the clinical state of the patient for whom a difficult decision is being contemplated. Levels of function, clinical symptoms, the expected trajectory of change and possible treatment options have to be balanced against the person's values and wishes, either self-expressed directly or through an advance directive, or communicated by surrogate decision makers. At times, physicians face difficult treatment dilemmas when patients or families request treatments that are not legally sanctioned, such as when physician-assisted suicide is requested by a suffering patient. At other times conflicts occur when patients or surrogates wish to continue with therapies that are no longer considered necessary or suitable by the physician. At the societal level, sometimes an expensive drug that is deemed necessary by the physicians is not covered by a government-sponsored or private health plan. The issue of distributive justice must be considered in a situation such as when long-term facilities or acute hospitals treating frail, cognitively impaired elders consider withholding or withdrawing various treatments because of poor clinical outcomes coupled with excessive costs. The often controversial issue of nutrition and hydration in the end-of-life period frequently causes treatment conflicts and dilemmas among surrogates and staff, as does the highly charged issue of cardiopulmonary resuscitation in this frail and very vulnerable population. The real challenge for healthcare providers in the field of geriatric long-term care is to balance compassionate and appropriate care with respect for the choices and wishes of patients and their families. This should be accomplished while at the same time safeguarding the professional standards and ethical integrity of healthcare providers responsible for this care.