"Rectal Feeding"-Unethical Medical Officer Participation at CIA Secret Interrogation Facilities.

This Viewpoint discusses recently released information regarding the practice of "rectal feeding" among detainees at Guantanamo Bay and Central Intelligence Agency (CIA) secret prisons.

Unpasteurized Shared Human Milk Use in Pediatric Inpatients: Health and Ethical Implications.

Growing evidence supporting the health benefits of human milk, particularly in the preterm population, has led to rising demand for donor human milk in NICUs and pediatric hospitals. There are no previous reports describing the use of unpasteurized shared human milk (USHM) in the hospital setting, but the use of USHM solicited from community donors through social networks appears to be common. Many pediatric hospitals permit inpatients to receive breast milk that has been screened and pasteurized by a human milk banking organization and will provide pasteurized donor human milk (PDHM) only to infants who are preterm or have specific medical conditions. These policies are designed to minimize potential adverse effects from improperly handled or screened donor milk and to target patients who would experience the greatest benefit in health outcomes with donor milk use. We explore the ethical and health implications of 2 cases of medically complex infants who did not meet criteria in our tertiary care hospital for the use of PDHM from a regulated human milk bank and were incidentally found to be using USHM. These cases raise questions about how best to balance the ethical principles of beneficence, nonmaleficence, justice, and patient autonomy in the provision of PDHM, a limited resource. Health care staff should ask about USHM use to provide adequate counseling about the risks and benefits of various feeding options in the context of an infant's medical condition.

Ethical Challenges in Infant Feeding Research.

Infants have a complex set of nutrient requirements to meet the demands of their high metabolic rate, growth, and immunological and cognitive development. Infant nutrition lays the foundation for health throughout life. While infant feeding research is essential, it must be conducted to the highest ethical standards. The objective of this paper is to discuss the implications of developments in infant nutrition for the ethics of infant feeding research and the implications for obtaining informed consent. A search was undertaken of the papers in the medical literature using the PubMed, Science Direct, Web of Knowledge, Proquest, and CINAHL databases. From a total of 9303 papers identified, the full text of 87 articles that contained discussion of issues in consent in infant feeding trials were obtained and read and after further screening 42 papers were included in the results and discussion. Recent developments in infant nutrition of significance to ethics assessment include the improved survival of low birth weight infants, increasing evidence of the value of breastfeeding and evidence of the lifelong importance of infant feeding and development in the first 1000 days of life in chronic disease epidemiology. Informed consent is a difficult issue, but should always include information on the value of preserving breastfeeding options. Project monitoring should be cognisant of the long term implications of growth rates and early life nutrition.

To Feed or Not to Feed? A Case Report and Ethical Analysis of Withholding Food and Drink in a Patient With Advanced Dementia.

It is well established that competent patients have the right to refuse artificial nutrition and hydration. There is less clarity regarding withholding nutrition in patients who lack decision-making capacity but who are still physically able to eat and drink. This case highlights the ethical dilemma of withholding food and drink in a patient with advanced dementia.

La alimentación del Ejército de Tierra en operaciones. La ración individual de combate / Ground Forces nutrition in operations. Individual ration in combat

La alimentación de los ejércitos ha sido tradicionalmente un problema bastante complejo, que ha estado en función de dos aspectos fundamentales, la capacidad económica del que lo financiaba, reyes, haciendas o estados, y la posibilidad de conseguir alimentos. Por otra parte, el valor alimenticio de aquellos «ranchos militares» dejaba mucho que desear, frecuentemente por falta de principios inmediatos y por carencias vitamínicas, ya que se trataba de raciones con muy poca carne y carentes de productos frescos, lo que daba lugar a enfermedades carenciales y a la falta de condiciones físicas entre los militares. De todas formas, la preocupación por una adecuada alimentación de los ejércitos también viene de lejos, habiendo dado lugar a la publicación de infinidad de libros y normas, hasta llegar a los verdaderos tratados de alimentación con carácter científico publicados a partir de finales del siglo XIX. El soldado del Ejército español ha padecido carencias alimentarias tanto en las colonias como en la península, debido siempre a la precariedad de recursos. Su alimentación fue mejorando cuando el país remontó las privaciones derivadas de la Guerra Civil a partir de los años sesenta del siglo pasado, siendo una verdadera novedad la introducción de las «raciones de previsión» en los años noventa, que no solo facilitó la alimentación en ejercicios y maniobras en territorio nacional sino la de los contingentes destacados en las diferentes misiones en el extranjero

The nutrition of the armies has traditionally been a fairly complex problem that has been based on two fundamental aspects, the economic capacity of those who were financing it (kings, the Inland Revenues or states), and the possibility of obtaining food. On the other hand, the nutritional value of those «military single-course meals» was leaving much to be desired, usually for the lack of immediate principles and vitamin deficiencies as the portions had very little meat and were lacking fresh products, what gave rise to deficiency diseases and the lack of physical condition among soldiers. Anyway, the concern for a proper nutrition of the armies reaches far back into the past, having led to the publication of countless books and standards all the way up to the real treaties of scientific character, published since the beginning of the 19th century. Soldiers of the Spanish army have suffered from food shortages both in the colonies and in the peninsula, always due to the resources instability. Their nutrition was improved when the country mended the losses arising from the Civil war in the decade of 1960, being a real novelty the introduction of «forecast rations» in the 1990s, which not only provided food in exercises and maneuvers in national territory, but also for the troops stationed in the different missions abroad

Efficacy and ethics of artificial nutrition in patients with neurologic impairments in home care.

Outcomes, particularly survival, for home-care patients with neurologic impairments who receive artificial nutrition, such as home parenteral nutrition (HPN) or percutaneous endoscopic gastrostomy (PEG) feeding, remain unclear. The efficacy of tube feeding for life prolongation in elderly patients remains controversial. The aim of this study was to assess the survival of elderly patients with neurologic impairments after the start of HPN or PEG. We retrospectively evaluated 80 patients with neurologic impairments who had received home care before they died. They were divided into three groups according to feeding method: oral-intake group (n = 23), HPN group (n = 21) and PEG group (n = 36). The factors considered were: age; survival period after commencement of home care; swallowing function; serum albumin concentration; level of activities of daily living (ADL); and behavioral, cognitive and communication functions. Survival periods of the patients in the PEG (736 ± 765 days) and HPN (725 ± 616 days) groups were twice that of the self-feeding oral-intake group (399 ± 257 days) despite lower serum albumin concentration (for PEG patients), reduced swallowing function and cognitive function, and poorer levels of ADL at the start of home care. Almost all patients were incapable of deciding whether they should receive artificial nutrition due to dementia or poor comprehension. Physicians should provide clinical evidence to families before commencing PEG feeding or HPN and support their decisions to maintain the dignity of the patient.

Patrón de comportamiento de monos ardilla (Saimiri sciureus macrodon) cautivos con diferentes enriquecimientos ambientales / Behavioral patterns of the squirrel monkey (Saimiri sciureus macrodon) captive with different environmental enrichment / Padrões de comportamento de macacos-de-chiero (Saimiri sciureus macrodon) em cativeiro com diferentes enriquecimentos ambientais

Las implicaciones del cautiverio sobre el comportamiento de los animales han sido muy bien documentadas, peropocos son los recursos existentes para la modificación de su efecto. Esta primer experiencia realizada en el Hogar dePaso de Fauna Silvestre (HPFS) de la Universidad de la Amazonía y Corpoamazonía, en Florencia- Caquetá, además de describir el patrón de comportamiento y de actividades expresadas por el mono ardilla en cautiverio (Saimirisciureus macrodon), en análisis comparativo con especímenes de la especie en vida silvestre, estableció mecanismosde modulación de la conducta, a partir del uso de enriquecimientos ambientales. La investigación realizada sobre un grupo conformado por doce especímenes en diferentes estadíos de desarrollo biológico, confinados en un encierro no mayor a los cuatro metros cuadrados, encontró, a través de la aplicación de etogramas, que los especímenes cautivos presentan grandes variaciones en sus actividades diarias y una gran cantidad de estereotipos que se hacíanevidentes en los horarios de alimentación (Horas de la mañana). Dichas conductas lograron ser moduladas con enriquecimientos ambientales (EA). Los resultados establecen la presencia de diferencias significativas del tipo decomportamiento y de actividad, entre los especímenes cautivos y los de vida libre, además de diferencias en rangosde peso, temperatura corporal y niveles de glucosa, siendo mayores en especímenes cautivos, lo que indica quefactores como cambios en la alimentación y el stress del cautiverio, son causantes del desequilibrio homeostático de S. sciureus.

The implications of captivity on animal behavior have been well documented, but few resources exist to alter its effect. This first experience, carried out at the Wildlife Foster Home of the Universidad de la Amazonía andCorpoamazonía, in Florencia, Caquetá, in addition to describing behavioral and activity patterns expressed bythe captive squirrel monkey (Saimiri sciureus macrodon) in comparison with specimens in the wild, establishedmechanisms for conduct modulation, based on the use of environmental enrichments. Research conducted on agroup of twelve specimens, in different stages of biological development and confined to an enclosure no largerthan four square meters, found through the application of ethograms that the captive specimens’ daily activitiesvary widely and that a great many stereotypes were evident at feeding times (morning hours). These behaviors were able to be modulated by environmental enrichments (EE). Results show the presence of significant differences in behavior and activity between captive specimens and those in the wild, as well as differences in weight ranges, body temperature and glucose levels, being higher in captive specimens, which indicate that factors such as changes in diet and the stress of captivity are causing homeostatic imbalance of S. sciureus.

As implicações de cativeiro sobre o comportamento dos animais têm sido bem documentadas, mas há poucosrecursos disponíveis para a modificação de seu efeito. Esta primeira experiência realizada no Lar Adotivo deFauna Silvestre da Universidad de la Amazonía e Corpoamazonía em Florencia – Caquetá, além de descrever o padrão de comportamento e atividades expressas pelo macaco-de-cheiro em cativeiro (Saimiri sciureus macrodon),em análise comparativa com espécimes da espécie na vida silvestre, estabeleceu mecanismos de modulação do comportamento, a partir do uso de enriquecimento ambiental. A pesquisa foi realizada em um grupo composto dedoze espécimes em diferentes estágios de desenvolvimento biológico, confinados em um recinto não maior quequatro metros quadrados, através de estudos de etogramas foi verificado que as atividades diárias dos espécimes emcativeiro variam muito e que um grande número de estereótipos eram evidentes às vezes na alimentação (horas damanhã). Esses comportamentos foram capazes de ser modulados por enriquecimento ambiental (EA). Os resultados estabelecem a presença de diferenças significativas no tipo de comportamento e de atividade, entre os espécimes em cativeiro e os de vida livre, além das diferenças em várias categorias de peso, temperatura corporal e níveis de glicose, sendo maior nos espécimes em cativeiro, o que indica que os fatores como mudanças na dieta e estresse docativeiro estão causando desequilíbrio homeostático de S. sciureus.

Clinical report--Forgoing medically provided nutrition and hydration in children.

There is broad consensus that withholding or withdrawing medical interventions is morally permissible when requested by competent patients or, in the case of patients without decision-making capacity, when the interventions no longer confer a benefit to the patient or when the burdens associated with the interventions outweigh the benefits received. The withdrawal or withholding of measures such as attempted resuscitation, ventilators, and critical care medications is common in the terminal care of adults and children. In the case of adults, a consensus has emerged in law and ethics that the medical administration of fluid and nutrition is not fundamentally different from other medical interventions such as use of ventilators; therefore, it can be forgone or withdrawn when a competent adult or legally authorized surrogate requests withdrawal or when the intervention no longer provides a net benefit to the patient. In pediatrics, forgoing or withdrawing medically administered fluids and nutrition has been more controversial because of the inability of children to make autonomous decisions and the emotional power of feeding as a basic element of the care of children. This statement reviews the medical, ethical, and legal issues relevant to the withholding or withdrawing of medically provided fluids and nutrition in children. The American Academy of Pediatrics concludes that the withdrawal of medically administered fluids and nutrition for pediatric patients is ethically acceptable in limited circumstances. Ethics consultation is strongly recommended when particularly difficult or controversial decisions are being considered.

Unnecessary time pressure in refusal of life-sustaining therapies: fear of missing the opportunity to die.

During an illness requiring brief use of life-sustaining therapy (LST), patients and surrogates sometimes feel that LST must be withdrawn before it becomes unnecessary to avoid later being stuck living in a debilitated condition that the patient considers worse than death. This fear depends on the belief that the patient can legitimately refuse only artificial LST, so that if such therapies are no longer required, he or she will have missed the 'opportunity to die.' This fear of being stuck with life can lead to premature decisions to terminate LST and is unfounded because adequate ethical and moral justification exists for refusal of not just artificial LST, but also for refusal of natural LST, including oral hydration and nutrition.