Withholding versus withdrawing treatment: artificial nutrition and hydration as a model.

PURPOSE OF REVIEW: This article explores various cultural perspectives of withholding and withdrawing of life-sustaining treatment utilizing a case involving artificial nutrition and hydration (ANH) to guide ethical discussion. RECENT FINDINGS: In the United States, there is a general consensus in the medical, ethical, and legal communities that the withholding and withdrawing of life-sustaining treatment are morally equivalent at the end of life. Despite this consensus, the withdrawal of treatment is still emotionally difficult, particularly with ANH. Recent literature challenges the evidence base that feeding tubes for people with advanced dementia lead to significant harm. In light of these new findings, we will reconsider end-of-life decision making that concerns ANH to determine whether these new findings undermine previous ethical arguments and to consider how to best educate and support patients and families during the decision-making process. SUMMARY: Despite many believing that there is no ethical, medical, or moral difference between withholding and withdrawing of life-sustaining treatment, there is no denying it is emotionally taxing, particularly withdrawal of ANH. Upholding the patient's values during high-quality shared decision making, facilitating rapport, and utilizing time limited trials will help, even when treatment is considered medically ineffective.

Caso: nutrición en paciente oncológico / Case: Nutrition in oncological patient

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Comentario al caso: Nutrición en paciente oncológico / Commentary on the case: Nutrition in oncological patient

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[Artificial nutrition: technical, scientific and ethical considerations]. / La nutrizione artificiale: aspetti tecnico-scientifici ed etico-deontologici.

Artificial nutrition (AN) is a relatively new medical treatment which started in the 1960 with parenteral nutrition (PN) and over the last 20 years has come to include enteral nutrition (EN) in hospitals and homes. Enormous clinical progress and continual evolution in techniques aimed at rendering organ funtion substitution more complete and efficient have come to the point where AN can only be suitably performed (indications for therapy, treatment regimen and monitoring) in specialized institutions. However, there has been much discussion about whether artificial nutrition should be considered a medical intervention or an essential intervention of care: in 2004 the Terri Schiavo case became worldwide news and the suspension of AN was decided by the law courts. In Italy, on 5 September 2014, the Council of State gave its opinion on case of Eluana Englaro. In 2007 the Italian Association for Dietetics and Clinical Nutrition (ADI) and the Professional Board of Physicians of the Province of Terni, have shared a paper that takes into account the scientific, technical and ethical considerations of AN in the light of the relative codes. The intent of this position paper was to supply a framework of clinical practices, ethical principles, and professional guidelines that will impart information and can assist decision making regarding AN and hydration. The document is still relevant today.

On omissions and artificial hydration and nutrition.

Understanding what sorts of things one might be responsible for is an important component of understanding what one should do in situations where the administration of artificial hydration and nutrition are required to sustain the life of a patient. Relying on work done in the philosophy of action and on moral responsibility, I consider the implications of omitting the administration of artificial hydration and nutrition and instances in which the omitting agent would and would not be responsible for the death of the patient. I am primarily interested in arguing against those who wish to seat responsibility for the death of a patient in an underlying pathology, even when the underlying pathology is not the cause of the patient's death.

Artificial nutrition at the end of life: ethical issues.

Artificial nutrition is a medical treatment that first of all needs a sound scientific base before prescribing it. This base is absent for dying patients and patients in the end stage of dementia. Because feeding is a very emotional and symbolical issue, patient and family may request this treatment despite the lack of evidence. These issues should be addressed in good communication with patient and relatives. For comatose patients and patients in a persistent vegetative state artificial nutrition is a necessary support to bridge the time until either recovery is imminent or improbable. At that moment artificial nutrition no longer contributes to the life of the patient and should be ceased. Artificial nutrition has no place in patients that voluntary decide to stop eating and drinking in order to die.

[A case report of the difficulty treating an endstage oncologic ENT patient with parenteral nutrition]. / Ein Fallbericht über die Problematik der Ernährung am Lebensende eines onkologischen HNO-Patienten.

The occurrence of cachexia at the end of life of patients suffering from cancer is a common seen problem. Within the last years new definitions, diagnostic criteria and classification systems of cachexia have been developed to improve the clinical practice. Still therapeutic interventions are limited; the role of parenteral nutrition (PN) remains controversial. PN cannot be generally recommended in patients with incurable malignancies, not even in ill-nourished patients with inadequate oral or enteral nutrition due to a changed metabolism. Treating a cachectic endstage patient suffering from head-neck-cancer we were faced with different problems.

[The PEG-dilemma - pleading for an ethically responsible medical treatment]. / Das PEG-Dilemma - Plädoyer für ein ethisch verantwortungsbewusstes ärztliches Handeln.

Within the 32 years of its existence our attitude towards artificial enteral nutrition via PEG-tubes has changed in a fundamental way: in our modern understanding nutrition via PEG is supportive, early, preventive, and in many cases temporary. PEG-feeding is not an alternative but a possible supplement to normal oral food intake and requires an individual medical indication as well as an ethical justification. This does not follow standardised algorithmic thinking but is decided on an individual base taking personal wishes, resources, and needs of the individual patient into account. Nutrition via PEG-tube is not a terminal basic or even symbolic treatment at the end of life. The present dilemma of the PEG is that the public discussion primarily focus one-sided on the problems of PEG-placement in multimorbid, elderly, and/or demented patients or patients in end-stage tumour diseases where indeed PEG-placement is neither medically nor ethically justified - we still place PEG-tubes to often in the wrong patients! On the other hand we still consider supportive and in many cases temporary nutrition via PEG too rare and even too late in those patients which clearly could benefit from an early, supportive, and preventive PEG-treatment on the base of our present evidence-based scientific knowledge - we still consider PEG-treatment not adequately and in most cases too late in the right patients! Placing a PEG-tube is not the second last step before death and physicians have to accept the ethically given limits of medical treatment by realizing our modern understanding of the benefits and limits of supportive artificial nutrition via PEG.

Consensus, clinical decision making, and unsettled cases.

The model of clinical ethics consultation (CEC) defended in the ASBH Core Competencies report has gained significant traction among scholars and healthcare providers. On this model, the aim of CEC is to facilitate deliberative reflection and thereby resolve conflicts and clarify value uncertainty by invoking and pursuing a process of consensus building. It is central to the model that the facilitated consensus falls within a range of allowable options, defined by societal values: prevailing legal requirements, widely endorsed organizational policies, and professional standards of practice and codes of conduct. Moreover, the model stipulates that ethics consultants must refrain from giving substantive recommendations regarding how parties to a moral disagreement in the clinic should evaluate their options. We argue that this model of CEC is incomplete, because it wrongly assumes that what counts as the proper set of allowable options among which the parties are to deliberate will itself always be clearly discernible. We illustrate this problem with a recent case on which one of us consulted-a neonate born with trisomy 18 (T18). We try to show that law, policy, and standards of practice reveal no clear answer to the question posed by the case: namely, whether forgoing gastrostomy tube feedings for a baby with T18 is allowable. We suggest there may be other kinds of cases in which it may simply be unsettled whether a given choice falls within the set of allowable options within which consensus is to be facilitated. What should an ethicist do when confronting such unsettled cases? We agree with the facilitation model that an ethicist should remain neutral among the allowable options, when it is clear what the allowable options are. But, in unsettled cases, the role of a consultant should be expanded to include a process of moral inquiry into what the allowable options should be. We end by raising the issue of whether this means an ethicist should share his or her own conclusions or views about the allowability of a given clinical option.

[Ethical questions related to nutrition and hidration: basic aspects]. / Problemas éticos en relación a la nutrición y a la hidratación: aspectos básicos.

Conditions that pose ethical problems related to nutrition and hydration are very common nowdays, particularly within Hospitals among terminally ill patients and other patients who require nutrition and hydration. In this article we intend to analyze some circumstances, according to widely accepted ethical values, in order to outline a clear action model to help clinicians in making such difficult decisions. The problematic situations analyzed include: should hydration and nutrition be considered basic care or therapeutic measures?, and the ethical aspects of enteral versus parenteral nutrition.

Ethical and legal points of view in parenteral nutrition - Guidelines on Parenteral Nutrition, Chapter 12.

Adequate nutrition is a part of medical treatment and is influenced by ethical and legal considerations. Patients, who cannot be sufficiently fed via the gastrointestinal tract, have the fundamental right to receive PN (parenteral nutrition) even so patients who are unable to give their consent. General objectives in nutrition support are to supply adequate nutrition with regards to the prevention of malnutrition and its consequences (increased morbidity and mortality), and thereby promoting improved outcome and/or quality of life for the patient considering always the patient's needs and wishes. The requests of the patient to renounce PN should be respected where a signed living will is helpful. During the course of a terminal illness the nutrition has to be adapted individually according to the needs and wishes of a patient in the corresponding phase. Capability of consent should be checked in each individual case and for each measure on an individual basis. Consent should only be accepted if the patient is capable of recognizing the nature, meaning and importance of the intervention as well as the consequences of relinquishment of such an intervention, and is capable to make a self-determined decision. If the patient is not capable of consenting, the patient's living will is the most important document when determining their assumed will and legally binding. Otherwise a guardian appointed by the patient, or the representative appointed by the court (if the patient has made no provisions) can make the decision.

Withholding hydration and nutrition in newborns.

In the twenty-first century, decisions to withhold or withdraw life-supporting measures commonly precede death in the neonatal intensive care unit without major ethical controversy. However, caregivers often feel much greater turmoil with regard to stopping medical hydration and nutrition than they do when considering discontinuation of mechanical ventilation or circulatory support. Nevertheless, forgoing medical fluids and food represents a morally acceptable option as part of a carefully developed palliative care plan considering the infant's prognosis and the burdens of continued treatment. Decisions to stop any form of life support should focus on the clinical circumstances, not the means used to sustain life.

Parenteral nutrition: ethical and legal considerations.

Parenteral nutrition is an expensive therapeutic modality that is used to treat patients with intestinal failure. The benefit it offers in terms of life prolongation needs to be weighed against its risks and burdens. Through the use of descriptive clinical vignettes, this article illustrates the ethical and legal principles that underpin decisions to administer and, more importantly, to withhold or withdraw parenteral nutrition.