Forgoing artificial nutrition and hydration: legal and ethical considerations.

Decisions to withhold or withdraw life-sustaining care are daily events in most hospitals and long-term care facilities. When the life-sustaining care includes artificial nutrition and hydration, however, families and other surrogate decision makers sometimes reach a different conclusion than when the care consists of ventilation or other life support. This tendency to view artificial nutrition and hydration as "different" is one that is sometimes shared by professional ethicists and courts. Over time there has emerged, however, a clear consensus concerning decisions to forgo nutrition and hydration, and there is near-unanimity in the court decisions on this subject. The author reviews the arguments that have been made for and against treating nutrition and hydration as a special case, court decisions in which patients or their surrogates have asked for the termination of nutritional support, and state and federal statutes that have addressed nutrition and hydration in the context of living wills and the care of imperiled newborns.

The Parkland approach to demands for "futile" treatment.

Recent literature in medical ethics has emphasized disputes concerning the relative usefulness or uselessness (futility) of medical treatments. In our institution, these disputes typically arise in the context of critical care, with patients or families requesting or demanding a treatment (such as cardiopulmonary resuscitation) that in the treating physician's view holds no promise of benefit. In the context of revising our general treatment refusal/withdrawal/withholding guidelines, we provided a structure for resolving such disputes in a manner that balances the often conflicting goods of patient/family autonomy, physician autonomy, and institutional responsibility.