Clinical nutrition and human rights. An international position paper.

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Ethical and Legal Considerations in End-of-Life Care.

In caring for dying patients, family medicine practitioners intentionally adopt care plans that affect the manner and timing of death. These decisions are morally weighty. This article provides guidance regarding the ethical and legal appropriateness of practitioner decisions near the end of life. Topics include surrogate decision making, advance care planning, medical nutrition and hydration, double effect, futile care, physician-assisted death, voluntarily stopping eating and drinking, palliative sedation to unconsciousness, and cultural humility.

[Withdrawal of artificial nutrition and hydration in severe stroke: medical, legal and ethical considerations]. / Aspects médicaux, législatifs et éthiques de l'arrêt de la nutrition et de l'hydratation artificielles dans l'accident vasculaire cérébral grave.

In the majority of cases, severe stroke is accompanied by difficulty in swallowing and an altered state of consciousness requiring artificial nutrition and hydration. Because of their artificial nature, nutrition and hydration are considered by law as treatment rather basic care. Withdrawal of these treatments is dictated by the refusal of unreasonable obstinacy enshrined in law and is justified by the risk of severe disability and very poor quality of life. It is usually the last among other withholding and withdrawal decisions which have already been made during the long course of the disease. Reaching a collegial consensus on a controversial decision such as artificial nutrition and hydration withdrawal is a difficult and complex process. The reluctance for such decisions is mainly due to the symbolic value of food and hydration, to the fear of "dying badly" while suffering from hunger and thirst, and to the difficult distinction between this medical act and euthanasia. The only way to overcome such reluctance is to ensure flawless accompaniment, associating sedation and appropriate comfort care with a clear explanation (with relatives but also caregivers) of the rationale and implications of this type of decision. All teams dealing with this type of situation must have thoroughly thought through the medical, legal and ethical considerations involved in making this difficult decision.

[Ethical issues of artificial nutritional support]. / Ethische Fragen der künstlichen Ernährung.

This review article discusses some ethical issues of clinical nutrition according to the Beauchamp and Childress principles of bioethics: "respect for autonomy, nonmaleficence, beneficence, and justice".

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.

Ética y tratamiento nutricional en el paciente con demencia / Ethics and nutritional management in the patient with dementia

La bioética surge como un intento de establecer un puente entre ciencia experimental y humanidades. De ella se espera una formulación de principios que permita afrontar con responsabilidad, las increíbles posibilidades que nos ofrece hoy en día la tecnología.En frecuentes ocasiones se plantea indicar soporte nutricional especializado, concretamente nutrición enteral por sonda nasogástrica o por gastrostomía, a pacientes con demencia avanzada que han perdido su capacidad de deglutir. La adopción o no de esta medida genera una situación conflictiva.La ausencia de directivas anticipadas o testamento vital expresado, y la falta de unanimidad entre las partes implicadas al entender esta medida como parte del cuidado o del tratamiento integral del paciente con demencia,condiciona la consideración del conflicto ético. Las evidencias técnicas establecen criterios de no indicar nutrición artificial en los pacientes con demencia avanzada, frente al pensamiento colectivo que establece la necesidad de alimentar a estos pacientes como símbolo de cariño, cuidado y atención. Estas situaciones de conflicto pueden ser evitadas si a lo largo de la historia de la enfermedad el paciente y sus familiares,junto con su equipo médico, debaten el tema. Por esto es fundamental, que en algún momento el paciente exprese o documente sus deseos en torno a los cuidados y tratamientos que quiere o no recibir en el momento en el que la incapacidad no le permita decidir por si mismo. En el caso de que el conflicto ya se hubiera establecido será necesario analizar metodológicamente el problema,e intentar encontrar la mejor solución para todos los implicados mediante un método de decisión participativo, atendiendo a la posibilidad moral óptima (AU)

Bioethics arises as an attempt to establish a bridge between the experimental science and humanities. We may expect from it the formulation of principles allowing facing with responsibility the incredible possibilities that technology offers us today. In many occasions one must consider indicating specialized nutritional support, particularly enteral nutrition by nasogastric tube or by gastrostomy, to patients with advanced dementia that are no longer able to swallow. Adopting or not this measure entails a conflictive situation. The absence of advanced directives or expressed living will, and the lack of a unanimous opinion between the parties by considering this measure as part of the integral care and management of the demented patient leads to the consideration of the ethical conflict. The technical evidences establish criteria of not indicating artificial nutrition in patients with advanced dementia, by contrast with the collective feeling that establishes the need for feeding these patients as a symbol of loving, care, and attention.These conflictive situations may be avoided if through the process of the disease the patient and his/her relatives, together with the medical team, discuss the issue. It is thus essential that at some point the patient expresses or documents his/her wishes regarding the care and treatments he/she wants to receive, or not receive, at the time when mental incapacity will not allow him/her to decide by him/herself.In the case that the conflict is already present, it will be necessary, to methodologically analyse the problem and try to find the best solution for all the parties through a participative decision-making process, considering the best moral possibility (AU)

Clinical ethics consultation: examining how American and Japanese experts analyze an Alzheimer's case.

BACKGROUND: Few comparative studies of clinical ethics consultation practices have been reported. The objective of this study was to explore how American and Japanese experts analyze an Alzheimer's case regarding ethics consultation. METHODS: We presented the case to physicians and ethicists from the US and Japan (one expert from each field from both countries; total = 4) and obtained their responses through a questionnaire and in-depth interviews. RESULTS: Establishing a consensus was a common goal among American and Japanese participants. In attempting to achieve consensus, the most significant similarity between Japanese and American ethics consultants was that they both appeared to adopt an "ethics facilitation" approach. Differences were found in recommendation and assessment between the American and Japanese participants. In selecting a surrogate, the American participants chose to contact the grandson before designating the daughter-in-law as the surrogate decision-maker. Conversely the Japanese experts assumed that the daughter-in-law was the surrogate. CONCLUSION: Our findings suggest that consensus building through an "ethics facilitation" approach may be a commonality to the practice of ethics consultation in the US and Japan, while differences emerged in terms of recommendations, surrogate assessment, and assessing treatments. Further research is needed to appreciate differences not only among different nations including, but not limited to, countries in Europe, Asia and the Americas, but also within each country.

Neuroethics with regard to treatment limiting and withdrawal of nutrition and hydration in long lasting irreversible full state apallic syndrome and minimal conscious state.

INTRODUCTION: Epidemiology in Europe shows constantly increasing figures for the Apallic Syndrome (AS)/Vegetative State (VS) as a consequence of advanced rescue, emergency services, intensive care treatment after acute brain damage, and high standard activating home nursing for completely dependent end stage cases secondary to progressive neurological disease. Management of patients in irreversible apallic syndrome has been the subject of sustained scientific and moral-legal debate over the last decade. METHODS: Neuroethics coming more and more into consideration when neurological societies address key issues relating to AS/VS prevalence and quality management. With regard to treatment limiting and withdrawal of nutrition and hydration of patients suffering from irreversible full state Apallic Syndrome and Minimal Conscious State. RESULTS: The overall incidence of new AS/VS full stage cases all aetiology is 0.5 - 2/ 100.000 population per year. About one third is traumatic and two thirds are non-traumatic cases. The worst prognosis might be expected from nontraumatic hypoxemic apallic syndrome. The main conceptual criticism is based on assessment and diagnosis of all different AS/VS stages based solely on behavioural findings without knowing the exact or uniform pathogenesis or neuropathologic findings. No special diagnostics, no specific medical management can be recommended for class II or III AS treatment and rehabilitation. But in United Kingdom, The Netherlands, Belgium, and Switzerland active euthanasia is now practiced in medicine taking into account the uncertainty of the right diagnose the clinical features for humanistic treatment of patients in irreversible "AS full or early, remission stages". DISCUSSION: As long as there is no single AS/VS specific diagnostic tool, no specific laboratory investigation regimen to be recommended neuroethical principles demands by all means a humanistic (ethical) activating nursing even in the irreversible full stage AS cases. Full acceptable is only the palliative pain therapy with renunciation of maximal therapy. Active euthanasia is a criminal act and has to be respected as such in neuroscience.