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Artificial Nutrition and Hydration

Artificial Nutrition and Hydration

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Published by: National Healthcare Decisions Day on Feb 02, 2011
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n engl j med
www.nejm.org december
15, 2005
sounding board
new england journal
Appropriate Use of Artificial Nutrition and Hydration —Fundamental Principles and Recommendations
David Casarett, M.D., Jennifer Kapo, M.D., and Arthur Caplan, Ph.D.
For two decades, clinicians have been guided by an agreement about the appropriate use of arti-ficial nutrition and hydration (ANH). In general,ANH has been seen as a medical treatment that patients or their surrogates may accept or refuseon the basis of the same considerations that guide all other treatment decisions: the potentialbenefits, risks, and discomfort of the treatment and the religious and cultural beliefs of the pa-tients or surrogates. Although this agreement hasnever been universal, it is well established amongethicists,
and the courts. For in-stance, the 1990 Supreme Court decision in the well-known case of Nancy Cruzan specifically stated that the administration of ANH without consent is an intrusion on personal liberty.
However, this agreement has faced recent challenges to its legitimacy. For instance, eventhough the cases of Terri Schiavo
and Robert Wendland
 were complicated by disagreementsamong family members, the cases also involvedpublic questioning of the premise that decisionsabout ANH should be made in the same way in which decisions about other treatments are made.Similarly, a recent papal statement that strong-ly discourages the withdrawal of ANH from pa-tients in a permanent vegetative state will havea profound effect on decisions about ANH if it is accepted into Catholic doctrine.
Severalstates have made the withdrawal of ANH moredifficult than the withdrawal of other forms of life-sustaining treatment.
Clinicians also face substantial obstacles that prevent them from applying sound, ethical rea-soning when discussing ANH with patients andfamilies. For instance, patients and families areoften not fully informed of the relevant risks andpotential benefits of ANH.
In addition, finan-cial incentives and regulatory concerns promotethe use of ANH in a manner that may be incon-sistent with medical evidence and with the pref-erences of patients and their families.
Final-ly, preferences about ANH may not be honoredafter a patient is moved from one care setting toanother.
It is not possible to prevent all disagreementsabout the use of ANH. But it is possible, and in-deed it is essential, to clarify the principles that should underlie decisions about ANH and to en-sure that these principles guide decisions in clin-ical practice. Therefore, in this article we examinethe ethical principles that have guided the appro-priate use of ANH during the past 20 years andrecommend steps to promote clinical practicesthat are more consistent with these principles.
clinical decisionsand medical evidence
ANH is usually administered enterally through anasogastric tube or a gastrostomy or jejunostomy tube that is placed with fluoroscopic or endoscop-ic guidance. ANH may also be administered paren-terally through peripheral or central venous access.Hydration alone can also be provided by subcuta-neous infusion.ANH may improve survival among patients who are in a permanent vegetative state. Thesepatients may live for 10 years or more with ANHbut will die within weeks without nutritional sup-port.
Parenteral ANH can also prolong the livesof patients with extreme short-bowel syndrome,
and tube feeding can improve the survival andquality of life of patients with bulbar amyotro-phic lateral sclerosis.
Finally, ANH may im-prove the survival of patients in the acute phaseof a stroke or head injury 
and among pa-tients receiving short-term critical care,
and it may improve the nutritional status of patients with advanced cancer who are undergoing in-tensive radiation therapy 
or who have proxi-mal obstruction of the bowel.
There is less evidence of benefit when ANHis used for other indications. For instance, somestudies suggest that ANH improves the survivalrate among patients receiving chemotherapy,
Copyright © 2005 Massachusetts Medical Society. All rights reserved.Downloaded from www.nejm.org by JENNIFER L. WEIL MD on January 7, 2008 .
new england journal
n engl j med
www.nejm.org december
15, 2005
but other studies do not support this finding.
 Studies of the effect of ANH on complicationrates after cancer surgery have also produced con-flicting results.
The bulk of the available evi-dence suggests that ANH does not improve thesurvival rate among patients with dementia.
ANH is associated with considerable risks. Forinstance, patients with advanced dementia whoreceive ANH through a gastrostomy tube arelikely to be physically restrained and are at in-creased risk of aspiration pneumonia, diarrhea,gastrointestinal discomfort, and problems as-sociated with feeding-tube removal by the pa-tient.
In addition, when a patient’s renalfunction declines in the last days of life, ANHmay cause choking due to increased oral and pul-monary secretions, dyspnea due to pulmonary edema, and abdominal discomfort due to ascites.
ethical principlesfor decision making
Because ANH is associated with uncertain bene-fits and substantial risks, it is essential to ensurethat decisions about its use are consistent withthe patient’s medical condition, prognosis, andgoals for care. Therefore, decisions about ANHrequire careful consideration of its risks and po-tential benefits.Decisions about the use of ANH should bemade in the same way in which decisions about other medical treatment are made. Many peoplebelieve that nutrition must always be offered, just as pain management, shelter, and basic per-sonal care must be. This view is deeply rootedin cultural and religious beliefs.
It is oftenexpressed with the use of the word “starva-tion”
to describe the condition of a patient  who does not receive ANH. Patients, families,and physicians are entitled to hold these beliefs, which are not easily set aside. However, to helppatients and families make decisions about ANH,physicians should present the contrary view by emphasizing three key points.First, physicians should emphasize that ANHis not a basic intervention that can be adminis-tered by anyone, as food is. ANH is a medical ther-apy administered for a medical indication (e.g.,dysphagia) with the use of devices that are placedby trained personnel using technical procedures.ANH therefore has more in common with othersurgical and medical procedures that require tech-nical expertise than with measures such as sim-ple feeding. Second, physicians should explain that unlike the provision of food or other forms of comfort (such as warmth or shelter), the proce-dures required for ANH and the subsequent administration of ANH are associated with un-certain benefits and considerable risks and dis-comfort.
These factors need to be consid-ered carefully before ANH is initiated. Finally,physicians should clarify that the goal of ANHis not to increase the patient’s comfort. In fact,during the administration of high-quality pal-liative care, symptoms of hunger or thirst gen-erally resolve in a short time or can be managedeffectively (e.g., mouth dryness can be allevi-ated with ice chips) without the provision of ANH.
Throughout the comprehensive in-formed-consent process for patients and fami-lies, physicians should explain the potential ben-efits of ANH for a patient, as well as its risks anddiscomfort and all relevant alternatives, just asthey would for other health care decisions.
After this discussion, patients and familiesmay remain convinced that ANH differs fromother treatments. Beliefs about food and the as-sociations concerning food are deep-seated, andin some cohorts and communities they are linkedto historical or personal experiences with star- vation (e.g., during the Holocaust or the Great Depression). Patients and families may decide toaccept or refuse ANH on the basis of these be-liefs. When physicians have beliefs about ANH
 that prevent them from supporting the decision-making process of a patient and his or her fam-ily in an unbiased way, they should considertransferring the patient’s care to another physi-cian. Hospitals and health care facilities shouldsupport physicians in doing so.
withholding or withdrawalof treatment
Many people believe it is more acceptable to with-hold a treatment than to withdraw it,
and onecannot discount the emotional burden that fami-lies in particular may feel when they believe that the withdrawal of treatment will allow a patient to die. This distinction is not supported, however,by currently accepted ethical and legal reason-ing.
In fact, a more cogent argument canusually be made for the withdrawal of ANH afterit has been administered for a trial period if it hasproved to be ineffective or if experience has pro- vided more information about its risks and dis-comfort.
Copyright © 2005 Massachusetts Medical Society. All rights reserved.Downloaded from www.nejm.org by JENNIFER L. WEIL MD on January 7, 2008 .
n engl j med
www.nejm.org december
15, 2005
evidence of patient preference
When a patient lacks the capacity to make deci-sions, a single surrogate (usually defined in a statelaw according to a hierarchy) should make choiceson that patient’s behalf on the basis of availableevidence of the patient’s preferences and values.
 These decisions may be based on previous state-ments (either oral or written) by the patient oron a surrogate’s knowledge of the patient. Thisstandard of surrogate decision making has been widely supported in the law 
and among ethi-cists.
In some states, however, a patient’s ad- vance directive must include a statement that thepatient would not want ANH.
This higher stan-dard of evidence is inappropriate for two reasons.First, decisions about ANH should not be heldto a higher standard of evidence, because the bal-ance of risks and potential benefits is, in most situations, no different for ANH than for many other medical treatments. For many patients, suchas those with dementia, the balance may favorother interventions over ANH. Therefore, it is il-logical to require a higher level of evidence inorder to withhold or withdraw ANH than wouldbe required for other medical treatments or pro-cedures that offer a similar risk–benefit balance.Second, a higher standard that requires spe-cific evidence of a patient’s preferences regard-ing ANH is not realistic. Although in its decisionin the Cruzan case, the Supreme Court upheldthe constitutionality of requiring clear and con- vincing evidence of a patient’s preferences,
any higher standard has proved to be very difficult to satisfy. Despite moderate increases in theprevalence of advance directives as a result of thePatient Self-Determination Act, most adults havenot executed a written advance directive,
andeven those who have may not have specifiedtheir preferences about ANH. Therefore, a higherevidentiary standard makes it harder for surro-gates to make decisions that reflect a patient’sgoals and preferences. Furthermore, a higherstandard is illogical because it would permit cer-tain restraints on liberty — the imposition of ANH without consent — whereas impositions of other treatments are prohibited.
lack of advance directive
Although surrogates should make decisions onthe basis of a patient’s preferences, sometimes anadvance directive is not available. In this situation,the patient cannot be assumed to want ANH. In-deed, there are a variety of reasons why patientsdo not complete advance directives, including cul-tural concerns, lack of information, and reluctanceto initiate discussions about advance directives.
 When a patient’s preferences are unknown, surro-gates must consider how a reasonable person witha cultural background, life experience, and world- view similar to the patient’s would weigh the risksand potential benefits of ANH. This “reasonableperson” standard often may be easier to apply than the related “best interest” standard, which re-quires surrogates to consider the difficult philo-sophical question of whether a decision that couldresult in death is in a patient’s best interest.Although only a minority of states explicitly permit the reasonable-person standard,
reason-able people often choose to forgo life-sustainingtreatment if its discomfort outweighs its bene-fits
or if those people perceive a health con-dition to be worse than death.
The balanceof risks and potential benefits for ANH may beless favorable than the balance for other treat-ments that surrogates refuse on a patient’s be-half. Therefore, states that allow surrogates tomake other health care decisions on the basis of a reasonable-person standard also should per-mit this standard for decisions about ANH.
provision of palliative care
Patients who forgo ANH may experience hungeror thirst. Although hunger typically resolves afterseveral days, thirst may persist.
Other symptomsattributable to the withholding or withdrawal of ANH include dry mouth, confusion and delirium,and diminished alertness.
Some of these symp-toms (in particular, altered mental status) are part of dying and may occur during any progressiveillness.
When ANH is withheld or withdrawn, physi-cians should reassure patients and families that most of the resulting discomfort can be managedeffectively.
Altered mental status can often beprevented by environmental modifications (suchas reducing noise at night and placing orientationcues in patients’ rooms), and delirium can betreated pharmacologically.
Thirst and mouthdryness can be alleviated with ice chips, a mouthrinse, or moistened swabs.
Evidence suggeststhat these and other interventions can help en-sure a comfortable death.
All patients who for-go ANH should be offered comprehensive palli-ative care, including hospice.
A comprehensivepalliative care or hospice plan should addressphysical and psychological symptoms and should
sounding board
Copyright © 2005 Massachusetts Medical Society. All rights reserved.Downloaded from www.nejm.org by JENNIFER L. WEIL MD on January 7, 2008 .

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