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Ethical Issues in Nutrition Support of Severely Disabled Elderly Persons: A

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Ethical Issues in Nutrition Support of Severely Disabled Elderly Persons: A Guide for Health
Professionals
Stéfanie Monod, René Chiolero, Christophe Büla and Lazare Benaroyo
JPEN J Parenter Enteral Nutr 2011 35: 295
DOI: 10.1177/0148607111405338

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Invited Review
Ethical Issues in Nutrition Support of
Severely Disabled Elderly Persons:
A Guide for Health Professionals
Stéfanie Monod, MD1,2; René Chiolero, MD3;
Christophe Büla, MD1; and Lazare Benaroyo, MD, PhD2
Financial disclosure: none declared.
Providing or withholding nutrition in severely disabled elderly
persons is a challenging dilemma for families, health profession-
als, and institutions. Despite limited evidence that nutrition sup-
port improves functional status in vulnerable older persons,
especially those suffering from dementia, the issue of nutrition
support in this population is strongly debated. Nutrition might be
considered a basic need that not only sustains life but provides
comfort as well by patients and their families. Consequently, the
decision to provide or withhold nutrition support during medical
care is often complex and involves clinical, legal, and ethical
considerations. This article proposes a guide for health profes-
Clinical Relevancy Statement
Decision to withhold or withdraw nutrition in severely dis-
abled older patients is a challenging dilemma for health
professionals. The decision-making process is complex
and requires clinicians to integrate scientific knowledge
together with legal, cultural, religious, ethical, as well as
emotional considerations. This paper proposes a guide for
health professionals to appraise ethical issues related to
nutritional support in severely disabled older persons. The
guide is based on an eight-step process to eventually reach
a consensus on the most relevant plan of care to implement
From 1Service of Geriatric Medicine and Geriatric Rehabilitation,
University of Lausanne Medical Center, Lausanne, Switzerland;
2
Ethos—Interdisciplinary Ethics Unit, University of Lausanne,
Lausanne, Switzerland; and 3Intensive Care Unit, University of
Lausanne Medical Center, Lausanne, Switzerland.
Received for publication October 25, 2010; accepted for publi-
cation November 6, 2010.
Address correspondence to: Stéfanie Monod, MD, Department
of Geriatric Medicine and Geriatric Rehabilitation, University
Hospital (CHUV) and Faculty of Biology and Medicine, CUTR
Sylvana, CH-1066 Epalinges, Switzerland; e-mail: Stefanie.
Monod-Zorzi@chuv.ch.
295
Journal of Parenteral and
Enteral Nutrition
Volume 35 Number 3
May 2011 295-302
© 2011 American Society for
Parenteral and Enteral Nutrition
10.1177/0148607111405338
http://jpen.sagepub.com
hosted at
http://online.sagepub.com
sionals to appraise ethical issues related to nutrition support in
severely disabled older persons. This guide is based on an 8-step
process to identify the components of a situation, analyze con-
flicting values that result in the ethical dilemma, and eventually
reach a consensus for the most relevant plan of care to imple-
ment in a specific clinical situation. A vignette is presented to
illustrate the use of this guide when analyzing a clinical situation.
(JPEN J Parenter Enteral Nutr. 2011;35:295-302)
Keywords:   nutrition support; tube feeding; elderly persons;
ethics
in a specific clinical situation. The use of this guide for
ethical reflection should help the health professionals to
get through difficult decision-making process.
Introduction
Biology and medicine have grown exponentially, pro-
viding broad diagnostic capacities and sophisticated life-
supportive therapies. These developments push the limits
of medicine beyond frontiers previously considered
impossible to cross, generating new ethical questions that
cannot be solved by science alone. Most frequently, these
ethical questions arise in fields of high-technology medi-
cine, but they also occur when using less sophisticated
life-supportive measures, such as nutrition support.1 In
these situations, a cautious ethical deliberation is required
to promote reasonable decisions and to choose the most
relevant plan of care for the patients, their relatives, and
the healthcare providers.2,3
Ethical issues are particularly relevant when caring
for severely disabled elderly persons who frequently suffer
multiple chronic conditions, are functionally dependent,
and are at high risk of death. Even though life-extending
measures might still be appropriate to consider in some of
these patients, the decision to offer or withhold such
296   Journal of Parenteral and Enteral Nutrition / Vol. 35, No. 3, May 2011
measures requires careful weighing of the potential ben-
efits and harm. In these patients, especially in those with
dementia,4 preserving their functional abilities and quality
of life are usually primary goals of care. Whether nutrition
support (oral supplementation or enteral nutrition [EN])
might contribute to these goals is controversial. However,
nutrition cannot be considered only from a healthcare
perspective. Nutrition (artificial or natural) might be con-
sidered by patients and their families a basic need that not
only sustains life but provides comfort as well. These
diverse perspectives explain the intense debate surround-
ing decisions to withhold or withdraw nutrition in patients,
including elderly patients with severe disability.5-8 For
some patients, nutrition might also be considered a basic
care that is associated with the respect for human dignity
and cannot therefore be interrupted. Cultural and reli-
gious representations play a major role in determining the
importance of nutrition in daily life and medical care.9-12
The influence of these cultural and religious differences
was well illustrated in the Ethicus study13 that observed
substantial variations in decisions to limit therapies and
manners of dying across Europe. For instance, this study
revealed that not only the patient’s but also the physician’s
religion influences therapeutic decisions at the end of
life.14
Determining the moral value of providing or with-
holding nutrition support in a given patient is therefore
particularly demanding.7 To address this issue and best
incorporate values and beliefs in their decision-making
process, clinicians need to acquire specific competencies.
This article proposes a guide for healthcare profes-
sionals to appraise ethical issues related to nutrition sup-
port in severely disabled older patients (ie, those with
multiple chronic conditions and/or functional impair-
ments) when many stakeholders support different ethical
points of view. Starting with a brief summary of medical
evidence regarding nutrition support in disabled older
patients, this practical guide is then outlined. Finally, a
vignette is presented to illustrate the application of this
guide when analyzing a clinical situation.
Summary of Medical Evidence
Regarding Nutrition Support in
Severely Disabled Elderly People
Older patients typically suffer from multiple diseases that
contribute to a high prevalence of malnutrition.15-17 In
disabled elderly persons, the benefits of nutrition support
have been essentially documented in terms of weight gain
and increased caloric intake. However, it remains unclear
whether these improvements translate into other benefits
such as reduced in-hospital morbidity (eg, infections,
pressure sores) and mortality, improved functional ability
and quality of life, or outcomes, especially in older
patients.18-23 A Cochrane review24 investigated the benefits
of oral nutrition supplementation in elderly people at risk
of malnutrition (55 trials, n = 9187 randomly assigned
participants) and provided mixed results. Nutrition sup-
plementation was associated with fewer complications
and reduced mortality in acutely ill, malnourished older
inpatients. In contrast, patients living at home only mod-
estly improved their weight but had unchanged mortality
and functional status. Furthermore, the overall method-
ological quality of the reviewed studies was judged as
poor, with several major methodological limitations,
including (but not limited to) the absence of blinding in
treatment allocation as well as outcome assessment,
unclear randomization processes, or lack of monitoring of
nutrition intake. The heterogeneity of these results
prompts subsequent attempts to better delineate indica-
tions for nutrition supplements and tube feeding in older
patients.25
In older patients suffering from dementia, EN is even
more controversial.26-30 Even though few studies found
that nutrition support significantly improved weight in
patients with Alzheimer disease, these benefits do not
translate into positive changes in cognitive ability or in
activities of daily living performances.30 There is no evi-
dence that tube feeding would prevent aspiration pneu-
monia, prolong survival, reduce the risk of pressure sores
or infections, improve function, or provide palliation in
patients with advanced dementia.26 Moreover, several
studies suggest that harm is substantial and may well
exceed the benefits in these patients.26,31 Side effects of
nutrition delivered through percutaneous enteral gastros-
tomy (PEG) have been described in dementia patients31
and include aspiration, infection, increased oral secre-
tions, tube malfunction, and discomfort.
In summary, evidence is still lacking regarding the
benefits in function, mobility, or quality of life resulting
from nutrition support in disabled older adults. In par-
ticular, risks associated with the PEG procedure might
well exceed potential benefits in those most severely disa-
bled, such as patients with dementia.
Ethical Framework
Despite the development of evidence-based medicine,
decision making remains a difficult process in older
patients where multimorbidity limits guideline applicabil-
ity. To tackle complex issues in care and provide patients
with the best possible option, health professionals need to
use all available evidence. However, health professionals
also need to incorporate factors such as personal values or
past experiences and to rely on ethical principles and legal
standards to navigate through ethical decision making.32
Medical ethics is based on a series of ethical princi-
ples that are particularly relevant to medical practice and
 Ethics and Nutrition Support in Disabled Elderly Persons / Monod et al   297
Table 1.  Bioethical Principles
Autonomy This principle guarantees that competent
patients have the right to accept or refuse
a given plan of care, without being influ-
enced by an outside authority.
Beneficence This principle implies that medical practi-
tioners should act in the best interest of
the patient.
Nonmaleficence This principle implies that medical practi-
tioners should not harm the patient.
Distributive This principle implies that health profes-
  justice sionals should be aware of distributing
healthcare resources in a fair way among
the members of society.
Dignity This principle implies that a person has an
innate right to respect and ethical treatment.
Integrity This principle implies respect of the whole-
ness of the human person.
Vulnerability Vulnerability refers to the fragility of an
intact but destructible human totality and
takes into account the biological, social,
and cultural characteristics of the person
living in the modern technological world.
It expresses the finitude of the human
condition. Vulnerable persons are those
whose autonomy, integrity, and dignity are
capable of being threatened.
patient care (Table 1). Four principles were first proposed
by Beauchamp and Childress33 and refer to the principles
of respect for autonomy, beneficence, nonmaleficence,
and justice. Three additional principles were proposed in
the European bioethics and biolaw conference34,35 to
enrich the clinical meaning and interpretation of the clas-
sic bioethical principles in the clinical setting. These
principles are the principles of dignity, integrity, and
vulnerability.
A classical way to approach ethical dilemmas arising
in a specific clinical situation is to analyze each principle
of biomedical ethics potentially challenged in this situa-
tion and to define potential conflicts between them. For
instance, conflicts frequently arise between the principles
of respect for autonomy and beneficence. Resolution of
the dilemmas is then performed through a strategy that
could address these ethical conflicts.
Relying on the analysis of bioethical principles at
stake in a situation, the practical guide proposed in this
article specifically focuses on the decision-making proc-
ess. This guide describes in detail the process through
which a consensus on the most relevant plan of care
might be implemented in a specific clinical situation. This
approach is supported by current trends in biomedical
ethics, particularly the ethics of responsibility taking its
roots in a caring perpesctive.3,34,36-39 This guide for ethical
reflection is currently used in workshops conducted with
Table 2.  Guide for Ethical Reflection
History, context, and reframing of the ethical question
  Identify the clinically relevant facts and clarify the ethi-
cal question(s).
  Identify the patient’s sociofamilial context and all stake-
holders involved in the situation.
Care responsibilities and values of each stakeholder
  Identify the care responsibilities of each stakeholder.
  Identify the values considered by each stakeholder as
essential to address the ethical questions. This step
includes identification of cultural and religious values.
Ethical analysis of the clinical situation
  Analyze the ethical conflicts at stake in the clinical situa-
tion.
Medical options
  Identify all possible options to solve the ethical conflicts.
  Identify the consensual option that best integrates values
of the patient, stakeholders, and health professionals.
Moral justification
  Discuss the moral justification for the choice.
health professionals in several services of the University of
Lausanne Medical Center, Lausanne, Switzerland.
Vignette cases are used to teach these professionals how
to apply this guide.
Description of the Guide for Ethical Reflection
Application of guide for ethical reflection is best per-
formed through a formal deliberative meeting that gets
together all health professionals involved in the situation.
They discuss the situation using an 8-step process that is
summarized in Table 2. The proposed process has been
previously described by one of the authors.40 The meet-
ing’s ultimate goals are to achieve a consensus on the best
option to manage the situation and to define a coherent
attitude within the team.
To achieve the best chance of success and reach
these goals, health professionals should be aware of
what the patient, as well as possibly what the patient’s
family, wants and expresses. This information is usually
gathered through prior meetings with them, either
together or separately. Professionals also need to care-
fully collect information about values supported by
other stakeholders (eg, other relatives and health profes-
sionals). The deliberation process should then take
place without the patient or his or her family. Including
patients or families in such a meeting would reveal
health professionals’ uncertainties to vulnerable patients
and relatives, and potential conflicts could worry them.
However, conclusions of the deliberation are subse-
quently transmitted to the patient, and possibly his or
her family, to reach a consensual plan of care and
ensure their adherence.
298   Journal of Parenteral and Enteral Nutrition / Vol. 35, No. 3, May 2011
Table 3.   Checklist of Conditions Required to Apply
the Guide for Ethical Reflection
 Organize a formal deliberative meeting.
Ensure participation of all professionals involved in the
 
situation.
 Identify a chair for the meeting to emulate participants (ide-
 has 2 daughters and 4 grandchildren. Since his retire-
ally, this person should not be the professional with the high-
est position to avoid expression of hierarchical authority).
The chair is responsible to maintain throughout the delibera-
tion process a benevolent atmosphere, allowing participants
to feel comfortable when expressing their point of view.
The chair organizes the discussion around the 8 steps pro-
 
posed in the tool for ethical reflection (Table 2).
The chair elicits the point of view of each professional
 
(fostering emergence of as many different viewpoints as
possible).
 The chair identifies a consensual decision on the ethical
 and brain metastases. The patient and his family are
option.
The chair and the group designate the person responsible
 
to oversee the implementation of the chosen ethical option.
Concrete Conditions Required to Use the
Guide for Ethical Reflection
To offer the best chances of success of this formal delib-
erative meeting, several basic conditions must be met,
such as providing an adequate environment for the dis-
cussion and ensuring participation of all professionals
involved in the situation by providing them protected time
for participation (see Table 3). Three specific conditions
deserve further comments because of their critical impor-
tance to the discussion process itself. First, a chair, who
should preferably be trained in clinical ethics, should be
designated for the meeting to emulate participants.
Second, the discussion should be organized around the 8
steps proposed in the ethical framework (Table 2). Third,
at the end of the process, the chair identifies the consen-
sual option that emerges, determines the chosen ethical
option, and together with health professionals designates
the person responsible to oversee the implementation of
the chosen option.
Clinical Case
To highlight ethical issues regarding nutrition support,
the situation of a frail older patient is presented below.
Resolution of the ethical dilemma will be performed
using the proposed guide.
Case Vignette
Mr R is an 81-year-old man admitted to the emergency
department for recurrent falls. He was diagnosed with
Alzheimer dementia 4 years earlier and has been suffering
from severe parkinsonism for 10 years. He has been mar-
ried for 58 years and is living at home with his wife. He
was born in Italy, is a devoted Catholic, and worked as a
road worker in Switzerland for more than 20 years. He
ment, he has spent most of his time with his family. His
mobility has been reduced for 1 year and he needs a
walker. His appetite has been reduced over the past 3
months, resulting in a 4-kg weight loss. His general prac-
titioner, who has been caring for him over the past 10
years, expresses his concern to the emergency physician
about malnutrition, with progressive weakness and occa-
sional confusion.
Radiology exams reveal a pulmonary tumor with liver
informed of the diagnosis. The patient’s wife and two
daughters request that all available care should be pro-
vided to him, in order to prolong his life. The patient is
able to speak but is confused and lacks understanding
regarding therapeutic choices. He repeatedly says that he
feels well. An oncology consult concludes that Mr R is not
a candidate for chemotherapy and proposes only support-
ive care, including dexamethasone.
During his hospital stay, Mr R is getting weaker and
more dependent, requiring assistance for transferring,
walking, bathing, and dressing. He expresses no pain or
needs when asked. He feeds himself, consuming a fourth
of his meals. His wife attends every meal to persuade her
husband to eat, expressing concern about his anorexia.
Most of the time the patient refuses to eat more and
becomes aggressive toward his wife. Nursing staff
expresses concern about these interactions.
After 2 weeks, the staff organizes a meeting with the
family. Mr R’s wife expresses her fear that her husband
will starve to death and requests nutrition by tube feed-
ing. She considers it unacceptable to not provide ade-
quate nutrition to her husband because nutrition means
life to her. Despite attempts to explain the lack of benefits
and substantial risks of tube feeding, she maintains her
request and expresses concerns that the medical staff is
killing her husband. She says that life is a gift from God
and should be respected at all costs. After the meeting,
the physician and nurses debate how they should provide
the best care for this patient, especially regarding nutri-
tion support.
Ethics Workup
The physician in charge of the patient organizes a meet-
ing with all staff members involved in the situation.
During the meeting, the group applies the 8 steps of the
guide. A nurse is designated to chair the meeting.
 Ethics and Nutrition Support in Disabled Elderly Persons / Monod et al   299
Step 1: Identifying Clinically Relevant Facts
and Clarifying the Ethical Questions
Mr R is suffering from a multimetastatic pulmonary can-
cer. He is demented and confused, and he requires assis-
tance for most activities of daily living. Owing to his
reduced appetite and weight loss, his wife requests to
start tube feeding.
Two joint ethical questions are identified: (1) What
is the best option regarding nutrition support? (2)
Should tube feeding be considered to address the wife’s
request?
Step 2: Identifying the Patient’s Sociofamilial
Context and All Stakeholders Involved in the
Situation
The sociofamilial context of Mr R is described in the
vignette. Stakeholders most closely involved include his
wife, the nurses, and the hospital physician. The two
daughters and the patient’s general practitioner represent
a second, more remote, group of actors.
Steps 3 and 4: Identifying Care Responsibilities
of Each Stakeholder and the Values They
Consider Essential to Address the Ethical
Question
It is difficult to assess Mr R’s values and preferences,
especially regarding nutrition support, but he is able to
express some irritation when his wife encourages him to
eat. His reaction might suggest discomfort associated
with nutrition.
The patient’s wife is concerned about her husband’s
care. In her view, life has inestimable value, and with-
holding tube feeding is like killing her husband. Her
stand is in line with the Catholic Church’s position that
considers life as a benefit, no matter how disabled the
person might be. Provision of food is therefore considered
a basic care due to all people. Whether tube feeding
would provide comfort or functional improvement is not
relevant to her.
Health professionals (physicians and nurses) believe
they have to act in the best interest of the patient and not
harm him. They need to provide interventions that have
been shown to improve health outcomes. In the case of
Mr R, this would mean interventions that maximize his
comfort. They also consider they are responsible to build
the best plan of care for the patient, a task that implies
taking into account the patient’s family, especially his
wife.
Unfortunately, no information was available at this
time about the positions of the daughters and the patient’s
general practitioner.
Step 5: Analyzing the Ethical Conflicts at Stake
In this step, the main bioethical principles will be dis-
cussed and ethical conflicts will be identified.
Mr R unfortunately is not autonomous. He lacks
understanding and judgment, making him unable to
express a choice on what he would consider the most
appropriate option regarding nutrition support. He did
not write advanced directives or designate a surrogate,
making it difficult to know his preference regarding nutri-
tion support. The family opinion has been sought during
the previous family meeting to better understand what
the patient would have chosen. But at this time, the
patient’s wife expressed mostly what appears to the team
as her choice rather than her husband’s. As the couple
has the same religious and cultural background, a hypoth-
esis might be made that the patient would have shared his
wife’s position regarding the value of life and the critical
need to prolong it. Inversely, based on his reaction to
feeding stimulation, it could also be hypothesized that the
patient would have refused tube feeding. Thus, despite
some presumptions about the patient’s wishes, it is
impossible to determine his position regarding tube feed-
ing and formally define the position that would best
respect his autonomy.
The patient expresses no specific needs or spontane-
ous wishes. It is therefore difficult to determine what
beneficence would mean to him. His irritation when
stimulated to eat by his wife could be interpreted as sug-
gesting maleficence from the patient’s perspective.
For the wife, beneficence would clearly be to provide
tube feeding to prevent her husband from starving to
death. In her view, withholding nutrition support is
assimilated to maleficence.
For the physician, beneficence and nonmaleficence
imply avoiding tube feeding (primum non nocere), accord-
ing to medical evidence about the risks and benefits of
tube feeding in patients with dementia. For nurses,
beneficence would be to maximize the patient’s comfort,
and forcing him to eat would be equivalent to malefi-
cence. Beneficence would also consist of encouraging the
patient’s wife to accept her husband’s situation and help
her in dealing with this life hardship. Alleviating the wife’s
anxiety would indeed also benefit Mr R.
Still, no information is available on the position of
other family members.
In summary, we can identify here an ethical conflict
between the wife’s and the health professionals’ concep-
tions of beneficence and nonmaleficence.
Issues regarding distributive justice arise from the
inappropriate use of healthcare resources considered
ineffective and futile for the patient at the detriment of
other patients who might not have access to these or
other effective measures. PEG placement, necessary for
300   Journal of Parenteral and Enteral Nutrition / Vol. 35, No. 3, May 2011
tube feeding in this patient with dementia, will likely
not achieve the intended goal and could therefore be
considered futile from the health professionals’ perspec-
tive. Inversely, from the wife’s perspective, distributive
justice would mean to provide treatment and basic care
to every patient, whatever his or her condition, age, or
severity of illness.
In summary, we can identify here an ethical conflict
between the wife’s and the health professionals’ concep-
tions of justice. Mr R is a vulnerable patient because of
his poor medical condition, his loss of competence, and
his closeness to death. The patient’s wife is also vulnera-
ble, as she feels troubled, anxious, and guilty regarding
the decision to withhold tube feeding. Considering the
vulnerability of both the patient and his wife, the ethical
and social responsibilities of the physician in charge are
engaged.
Step 6: Identifying All Possible Options
to Solve the Ethical Conflicts
At least 3 medical options may be considered in this situa-
tion. For each option, the way the option helps or does not
help to solve the conflicts between principles is clarified.
Option 1: Aggressive renutrition with tube feeding. The
goals of aggressive renutrition would be to improve the
patient’s nutrition intake and, possibly, extend his survival.
Nevertheless, tube feeding may be associated with com-
plications due to PEG placement and increased confu-
sion, aspiration, and discomfort. This option would respect
the position of the patient’s wife and her definition of
beneficence and nonmaleficence. It would also respect
her values. However, from the physicians’ and nurses’
point of view, the medical justification of this option is
lacking and would force them to provide inappropriate
medical treatment. Moreover, this option could even
result in maleficence because physical or chemical
restraints might be needed to keep the patient from pull-
ing out the tube. Thus, tube feeding does not help to solve
conflicts between the wife’s and the health professionals’
conceptions of beneficence, nonmaleficence, and justice.
Option 2: Active oral renutrition without tube feeding. In
this option, efforts would be made to enhance oral feed-
ing, using oral supplementation, encouragement to eat
(organizing pleasant mealtimes and providing favorite
meals), and creating a patient-centered approach.41 The
goal would be to improve the patient’s nutrition intake
without requiring tube feeding. This option might still
correspond to beneficence from the wife’s perspective if it
increases nutrition intake. However, in case of failure,
she would probably believe that healthcare providers did
not respect her husband’s life. For health professionals,
this option could also be acceptable, as long as the patient
would accept the stimulation and not become agitated.
Otherwise, eating encouragement would be assimilated to
maleficence (force feeding).
This option might help solve the conflict between the
wife’s and the health professionals’ understandings of
beneficence, nonmaleficence, and justice.
Option 3: Nutrition for pleasure. In this option, usual
nutrition would be adapted to the patient’s wishes and
preferences. Mealtimes would be associated with plea-
sure instead of a task to complete. Efforts to lower
stress associated with feeding would be fostered. The
goal would change from caloric intake to comfort.
However, this option would not be understood by the
patient’s wife. It could worsen her distress, will disre-
spect her values, and could be considered maleficence
by her. For the physician, this option would be realistic
given Mr R’s poor prognosis. For the nurses, this option
would be beneficial for the patient’s quality of life but
deleterious to his wife. Nutrition for pleasure does not
solve conflicts between the wife’s and the health profes-
sionals’ conceptions of beneficence, nonmaleficence,
and justice.
Step 7: Identifying the Consensual Option
That Best Integrates Values of the Patient,
Stakeholders, and Health Professionals
Based on the analysis described above, the most appropri-
ate option was consensually defined in the group and
enforced.
Aggressive renutrition with tube feeding (option 1)
and nutrition for pleasure (option 3) appeared less ade-
quate because these options do not help to solve conflicts
between the wife’s and the health professionals’ concep-
tions of beneficence, nonmaleficence, and justice. Option
2, active oral renutrition without tube feeding, appeared
the most acceptable compromise, as this option might
help solve the ethical conflicts. However, the group
acknowledged that it could also raise questions and prob-
lems. If the wife still considers nutrition intake insuffi-
cient (maleficence) or if health professionals perceive the
patient suffering from eating encouragement (malefi-
cence), then ethical issues will remain unsolved.
The deliberation group proposes implementing
active oral renutrition without tube feeding as the most
appropriate option with a careful monitoring of its ben-
efits. The following propositions were made: (1) Imple­
mentation, monitoring, and adjustment of the option
will be the physician’s responsibility. (2) External stake-
holders’ (daughters and primary care physician) perspec-
tives will be actively sought to know their position and
determine whether they could help the patient’s wife in
 Ethics and Nutrition Support in Disabled Elderly Persons / Monod et al   301
renouncing tube feeding. (3) Adverse outcomes resulting
from the option will be anticipated, especially the
patient’s reluctance to adhere to nutrition intake
improvement, or insufficient nutrition intake, from the
wife’s point of view. A strict follow-up of the feelings of
the patient, his wife, and health professionals will be
mandatory, with planned meetings for review at regular,
predetermined intervals. (4) As the wife’s anxiety appears
to be harmful to the patient, the care plan will include
psychological support for the patient’s wife to address
her guilty feelings and relieve her anxiety. (5) An active
contribution of Mrs R to her husband’s care will be
encouraged in a precise framework. Contribution to her
husband’s feeding will be avoided, and participation in
other activities enjoyed by the patient (going for a walk,
helping him to dress, and providing other basic care) will
be encouraged. Acknowledging the wife’s dedication to
her husband will probably help her in accepting the situ-
ation and taking a first step toward the difficult task of
allowing her husband to die. (6) Spiritual or religious
support by the department’s chaplain will be provided to
the couple to help them make sense of what is happen-
ing and lower doubts, especially regarding religious
beliefs.
Step 8: Moral Justification for the Choice
From a medicolegal perspective, renouncement to nutri-
tion would have been justified. However, the selected
option (active oral renutrition without tube feeding)
allows going beyond the sole respect of the patient’s rights
and duty. The proposed ethical approach takes into
account the ethical responsibility of the health profes-
sionals and integrates clinico-ethical values, such as vul-
nerability, trust, and care as key components in the
situation. The notion of responsibility toward the vulner-
ability of the patient and toward his wife is emphasized.
Indeed, even though the ethical question involves primar-
ily the patient, his wife cannot be excluded from this
decision-making process, owing to her own vulnerability
in the situation.2,42 Thus, in this option, the physician’s
role and responsibility are extended in a humanistic view
of medical care.
Conclusion of the Clinical Case
After this meeting, decisions were progressively imple-
mented. The daughters’ opinions were found to be helpful
as they supported their mother in progressively accepting
the medical situation of Mr R and foregoing tube feeding.
With their support, a meaningful accompaniment was
provided to Mrs R, who finally got through this difficult
situation. Mr R progressively declined and eventually died
2 months later.
The use of the guide for ethical reflection helped the
health professionals to get through the difficult decision-
making process. It concretely helped the deliberation
process and benevolent confrontation between profes-
sionals. Structuring the decision-making process also
undoubtedly helped professionals to step back in this
situation and analyze the ethical question with less emo-
tion. The use of this guide allowed a thoughtful analysis
of the bioethical principles at stake and the identification
of the best option of care. The consensus reached among
the health professionals as between them and the wife
probably helped her grieving process as well.
Conclusion
Decision to withhold or withdraw nutrition in severely
disabled older patients remains a difficult, emotionally
troubling, and controversial process. The decision-making
process is complex and requires clinicians to integrate
scientific knowledge with legal, cultural, religious, ethi-
cal, and emotional considerations. Although time inten-
sive and resource consuming, this process is essential to
build with the patient and his or her next of kin the most
meaningful plan of care in a morally responsible way. The
proposed guide for ethical reflection helps health profes-
sionals in better appraising any clinical situations where
controversial attitudes need to be debated.
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