Ethical Issues in Nutrition Support

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Ethical Issues in Nutrition Support

• Dr Simon Gabe

Consultant Gastroenterologist St Marks
Hospital London
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Religion
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Human Rights
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Human Rights

• Fundamental right to life
• Does not mean bare existence
• Existence that has a minimum quality as free as
  possible from distress pain
• Right to die
• When individuals decide that their life is below
  the minimum
• Considerations of humanity imply a right to
  assistance (medical) to die painlessly easily

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Death Dying

• Death, like birth, is a natural event
• A professional carer
• has a duty to prolong life but not to
  inappropriately prolong dying
• The difficulty

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Dying

• Sudden / final event of deterioration
• When deterioration is quick dying
• Appropriate to
• Basic human support
• Compassion
• Emotional support
• Medical treatment
• Withdraw medical treatment

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Ashby Stofell, 1995

• The purpose of medical science is to benefit the
  life and health of those who turn to medicine.
• It surely was never intended that it be used to
  prolong biological life in patients bereft of the
  prospect of returning to an even limited exercise
  of human life.

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• I'm not afraid to die
• I just don't want to be there when it happens!

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Essentials for life

• Oxygen - minutes
• Water - days
• Food - weeks
• Reproduction - years

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Community
Psychiatry
Nursing
Surgery
Paediatrics
Nutrition
Medicine
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When is it lawful to withhold or withdraw
life-prolonging treatment?
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Ethics Nutrition Support

• Hippocratic Tradition
• Reduce violence or disease
• Do no harm
• Do away with suffering
• Refuse to treat where medicine powerless

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Duty to provide nutrition

• Is the duty absolute, without exception or regard
  to consequence or circumstance?
• If the body cannot tolerate nutrition
• The leading criterion is the patients best
  interest
• The duty to feed is presumptive not absolute. It
  is rebuttable in certain circumstances
• Patients refusal of consent
• A persistent vegetative state?

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Ethics Nutrition Support

• Does the provision of nutritional support
  constitute a medical treatment?
• Does removal of an IV line or feeding tube
  cause the death of a patient?
• Is discontinuation of feeding, murder?

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Murder

• The wilful killing of any subject whatever, with
  malice aforethought
• Can be a deliberate act or neglect

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Competence

• Patients are competent to consent to treatment,
  or to refuse consent, if they have capacity to
  arrive at the decision
• All adults are presumed competent, although this
  can be rebutted
• A doctor who overrides a competent patients
  refusal of treatment can be liable in battery

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Mrs B

• 43 year old lady
• Paralysed from the neck down
• Kept alive by ventilation
• Felt that her life was not worth living
• Asked doctors to switch off the ventilator
• Doctors refused
• Court felt that she was competent
• Ventilator switched off at her request

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Diane Pretty

• 43 year old, MND
• Paralysed from the neck down
• Not on a ventilator
• Virtually unable to speak
• Enteral tube feeding
• Wanted to die in a humaine dignified manner
  (assisted by her husband)
• Court refused

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IncompetenceAdvance directive

• Anticipatory refusal of treatment
• Can be written or oral
• An advance refusal is legally binding if
• clearly established applicable to the
  circumstances
• However, may not be directly applicable to
  current circumstances
• A doctor who overrides a binding advance
  directive is liable for battery

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IncompetenceNo advance directive

• The legal duty of the doctor is to act in the
  patients best interests

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Best interests
?
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Airedale Trust vs. Bland (1993)

• Anthony Bland
• Age 17
• Crushed in the Hillsborough stadium disaster
• Persistent vegetative state for over 3 years
• Completely insensate with no hope of recovery
• His doctors, with the full agreement of his
  parents, wished to withdraw the means of
  intensive care

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Airedale Trust vs. Bland (1993)

• High Court declared that the withdrawal of
  hydration and feeding would be unlawful
• Court of Appeal supported the High Court
• House of Lords dismissed the Court of Appeal
  judgement
• The provision medical treatment could no longer
  provide the chance of recovery
• Therefore medical treatment could be withdrawn

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Important rulings after Bland

• Best interests
• Medical decisions for a mentally incapable
  patient should be made in the best interests of
  the patient
• If a decision to withdraw or withhold life
  prolonging treatment is in best interests of the
  patient then it is lawful (i.e. best interests
  can include death)
• Feeding
• Artificial nutrition hydration are medical
  treatments
• Feeding against a patients wishes constitutes
  assault
• Withholding and withdrawing treatment
• There is no legal difference

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Terri Schiavo

• Feb 1990 Cardiac arrest with severe brain damage
  (PVS)
• May 1998 Mr Schiavo files petition to remove
  feeding tube
• Oct 2003 Feeding tube removed Florida lower
  house passes "Terri's Law", allowing the Governor
  to order doctors to feed Mrs Schiavo
• Sept 2004 Florida Supreme Court strikes down law
• 18 Mar 2005 Florida court allows removal of tube
• 22 Mar 2005 Federal judge rejects appeal
• 23 Mar 2005 Appeals court backs federal ruling
• 29 Mar 2005 Federal court grants parents leave to
  appeal
• 30 Mar 2005 Federal court Supreme Court reject
  parents' appeal
• 31 Mar 2005 Terri Schiavo dies

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Passive Euthanasia

• The intentional hastening of a patients death by
  withholding or withdrawing treatment where
  causing death is the doctors aim

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Pauline

• 61 year old lady
• 2001 Ileal resection then EC fistula Massive
  intestinal infarction
• Residual duodenal stump (then fistulated)
• HPN established
• 1/2002 SVC thrombosis stented successfully
• 3/2002 Abnormal LFTs
• 3/2002 Bleeding GU
• 11/2002 L pleural effusion .. ?TB
• 12/2002 Recurrent SVC thrombosis (stented)
• 12/2002 Recurrent GI bleed (small)

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Enough!

• After mentioning about the possibility of an
  endoscopy for her GI bleed
• I cant cope any longer
• Wants to stop her treatment
• Including her IV fluids and nutrition

What would you do now?
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What we did

• Listen to the patient
• Discussions with her family
• Competence
• Was she competent to make the decision?
• Yes, in my opinion
• Psychiatrist also
• Carers views sought
• Religious perspective
• Legal perspective
• Assault to feed against her wishes

• Then
• Palliative care team involved
• Allowed to die
• by withdrawing fluids nutrition
• husband at her bedside

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Advanced dementia

• 4 million cases in the USA
• Frequently
• swallowing difficulties
• Anorexia / loose interest in eating
• aspiration
• Decision to insert a feeding tube

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Advanced dementiafeeding tubes

• Often difficult to provide adequate nutrition
• Disputed whether aspiration is reduced by NG or
  PEG tubes
• Morbidity mortality with PEG insertion
• Little evidence to suggest that tube feeding
  prolongs life
• Purpose of tube usually unclear for the patient
  (resulting in tube withdrawal)

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Advanced dementiafeeding tubes

• Increasing view that artificial nutrition should
  not be used in patients with advanced dementia
• But there will always be exceptions
• Vascular disease (cognitive function may improve)
• Patient autonomy paramount
• Requires close discussion with family

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Advanced Dementia

• Cultural variations in treatment
• Germany / UK
• Nursing homes insist on PEG over NG
• Dementia, CVA

Ethical issues?
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Should I tube feed this patient?

• If in doubt
• A trial of treatment is recommended
• NG or PEG?
• NG feeding may be more appropriate than PEG in
  this setting
• However, trial of PEG feeding possible

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Hippocratic or Hypocritical?

• The law the BMA guidance relating to
  withholding withdrawal of treatment tube
  feeding are ethically incoherent
• The intentional shortening of a patients life
• ? Passive euthanasia (by omission)
• ? Active euthanasia
• Assisted suicide
• ? Passive assisted suicide
• ? Active assisted suicide

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Medical Ethics

• moral obligations which govern the practice of
  medicine

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• Autonomy
• principle of self-determination
• recognition of the patients rights
• Non-maleficence
• Deliberate avoidance of harm
• Beneficence
• Provides the patient with some benefit
• Justice
• The fair and equitable provision of available
  medical resources to all

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Justifiable conditions of non-treatment

• Imminent or irreversible closeness to death
• Extensive neurological damage leading to
  destruction of self-awareness intentional
  action
• Little self-awareness accompanied by severe motor
  disability
• Destruction of short long-term memory
• Limited understanding by patient

Doyal et al. BMJ 19943081689