Obligations and Options in Artificial Nutrition and Hydration

A wealth of experience and a burgeoning literature, supported by sound ethical and legal principles, are questioning the appropriateness of artificial nutrition and hydration in clinical settings like the ones discussed here. (Among these are Finucane; Cillick; Lynn; Post; Slomka; Steinbrook; and Winter.) Yet many providers and laypersons are unaware, or because of personal views rooted in their own moral background, do not accept these concepts. It is important, therefore, to first educate patients and families to insure that knowledge and understanding are on an even par so that decision making may be shared. A second step is to define goals as one might with any treatment modality. Considerations include the patient's prognosis, and how feeding is expected to either positively or negatively affect the medical condition (benefits and burdens), taking into account expected life span, patient comfort, and, as applicable, any previously expressed wishes about use of life sustaining treatment. The availability of technology is coercive and constitutes a challenge to the physician; yet a recommendation to withhold or withdraw a useless, burdensome treatment can be a more caring act than any other. Nonetheless, in the event of uncertainty about prognosis, or with failure to reach a consensus, initiation of artificial feeding as a trial, for an agreed-upon time frame with defined goals, may be an appropriate option, which does not jeopardize the relationship between physician and the patient or surrogate. Decisions about continuation or withdrawal can then be made with more confidence.

Providing food for dying patients is much more likely rooted in the act of eating than in the provision of nutrition and fluid by an alternate route. While both options offer physiological benefits, oral feeding provides comfort and pleasure to the extent one wants to eat. It also respects autonomy in that one is left in control of oral intake. Assisting in this process is a nurturing act. Even thought artificial feeding may be rejected, assisted oral feeding should be considered an obligation rather than an option, as permitted by the clinical situation.

With disagreements about management that involves ethical issues for some, the institutional ethics committee can be helpful by shedding light on the pertinent issues and improving communication among the involved parties. This is a valuable resource when conflicts are looming, but also in providing support for providers and family in emotionally charged situations.

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