Ethical Issues in Nutrition Support

Dr Simon Gabe

Consultant Gastroenterologist

St Mark’s Hospital

London

Religion

Human Rights

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

Death & Dying

Death, like birth, is a natural event

A professional carerhas a duty to prolong life but not to inappropriately prolong dying

The difficulty …

to recognise when death is occurringto recognise when death is occurring

Dying

Sudden / final event of deterioration When deterioration is quick – dying Appropriate to:

– Basic human support– Compassion– Emotional support– Medical treatment– Withdraw medical treatment

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.”

I'm not afraid to die…

I just don't want to be there when it happens!

Essentials for life

Oxygen -minutes

Water - days

Food - weeks

Reproduction - years

NutritionMedicine

Nursing

Surgery

Psychiatry

Community

Paediatrics

When is it lawful to withhold or

withdraw life-prolonging treatment?

Ethics & Nutrition Support

Hippocratic Tradition

Reduce violence or disease

Do no harm

Do away with suffering

Refuse to treat where medicine powerless

Duty to provide nutrition

Is the duty absolute, without exception or Is the duty absolute, without exception or regard to consequence or circumstance?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. The duty to feed is presumptive not absolute. It is rebuttable in certain circumstances:It is rebuttable in certain circumstances:– Patients refusal of consent– A persistent vegetative state?

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?

Murder

The wilful killing of any subject whatever, with malice aforethought …

Can be a deliberate act or neglect

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

Mrs B

43 year old ladyParalysed from the neck downKept alive by ventilationFelt that her life was not worth living

Asked doctors to switch off the ventilator– Doctors refused

Court felt that she was competentVentilator switched off at her request

Passive assisted suicide allowedPassive assisted suicide allowed

Autonomy Rules!

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

Assisted suicide refusedAssisted suicide refused

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

IncompetenceNo advance directive

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

““Best interests”Best interests”

??

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

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

Airedale Trust vs. Bland (1993)

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

Terri SchiavoFeb 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

Passive Euthanasia

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

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)

Enough!

After mentioning about the possibility of an endoscopy for her GI bleed

“I can’t cope any longer”

Wants to stop her treatment– Including her IV fluids and nutrition

What would you do now?

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 soughtReligious perspectiveLegal perspective

– Assault to feed against her wishes

ThenPalliative care team

involved Allowed to die

– by withdrawing fluids & nutrition

– husband at her bedside

Advanced dementia

4 million cases in the USA Frequently

– swallowing difficulties– Anorexia / loose interest in eating– aspiration

Decision to insert a feeding tube

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)

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

Advanced Dementia

Cultural variations in treatment– Germany / UK

Nursing homes insist on PEG over NG– Dementia, CVA

Ethical issues?

Should I tube feed this patient?

If in doubtIf 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

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