Home Archive Vol.39, No.3, 2013 Updates Patient`s Nutrition in Palliative Care: Ethical Values

Patient`s Nutrition in Palliative Care: Ethical Values

ADRIANA ILIESCU, B.V. COTOI

General Nursing Department, Faculty of Nursing and Midwives, University of Medicine and Pharmacy of Craiova

ABSTRACT: Diet is inseparable from the concept of life. When this function cannot be physiologically done by the patient receiving palliative care, may she always be replaced by invasive medical therapy? What are the benefits of nutrition and hydration in terminally ill patients versus the risks posed by this type of intervention? This issue is dealing with the representations related to life, death and health. Parenteral nutrition can be justified medically and ethically, in the same extent?

KEYWORDS  : nutrition , artificial alimentation , ethical principles , ethical dilemmas


In recent years, numerous voices have been heard through articles, conferences and debates that have as main topic medically assisted nutrition and hydration and especially the decision to discontinue this during the last phase of incurable disease in the case of palliative care.

The term nutrition indicates oral ingestion of food  that always accompanies the pleasure and satisfaction. The term nutrition refers to the physiological function and includes deglutition, transformation, absorption and metabolism of ingested food. Nutritional function calls on biomedical factors, psychological and sociocultural. When this type of diet is inappropriate we will use techniques of artificial nutrition of each individual such as enteral way(through a tube that goes directly into the stomach) or parenteral way(intra-venous).These medically assisted  nutrition and hydration techniques  are invasive .

The medical team and the patient with his family and every individual in society can questioned themselves on several key aspects of this situation. What are the factors making such a decision correctly oriented? The responsibility of interrupting artificial diet belongs only to the doctor, the individual concerned, the entire medical team or patient's family ? What are the consequences of continuing or stopping artificial nutrition? It represents a care that brings comfort or discomfort to the patient? Artificial nutrition once established should be stopped  only after the patient's death?

Artificial enteral nutrition is an invasive medical intervention  intended to improve the quality of life or its extension.

Three principles must be observed in patients receiving palliative care, especially when we will take in consideration the fact to stop feeding them in order to improve the quality of life and to avoid the risks of abuse:

The principle of benefaction that encompasses respect for life, compassion and the care not to harm with untimely interventions.

The principle of autonomy that expresses the patient's right to participate in decision-making in its own interest. The quality of information provided by the physician is essential: it must be adapted to the patient or his family, expressed in simple terms that present the diagnosis and prognosis, the nature of the intervention, the benefits and risks involved.

The principle of justice states that any patient is entitled to the most sophisticated techniques.

A controversy exists in determining whether nutrition and hydration should be considered as part of drug treatments or they occupy a special place and as such should never be interrupted. The fundamental question is the principle of benefaction: where is the patient's interest? Artificial nutrition can prolong life but in the presence of certain pathologies, cannot improve functional status or quality of life. Renouncing to use artificial alimentation or  even its interruption, may arise a sense of  guilt within  the medical team. 

In many cases, the principle of benefaction is in contradiction with the principle of autonomy. In these situations, the process of informing the patient and his family by the doctor is very long. To this we add prognostic uncertainty where therapeutic benefit can be seen from a totally different angle depending on the personal values of each individual who is part of the medical team. This justifies the need for multi-disciplinary meetings before making a decision concerning artificial nutrition of the individual that is in the terminal phase of incurable diseases.

Arguments against artificial nutrition put value on quality of life at the expense of the extension of life, estimating that death is inevitable and secondary to fatal disease and not to interruption of artificial nutrition.

The administration of artificial nutrition is also not without complications and thus generates discomfort for the patient. This becomes flagrant if needed to use physical restraint to prevent removal of the materials used (eg, nasogastric tube, stomii etc.). In this case recommendation of artificial nutrition should be viewed more critical and restrictive.

Respect for fundamental ethical principles must be put into practice in a multidisciplinary context, after discussion with the patient and his family. Any kind of initial attitude can not be definitive and should be constantly reassessed in a critical sense in light of developments within the patient.

From the medical point of view have been highlighted pathophysiological consequences of stopping artificial feeding. Stopping nutrition and hydration can accelerate the installation of his death. Symbolic value attached to this intervention is very strong and affects in the most of cases ,the acceptance of such a decision making. Discontinuation of artificial nutrition alters consciousness within about 48 hours with coma. Death occurs in this case within a period ranging between 8 and 15 days. It causes a reduction in urine output, vomiting and bronchial secretions with the appearance of a painkiller effect. The sensation of thirst is not felt in the presence of a proper mouth care. Various important changes are taking place throughout the  metabolic aspect translate into reducing hunger. Total fasting is better tolerated than the partial one, because increases the nociceptive threshold and induces a sensation of well. However, there are trophic disorders, central neurological alterations, alterations in immune defense, asthenia, malabsoption diarrhea, urinary infection and a propitious field  to toxic accumulations , particularly opiates.

The decision to stop artificial feeding must take into account all these medical considerations but not before to state that the diagnosis and prognosis of the patient are paramount in making a decision. Lack of potential to regain independent function is a valid reason not to continue any kind of treatment.

Medical resources that are invested in such cases where the prognosis is very bleak could be better used for patients who have a better prognosis. American Medical Association said since 1986 that the medical treatment  prolongs life, but breathing, artificial nutrition and hydration should be stopped for a patient who is in irreversible coma even death is not imminent.

Using artificial nutrition methods not necessarily provide a well being in terminally ill patients. In most cases intravenous treatments are maintained until death because it is believed that dehydration and electrolyte imbalances cause suffering. Numerous studies show that intravenously alimentation will not diminish pain but may be causing the patient discomfort and anxiety. Any patient able to take decisions may refuse artificial nutrition like any other medical treatment. If  patient’s will is unknown the justice may decide to stop treatment in terminally ill patient when difficulties and suffering caused by the application of these methods far outweigh the advantages. Morality to continue or stop artificial feeding depends on the patient's perception. Any patient able to take decisions to refuse artificial nutrition like any other medical treatment. Unless there is justice patient will decide to stop treatment when terminally ill patient difficulties and suffering caused by the application of these methods far outweigh the advantages. Morality to continue or stop artificial feeding depends on the patient's perception. If the patient perceives artificial nutrition as a burden that is sufficient not to establish or to curb it. If treatment is difficult, unbearable to the patient physically, psychologically, economically, emotionally and spiritually he is not morally binding and therefore can be interrupted or not put into practice.

Only reasonable and proportionate treatment should be applied and each patient can decide whether or not to apply the treatment in his case.

Theologists also have a say in this debate. Some believe that artificial food intake is necessary to maintain life and is an act of conscience clean. Others think that there is not a moral obligation to artificially feed a dying patient because this technique is not useful and does not offer any hope of improving its health.

Conclusions

Contrary to medical advances, new technologies and effective methods of patient care has not yet found a unanimous answer to the question: is moral or not to discontinue nutrition and hydration in terminally ill patient? Fundamental principles of ethics and patient’s right to complex care are in balance with the desire of the patient, illness prognosis and moral values of the people involved in this process. Neither ethics nor medical science didn’t succeed  until now to finally tip the scales in favor of one or another.

In this debate that highlights the practice of medicine in connection with the subject matter above, the vulnerability of people concerned demands not to economize on knowledge and reflection.

References

1.   Muriel R. Gillick- Rethinking the role of tuber feeding in patients with advanced dementia. N Engl J   Med 342: 206-209, 2000

2.   Verspieren P., Richard M.S., Ricot J.- La tentation de l euthanasie. Desclee de Brouwer, Paris, 2004

3.    Hallenbeck L.J.- Palliative Care Perspectives. Oxford University Press, 2003

4.    Mugurel Ştefan Ghelase (sub redacţia) – Bioetică medicală, 2005, Editura medicală universitară, Craiova

5.   Legea 46/21 ian 2003- Legea drepturilor pacientului, publicată în Monitorul Oficial nr 51/29 ian 2003

6.   Convenţia Europeană privind drepturile omului şi biomedicina , Oviedo , 04 aprilie 1997

7.   Declaraţia universală a drepturilor omului, proclamată la Adunarea generală a Naţiunilor Unite, 10 dec 1948


Corresponding author: Adriana Iliescu, M.D., University of Medicine and Pharmacy of Craiova, Faculty of Nursing and Midwives, No.2, Petru Rareş Str., Craiova 200349, Romania


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