Tube feeding. Internists' attitudes regarding ethical obligations.

BACKGROUND: Little is known about the attitudes of internists regarding their ethical obligation to provide or withhold tube feeding in three clinical contexts when patient preferences are not known: acute pneumonia, severe dementia, and persistent vegetative state. METHODS: A written questionnaire with patient scenarios was mailed to a randomized national sample of 1000 internist members of the American College of Physicians. RESULTS: Response was received from 58% of our sample (n = 581). Only physicians with personal experience with tube feeding decisions were included in the subsequent analysis (n = 326). Respondents were mostly male board-certified internists active in patient care in urban/suburban settings. Physicians demonstrated a predominant attitude for each scenario: 98% favored initiation of tube feeding for the patient with acute pneumonia; 84% opposed initiation of tube feeding for the patient with advanced dementia when depicted with a mixed happy/sad affect; and 80% favored withdrawal of tube feeding for the patient with established persistent vegetative state. Sixteen percent (n = 51) described tube feeding as basic humane care, whereas 84% (n = 265) believed tube feeding is medical therapy. Physicians were more opposed to tube feeding in certain patient scenarios than the literature suggests occurs in actual practice. CONCLUSIONS: Our data suggest that when patient wishes are not known, physician decisions regarding tube feeding are strongly influenced by prognosis. State legislation that categorizes tube feedings differently from other medical treatments conflicts with the judgment of the majority of internist respondents.

Physicians as patients. Choices regarding their own resuscitation.

BACKGROUND: Attitudes toward cardiopulmonary resuscitation have changed considerably during the last 30 years. Although physicians are routinely involved in the decision making about cardiopulmonary resuscitation for their patients, little is known about their collective preferences regarding it for themselves. METHODS: A questionnaire was distributed at an internal medicine primary care review course at an urban community hospital. Of the 111 physicians registered at the meeting, 72 (65%) completed the questionnaire and serve as the basis for the results. Physicians were asked if they would want cardiopulmonary resuscitation for themselves in the presence of an acute myocardial infarction, Alzheimer's disease, and nine other advanced chronic diseases at the projected ages of 40, 60, and 80 years. RESULTS: At all projected ages, physicians' desire for cardiopulmonary resuscitation with any advanced chronic disease was significantly less than with an acute myocardial infarction (P < or = .000001 except for rheumatoid arthritis). Fewer physicians wanted cardiopulmonary resuscitation at age 80 years than at 40 years for any disease (P < or = .002). The results did not differ when analyzed by respondents' age, gender, or primary care specialty, or the size of the community in which they practiced. CONCLUSIONS: The results of this initial survey indicate that most physicians would not want cardiopulmonary resuscitation with a variety of underlying chronic diseases and corresponding functional impairments--particularly with advancing age. Conversely, with an acute myocardial infarction, all physicians surveyed would desire cardiopulmonary resuscitation at age 40 years, and many would continue to desire it with advancing age.

Tube-feeding decisions in the elderly.

Tube-feeding decisions in the elderly can be most challenging. We begin our decision making with the premise that artificial nutrition is a medical therapy and therefore that its prescription is based on a calculation of net benefits over burdens for the patient to whom it is given. When the burdens of this therapy outweigh the benefits of prolonged life, tube feeding may be ethically withheld or withdrawn. For the cognitively impaired and in the absence of known patient preferences, the ratio of benefits to burdens may best be figured after a time trial of therapy. If restraints are needed to keep the tube in place, or if significant medical complications ensue, the burdens of the therapy have outweighed its potential benefits, and the therapy may be ethically withdrawn. State statutes and institutional policies are often confusing and at times in conflict with the ethical choice made by families and health care providers for their loved ones and patients. The options--starting a court battle (Cruzan7), moving the patient to a different state (Busalacchi), or committing civil disobedience--are not best for the welfare of the patient, family, or health care team. We well recognize that what is legal is not always what is ethical. Ethics should lead the law as we consider how to use new health care technologies wisely. We hope that the state legislatures will work to minimize future conflicts by acknowledging that (1) artificial nutrition is a life-sustaining therapy that should not have special status distinct from other life-sustaining therapies and (2) artificial nutrition and hydration are medical therapies that can and should be ethically withdrawn or withheld when their burdens outweigh their benefits.