Enteral Nutrition by Nasogastric Tube in Adult Patients under Palliative Care: A Systematic Review.

Nutritional management of patients under palliative care can lead to ethical issues, especially when Enteral Nutrition (EN) is prescribed by nasogastric tube (NGT). The aim of this review is to know the current status in the management of EN by NG tube in patients under palliative care, and its effect in their wellbeing and quality of life. The following databases were used: PubMed, Web of Science (WOS), Scopus, Scielo, Embase and Medline. After inclusion and exclusion criteria were applied, as well as different qualities screening, a total of three entries were used, published between 2015 and 2020. In total, 403 articles were identified initially, from which three were selected for this review. The use of NGT caused fewer diarrhea episodes and more restrictions than the group that did not use NG tubes. Furthermore, the use of tubes increased attendances to the emergency department, although there was no contrast between NGT and PEG devices. No statistical difference was found between use of tubes (NGT and PEG) or no use, with respect to the treatment of symptoms, level of comfort, and satisfaction at the end of life. Nevertheless, it improved hospital survival compared with other procedures, and differences were found in hospital stays in relation to the use of other probes or devices. Finally, there are not enough quality studies to provide evidence on improving the health status and quality of life of the use of EN through NGT in patients receiving palliative care. For this reason, decision making in this field must be carried out individually, weighing the benefits and damages that they can cause in the quality of life of the patients.

How Should Compassion Be Expressed as a Primary Clinical and Ethical Value in Anorexia Nervosa Intervention?

Use of force in the care of patients with severe anorexia nervosa is controversial but can be justified when the disorder becomes life-threatening. This commentary examines the role of force in compassionate care of an adolescent patient hospitalized with extreme anorexia nervosa and suggests strategies for reaching consensus, minimizing harm, and maximizing the chance of a therapeutic outcome when forced intervention is a compassionate thing to do.

Management of hunger strike: A medical, ethical and legal conundrum.

Hunger strike is a protest where an informed person refuses essential nourishment with the intention of accomplishing a specific goal. Hunger strikes conflict with medical, ethical, humanitarian and legal values. A multidisciplinary approach is important when dealing with hunger strike patients. On one hand, there is the wish to preserve life, and on the other to respect the strikers' autonomy and their wishes, values and advanced directives (or living will). Most hunger strikes are short-lived, but in complex and prolonged circumstances, legal advice must be sought from health service solicitors and a doctor's medical indemnity organisation. There is an emergent need to have defined guidelines for the management of these hunger strikes to be followed.

Cultural considerations in forgoing enteral feeding: A comparison between the Hong Kong Chinese, North American, and Malaysian Islamic patients with advanced dementia at the end-of-life.

Cultural competence, a clinical skill to recognise patients' cultural and religious beliefs, is an integral element in patient-centred medical practice. In the area of death and dying, physicians' understanding of patients' and families' values is essential for the delivery of culturally appropriate care. Dementia is a neurodegenerative condition marked by the decline of cognitive functions. When the condition progresses and deteriorates, patients with advanced dementia often have eating and swallowing problems and are at high risk of developing malnutrition. Enteral tube feeding is a conventional means of providing artificial nutrition and hydration to meet nutritional needs, but its benefits to the frail population are limitedly shown in the clinical evidence. Forgoing tube feeding is ethically challenging when patients are mentally incompetent and in the absence of an advance directive. Unlike some developed countries, like the United States of America, death and dying is a sensitive issue or even a taboo in some cultures in developing countries that forgoing enteral tube feeding is clinically and ethically challenging, such as China and Malaysia. This article in three parts 1) discusses the clinical and ethical issues related to forgoing tube feeding among patients with advanced dementia, 2) describes how Hong Kong Chinese, North American, and Malaysian Islamic cultures respond differently in the decision-making patterns of forgoing tube feeding for patients with advanced dementia, and 3) reiterates the clinical implications of cultural competence in end-of-life care.

[Nutritional management of advanced dementia: summary of recommendations of the SENPE Ethic Group]. / Manejo nutricional de la demencia avanzada: resumen de recomendaciones del Grupo de Trabajo de Ética de la SENPE.

INTRODUCTION: This paper from the ethics Working Group presents a summary of the recommendations of the nutritional management of patients with advanced dementia.

INTRODUCCIÓN: En este documento del Grupo de Trabajo de Ética se presenta un resumen sobre las recomendaciones del manejo nutricional de pacientes con demencia avanzada.

Withholding Treatment From the Dying Patient: The Influence of Medical School on Students' Attitudes.

PURPOSE: To determine motives and attitudes towards life-sustaining treatments (LSTs) by clinical and preclinical medical students. METHODS: This was a scenario-based questionnaire that presented patients with a limited life expectancy. The survey was distributed among 455 medical students in preclinical and clinical years. Students were asked to rate their willingness to perform LSTs and rank the motives for doing so. The effect of medical education was then investigated after adjustment for age, gender, religion, religiosity, country of origin, and marital status. RESULTS: Preclinical students had a significantly higher willingness to perform LSTs in all cases. This was observed in all treatments offered in cases of a metastatic oncologic patient and an otherwise healthy man after a traumatic brain injury (TBI). In the case of an elderly woman on long-term care, preclinical students had higher willingness to supply vasopressors but not perform an intubation, feed with a nasogastric tube, or treat with a continuous positive air-pressure ventilator. Both preclinical and clinical students had high willingness to perform resuscitation on a twelve-year-old boy with a TBI. Differences in motivation factors were also seen. DISCUSSION: Preclinical students had a greater willingness to treat compared to clinical students in all cases and with most medical treatments offered. This is attributed mainly to changes along the medical curriculum. Changes in reasons for supplying LSTs were also documented.

On the Force-Feeding of Prisoners on Hunger Strike.

Roughly 80,000 U.S. prisoners are held in solitary confinement at any given time. A significant body of research shows that solitary confinement has severe, long-term effects, and the United Nations has condemned the practice of solitary confinement as torture. For years, prisoners have been organizing hunger strikes in order to protest solitary confinement. But such action is not without consequences, and some inmates have suffered serious injury or death. The question I raise in this paper is whether we ought to force-feed hunger striking prisoners when serious harm is imminent. Both the World Medical Association and the American Medical Association have denounced the practice of force-feeding prisoners on hunger strike, and yet, the practice is common. Such prevalence is likely a result of the tension between the person-as-patient and person-as-prisoner and cannot easily be resolved. Instead, we must take seriously the complaint that solitary confinement is inhumane and avoid placing health professionals in the position where they must choose to force-feed the prisoner against his will or not. I argue that a conventional bioethics debate centering on polarizing principles of prisoner autonomy and a duty-to-protect the prisoner from harm is an inadequate framework for this complex issue. Instead, we must examine the prisoner's intent and his right to freedom of speech. I argue that when the prisoner's intent is to raise awareness and communicate with others, his hunger strike is a form of speech. Protest-as-speech is constitutionally protected-even for prisoners-and remains a minimum ethical obligation for society to uphold.

Prisoners' competence to die: hunger strike and cognitive competence.

Several bioethicists have recently advocated the force-feeding of prisoners, based on the assumption that prisoners have reduced or no autonomy. This assumed lack of autonomy follows from a decrease in cognitive competence, which, in turn, supposedly derives from imprisonment and/or being on hunger strike. In brief, causal links are made between imprisonment or voluntary total fasting (VTF) and mental disorders and between mental disorders and lack of cognitive competence. I engage the bioethicists that support force-feeding by severing both of these causal links. Specifically, I refute the claims that VTF automatically and necessarily causes mental disorders such as depression, and that these mental disorders necessarily or commonly entail cognitive impairment. Instead, I critically review more nuanced approaches to assessing mental competence in hunger strikes, urging that a diagnosis of incompetence be made on a case-by-case basis-a position that is widely shared by the medical community.

How many patients in a prolonged disorder of consciousness might need a best interests meeting about starting or continuing gastrostomy feeding?

OBJECTIVE:: To estimate the number of people in a prolonged disorder of consciousness (PDOC) who may need a formal best interests decision-making process to consider starting and/or continuing life-sustaining treatment each year in the population of a developed country. METHOD:: Identification of studies on people with a PDOC giving information about incidence, and/or prevalence, and/or cause, and/or location of long-term care. Sources included systematic reviews, a new search of MEDLINE (April 2018), and a personal collection of papers. Validating information was sought from existing data on services. RESULTS:: There are few epidemiologically sound studies, most having bias and/or missing information. The best estimate of incidence of PDOC due to acute onset disease is 2.6/100,000/year; the best estimate of prevalence is between 2.0 and 5.0/100,000. There is evidence that prevalence in the Netherlands is about 10% of that in other countries. The commonest documented causes are cerebral hypoxia, stroke, traumatic brain injury, and tumours. There is some evidence suggesting that dementia is a common cause, but PDOC due to progressive disorders has not been studied systematically. Most people receive long-term care in nursing homes, but a significant proportion (10%-15%) may be cared for at home. CONCLUSION:: Each year, about 5/100,000 people will enter a prolonged state of unconsciousness from acute onset and progressive brain damage; and at any one time, there may be 5/100,000 people in that state. However, the evidence is very limited in quality and quantity. The numbers may be greater.

Enteral Nutrition and Dementia Integrating Ethics.

This narrative review highlights topics related to feeding patients with dementia, including the use of ethical principles and legal precedents; specifies guidelines and practice recommendations; provides an option to assist in applying the recommendations, such as comfort feedings instead of enteral nutrition; promotes the use of early advance care planning to achieve medical therapies based on an individual's wishes; and provides 3 case studies to demonstrate the clinical application of the information presented in the article. Enteral nutrition guidelines and recommendations have been developed by the American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics for individuals with dementia. Predominately these guidelines and recommendations focus on patients with advanced dementia due to the dysphagia and progressive disease process. Despite the research and recommendations to forgo enteral nutrition in advanced dementia, the practice continues. The detailed case studies, integrating an interprofessional approach, provide tools for clinicians to incorporate ethical principles and address the communication aspect when dealing with families and surrogate decision-makers for individuals with advanced dementia.

[Seeking compulsory treatment as life-saving in the presence of eating disorders: a complex choice]. / Il trattamento sanitario obbligatorio come salvavita in presenza di disturbi dell'alimentazione: una scelta complessa.

Eating disorders (and especially anorexia nervosa) are associated with severe disability, poor quality of life and high mortality rate. Anorexia nervosa ranks among the main causes of death among young women. Despite physical and psycho-social impairment, patients suffering from anorexia nervosa do not recognize low body weight and extreme calorie restriction as a clinical problem and are ambivalent towards treatment. Some patients with anorexia nervosa refuse treatments though presenting severe medical complications and having a high mortality risk. Hence the need to evaluate when it could be appropriate to prescribe a compulsory treatment in the more complex cases who refuse interventions, deemed necessary for them. To date, the compulsory treatment in anorexia nervosa is still under debate: some authors take into account the negative impact on the therapeutic relationship, other authors consider it as a compassionate treatment or as life-saving therapy. Indeed, compulsory treatment for eating disorders must always be weighed very carefully because it is considered by law as the highest form of restriction of personal freedom. Political Institutions must provide a clear framework for the society and for professionals, while the health care services must face the problem of the adequacy of available resources (not only in terms of hospital beds but also of skilled professionals) compared to patients' needs, considering the organization and the integration of clinical services dedicated to the treatment of eating disorders.

The Role of Doctors in Hunger Strikes.

In its Malta Declaration, The World Medical Association prohibits force-feeding of hunger strikers as "degrading and inhuman," even when this is the only way to save their lives. The European Court of Human Rights ruled that lifesaving force-feeding is compatible with the state's duty to protect the lives of prisoners. To understand how such extreme divergence of opinions has become possible, this paper offers a critical examination of the social history of prisoners' hunger strikes, the philosophy of nonviolence, and the debate on its medicalization. The discourse by actors, professionals, regulators, and scholars on hunger strikes is divided into three paradigms: the "communicative," the "extreme violence," and the "psychiatric." I argue that another paradigm is in play, and its incorporation may enrich and balance the discourse. This is the "wounded combatant" paradigm, according to which hunger strikers are like enemy soldiers who are injured in battle.

The land of no milk and no honey: force feeding in Israel.

In 2015, the Israeli Knesset passed the force-feeding act that permits the director of the Israeli prison authority to appeal to the district court with a request to force-feed a prisoner against his expressed will. A recent position paper by top Israeli clinicians and bioethicists, published in Hebrew, advocates for force-feeding by medical professionals and presents several arguments that this would be appropriate. Here, we first posit three interrelated questions: 1. Do prisoners have a right to hunger-strike? 2. Should governing institutions force-feed prisoners and/or is it ethical to force-feed prisoners? 3. Should healthcare professionals force-feed prisoners? We then focus on the first and third questions. We first briefly provide several arguments to support the right of prisoners to refuse treatment. Next, we critically review the arguments presented in the Israeli position paper, demonstrating that they are all misguided at best. Lastly, we briefly present arguments against force-feeding by medical professionals. We conclude that healthcare providers should not participate in the force-feeding of prisoners.

Incidencia de hipofosfatemia en pacientes ingresados no críticos con nutrición enteral / Incidence of hypophosphatemia in not critically ill patients with enteral feeding

Introducción: se ha descrito una incidencia de hipofosfatemia en pacientes con soporte nutricional especializado (SNE) de hasta el 30-40%. La hipofosfatemia leve y la moderada son generalmente asintomáticas, mientras que la severa es el hecho fundamental del síndrome de realimentación. Objetivo: evaluar la incidencia y gravedad de la hipofosfatemia en pacientes hospitalizados no críticos con nutrición enteral (NE). Material y métodos: se diseñó un estudio observacional y prospectivo en condiciones de práctica clínica habitual. Se recogieron datos clínicos, antropométricos y analíticos de 181 pacientes a los que se les inició nutrición enteral. El seguimiento fue de siete días. Resultados: el 51,9% de los pacientes estaban en riesgo de desarrollar síndrome de realimentación según las guías del United Kingdom National Institute for Health and Clinical Excellence (NICE). La incidencia de hipofosfatemia fue del 31,5% y la de la hipofosfatemia severa, del 1,1%. De todos los parámetros clínicos, antropométricos y analíticos analizados, solo la edad y unas proteínas séricas más bajas se correlacionaron de forma estadísticamente significativa con el aumento en la incidencia de hipofosfatemia. Conclusión: la incidencia de hipofosfatemia grave en nuestra serie es muy baja, lo que hace imposible extraer conclusiones específicas para este grupo de pacientes (AU)

Background: Up to 30-40% of the patients starting artificial nutritional support develop hypophosphatemia. In general, patients with mild and moderate hypophosphatemia do not have symptoms, but severe hypophosphatemia is the hallmark of refeeding syndrome. Aim: To determine the incidence of hypophosphatemia in not critically ill patients receiving enteral feeding. Material and methods: Prospective study. We assessed during seven days 181 not critically ill patients started on enteral artificial nutrition support during seven days. Results: 51.9% of the patients were considered to be at risk of developing refeeding syndrome (United Kingdom National Institute for Health and Clinical Excellence criteria). The incidence of hypophosphatemia was 31.5%, but only 1.1% of the patients developed severe hypophosphatemia. Older age and lower plasma proteins were significantly associated with hypophosphatemia. Conclusion: The incidence of severe hypophosphatemia in our study is low, so we can’t offer robust conclusions about the risk of hypophosphatemia in the type of patients receiving enteral nutrition (AU)

Caso: negativa de los padres al tratamiento en un menor de edad. Nutrición enteral a una paciente con déficit neurológico severo / Case: parental refusal to treatment in a minor enteral nutrition to a patient with severe neurologial deficit

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