Artificial Hydration at the End of Life.

Initiation or continuation of artificial hydration (AH) at the end of life requires unique considerations. A combination of ethical precedents and medical literature may provide clinical guidance on how to use AH at the end of life. The purpose of this review is to describe the ethical framework for and review current literature relating to the indications, benefits, and risks of AH at the end of life. Provider, patient, and family perspectives will also be discussed.

Withholding versus withdrawing treatment: artificial nutrition and hydration as a model.

PURPOSE OF REVIEW: This article explores various cultural perspectives of withholding and withdrawing of life-sustaining treatment utilizing a case involving artificial nutrition and hydration (ANH) to guide ethical discussion. RECENT FINDINGS: In the United States, there is a general consensus in the medical, ethical, and legal communities that the withholding and withdrawing of life-sustaining treatment are morally equivalent at the end of life. Despite this consensus, the withdrawal of treatment is still emotionally difficult, particularly with ANH. Recent literature challenges the evidence base that feeding tubes for people with advanced dementia lead to significant harm. In light of these new findings, we will reconsider end-of-life decision making that concerns ANH to determine whether these new findings undermine previous ethical arguments and to consider how to best educate and support patients and families during the decision-making process. SUMMARY: Despite many believing that there is no ethical, medical, or moral difference between withholding and withdrawing of life-sustaining treatment, there is no denying it is emotionally taxing, particularly withdrawal of ANH. Upholding the patient's values during high-quality shared decision making, facilitating rapport, and utilizing time limited trials will help, even when treatment is considered medically ineffective.

ESPEN guideline on ethical aspects of artificial nutrition and hydration.

BACKGROUND: The worldwide debate over the use of artificial nutrition and hydration remains controversial although the scientific and medical facts are unequivocal. Artificial nutrition and hydration are a medical intervention, requiring an indication, a therapeutic goal and the will (consent) of the competent patient. METHODS: The guideline was developed by an international multidisciplinary working group based on the main aspects of the Guideline on "Ethical and Legal Aspects of Artificial Nutrition" published 2013 by the German Society for Nutritional Medicine (DGEM) after conducting a review of specific current literature. The text was extended and introduced a broader view in particular on the impact of culture and religion. The results were discussed at the ESPEN Congress in Lisbon 2015 and accepted in an online survey among ESPEN members. RESULTS: The ESPEN Guideline on Ethical Aspects of Artificial Nutrition and Hydration is focused on the adult patient and provides a critical summary for physicians and caregivers. Special consideration is given to end of life issues and palliative medicine; to dementia and to specific situations like nursing care or the intensive care unit. The respect for autonomy is an important focus of the guideline as well as the careful wording to be used in the communication with patients and families. The other principles of Bioethics like beneficence, non-maleficence and justice are presented in the context of artificial nutrition and hydration. In this respect the withholding and withdrawing of artificial nutrition and/or hydration is discussed. Due to increasingly multicultural societies and the need for awareness of different values and beliefs an elaborated chapter is dedicated to cultural and religious issues and nutrition. Last but not least topics like voluntary refusal of nutrition and fluids, and forced feeding of competent persons (persons on hunger strike) is included in the guideline.

Court applications for withdrawal of artificial nutrition and hydration from patients in a permanent vegetative state: family experiences.

Withdrawal of artificially delivered nutrition and hydration (ANH) from patients in a permanent vegetative state (PVS) requires judicial approval in England and Wales, even when families and healthcare professionals agree that withdrawal is in the patient's best interests. Part of the rationale underpinning the original recommendation for such court approval was the reassurance of patients' families, but there has been no research as to whether or not family members are reassured by the requirement for court proceedings or how they experience the process. The research reported here draws on in-depth narrative interviews with 10 family members (from five different families) of PVS patients who have been the subject of court proceedings for ANH-withdrawal. We analyse the empirical evidence to understand how family members perceive and experience the process of applying to the courts for ANH-withdrawal and consider the ethical and practice implications of our findings. Our analysis of family experience supports arguments grounded in economic and legal analysis that court approval should no longer be required. We conclude with some suggestions for how we might develop other more efficient, just and humane mechanisms for reviewing best interests decisions about ANH-withdrawal from these patients.

Hidratación y alimentación en los recién nacidos: adecuación del esfuerzo terapéutico / Nutrition and hydration in newborns: limiting treatment decisions

La nutrición e hidratación artificial constituyen elementos básicos en la atención de los recién nacidos prematuros y han contribuido a la mejoría en la esperanza de vida y el los resultados clínicos en estos pacientes. Aunque se considera que la nutrición artificial es un tratamiento médico y está sujeto, por tanto, a las mismas consideraciones que otros tratamientos (oportunidad, ventajas, inconvenientes), por sus connotaciones especiales las decisiones sobre no iniciar o retirar el soporte nutricional tienen una carga emocional especial. Este hecho es todavía más relevante en el caso de los prematuros, pues por debajo de la 34 semana de edad gestacional no es posible la alimentación por vía oral. Aunque la toma de decisiones y cuidados al final de la vida en neonatos debe realizarse no sólo basada en datos clínicos, sino también teniendo en cuenta los valores y las creencias de todos los intervinientes en el proceso, y siempre teniendo en cuenta el mejor interés del niño. Con el fin de poder conjugar todos los intereses y bajo la perspectiva de considerar que no hay ninguna vida inferior a las demás, podemos considerar adecuado incluir la retirada de la alimentación e hidratación artificial al final de la vida en aquellos niños en los que el pronóstico de vida sea infausto a corto plazo. No ocurre lo mismo en las situaciones en las que se prevé un mal pronóstico funcional, por ejemplo secuelas de daño neurológico, sin riego vital inmediato aumentado, y en quienes la retirada del soporte nutricional significaría el fallecimiento por este motivo

Artificial hydration and nutrition are key elements in the treatment in Neonatal Units, especially in premature babies. It has led to improved survival and better clinical outcomes. Artificial nutrition is considered a medical treatment and, in such a way, a balance between burdens and benefits should be taken into consideration. Nevertheless decisions on withholding or withdrawing artificial nutrition and hydration have special and emotional considerations. In premature babies it is also necessary to consider than below the 34th week of gestational age, effective suckling is not present, and so, oral nutrition is not a possibility. Decisions regarding the end-of-life care of neonates should be made taking into account clinical facts but also values and beliefs of all concerned, and always "in the best interest" of infants. In order to consider all this aspects, we could respect withdrawing or withholding artificial nutrition and hydration in those babies with an ominous prognosis in a short term basis. It has not the same consideration if there is a clear life risk but a prognosis based on severe future burden, mainly because of neurologic damage. In those cases withholding or withdrawing fluids and feedings would be the direct cause of death

[Indication and control of volume therapy. First things first]. / Indikation und Steuerung der Volumentherapie. Das Wichtigste zuerst.

BACKGROUND: Fluid therapy is a core concept in the management of perioperative and critically ill patients for maintenance of intravascular volume and organ perfusion. The clinical determination of the intravascular volume can be extremely difficult. Indication and control for intravascular volume therapy are among the most difficult aspects of intensive care. MATERIALS AND METHODS: A literature review was performed. RESULTS: The goal of cardiovascular therapy is to enhance adequate blood flow and oxygen delivery to the tissues to meet the varying metabolic demands of the tissues without inducing untoward cardiorespiratory complications. A careful history and clinical examination are indispensable and allow evaluation of tissue and organ perfusion. Laboratory examinations, bedside ultrasonography as well as invasive hemodynamic monitoring complete the assessment and allow guidance of fluid therapy. CONCLUSIONS: Case history, clinical examinations, bedside ultrasonography, and invasive hemodynamic monitoring complete the assessment and allow clinicians to assess volume responsiveness.

[Withdrawal of artificial nutrition and hydration in severe stroke: medical, legal and ethical considerations]. / Aspects médicaux, législatifs et éthiques de l'arrêt de la nutrition et de l'hydratation artificielles dans l'accident vasculaire cérébral grave.

In the majority of cases, severe stroke is accompanied by difficulty in swallowing and an altered state of consciousness requiring artificial nutrition and hydration. Because of their artificial nature, nutrition and hydration are considered by law as treatment rather basic care. Withdrawal of these treatments is dictated by the refusal of unreasonable obstinacy enshrined in law and is justified by the risk of severe disability and very poor quality of life. It is usually the last among other withholding and withdrawal decisions which have already been made during the long course of the disease. Reaching a collegial consensus on a controversial decision such as artificial nutrition and hydration withdrawal is a difficult and complex process. The reluctance for such decisions is mainly due to the symbolic value of food and hydration, to the fear of "dying badly" while suffering from hunger and thirst, and to the difficult distinction between this medical act and euthanasia. The only way to overcome such reluctance is to ensure flawless accompaniment, associating sedation and appropriate comfort care with a clear explanation (with relatives but also caregivers) of the rationale and implications of this type of decision. All teams dealing with this type of situation must have thoroughly thought through the medical, legal and ethical considerations involved in making this difficult decision.

What influences attitudes towards clinically assisted hydration in the care of dying patients? A review of the literature.

BACKGROUND: An equivocal evidence base on the use of Clinically Assisted Hydration (CAH) in the last days of life presents a challenge for clinicians. In an attempt to provide clarity, the General Medical Council (GMC) has produced reasoned guidelines which identify that clinical vigilance is paramount, but that healthcare professionals should consider patient and family beliefs, values and wishes when making a decision to commence, withhold or withdraw CAH. AIMS: To describe the attitudes and knowledge of patients, families, healthcare professionals and the general public regarding CAH in the care of dying patients. METHODS: Four electronic databases were searched for empirical studies relating to attitudes and knowledge regarding CAH in the care of dying patients or end-of-life care (1985 and 2010). Selected studies were independently reviewed and data collaboratively synthesised into core themes. RESULTS: From 202 identified articles, 18 papers met inclusion criteria. Three core themes emerged: (1) the symbolic value of hydration; (2) beliefs and misconceptions and (3) cultural, ethical and legal ideas about hydration. CONCLUSIONS: Developing international evidence suggests that cultural norms and ethical principles of a family, population or healthcare environment influence attitudes towards CAH, particularly where CAH has symbolic meaning; representing care, hope and trust. However, there is surprisingly little robust evidence regarding dying patients, or the wider general public's views, on the perceived value of CAH in the last days and hours of life. Accordingly, a need for greater understanding of the perceptions regarding CAH, and their effects, is required.

[The practices of withdrawing artificial nutrition and hydration in the neonatal intensive care unit: a preliminary study]. / Étude pilote sur les pratiques de l'arrêt de la nutrition/hydratation artificielle en réanimation néonatale.

INTRODUCTION: Prematurity is one of the etiologies for severe neurological complications. Decisions to withdraw therapeutics, including artificial nutrition and hydration (ANH), are sometimes discussed. But can one withdraw ANH if the patient is a child suffering from severe neurological conditions, based on his best interests? The aim of this study was to further the understanding of the complexity of the withdrawal of ANH and its implementation in the neonatal intensive care unit (NICU). METHOD: This qualitative preliminary study based on a questionnaire was conducted on the staff in the NICU of the Pontoise medical center (France) in February 2012. The results were compared with the current knowledge on this issue and sociological data. RESULTS: Ten of the hospital staff members responded to the questionnaire: 60% considered ANH as a treatment, but the status of ANH (i.e., treatment or care) remained undefined for several respondents. Comparison with the withdrawal of mechanical ventilation or adult practices seemed to be inadequate. The staff had little experience in the domain and therefore few certainties on practices. Half of the respondents indicated that terminal sedation needed to be used. For the other half, it depended on the patient's pain. Timing was also an important notion given that the newborn is a being developing and evolving each in its own way. CONCLUSION: The withdrawal of ANH remains controversial in the NICU. Humanity, culture, and the relationship to others are ever present in the decision-making process, creating a moral opposition above and beyond ethical reflection.

Religion and United States physicians' opinions and self-predicted practices concerning artificial nutrition and hydration.

This study surveyed 1,156 practicing US physicians to examine the relationship between physicians' religious characteristics and their approaches to artificial nutrition and hydration (ANH). Forty percent of physicians believed that unless a patient is imminently dying, the patient should always receive nutrition and fluids; 75 % believed that it is ethically permissible for doctors to withdraw ANH. The least religious physicians were less likely to oppose withholding or withdrawing ANH. Compared to non-evangelical Protestant physicians, Jews and Muslims were significantly more likely to oppose withholding ANH, and Muslims were significantly more likely to oppose withdrawing ANH.

Position of the academy of nutrition and dietetics: ethical and legal issues in feeding and hydration.

It is the position of the Academy of Nutrition and Dietetics that individuals have the right to request or refuse nutrition and hydration as medical treatment. Registered dietitians (RDs) should work collaboratively as part of the interprofessional team to make recommendations on providing, withdrawing, or withholding nutrition and hydration in individual cases and serve as active members of institutional ethics committees. RDs have an active role in determining the nutrition and hydration requirements for individuals throughout the life span. When individuals choose to forgo any type of nutrition and hydration (natural or artificial), or when individuals lack decision-making capacity and others must decide whether or not to provide artificial nutrition and hydration, RDs have a professional role in the ethical deliberation around those decisions. Across the life span, there are multiple instances when nutrition and hydration issues create ethical dilemmas. There is strong clinical, ethical, and legal support both for and against the administration of food and water when issues arise regarding what is or is not wanted by the individual and what is or is not warranted by empirical clinical evidence. When a conflict arises, the decision requires ethical deliberation. RDs' understanding of nutrition and hydration within the context of nutritional requirements and cultural, social, psychological, and spiritual needs provide an essential basis for ethical deliberation. RDs, as health care team members, have the responsibility to promote use of advanced directives. RDs promote the rights of the individual and help the health care team implement appropriate therapy. This paper supports the "Practice Paper of the Academy of Nutrition and Dietetics: Ethical and Legal Issues of Feeding and Hydration" published on the Academy website at: www.eatright.org/positions.

Translation and cross-cultural adaptation of a family booklet on comfort care in dementia: sensitive topics revised before implementation.

INTRODUCTION: Families of patients with dementia may need support in difficult end-of-life decision making. Such guidance may be culturally sensitive. METHODS: To support families in Canada, a booklet was developed to aid decision making on palliative care issues. For reasons of cost effectiveness and promising effects, we prepared for its implementation in Italy, the Netherlands and Japan. Local teams translated and adapted the booklet to local ethical, legal and medical standards where needed, retaining guidance on palliative care. Using qualitative content analyses, we grouped and compared adaptations to understand culturally sensitive aspects. RESULTS: Three themes emerged: (1) relationships among patient, physician and other professionals-the authority of the physician was more explicit in adapted versions; (2) patient rights and family position-adding detail about local regulations; and (3) typology of treatments and decisions. Considerations underlying palliative care decisions were detailed (Dutch and Italian versions), and the Japanese version frequently referred to professional and legal standards, and life-prolongation was a competing goal. Text on artificial feeding or fluids and euthanasia was revised extensively. CONCLUSIONS: Providing artificial feeding and fluids and discussing euthanasia may be particularly sensitive topics, and guidance on these subjects needs careful consideration of ethical aspects and possible adaptations to local standards and practice. The findings may promote cross-national debate on sensitive, core issues regarding end-of-life care in dementia.