Ethical Issues in Nutrition Support

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 carer has a duty to prolong life but not to inappropriately prolong dying The difficulty … to recognise when death is occurring to 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 Water Food minutes days weeks Reproduction - years Community Psychiatry Nursing Surgery Paediatrics Nutrition Medicine 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 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. 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 Autonomy Rules! 43 year old lady Paralysed from the neck down Kept alive by ventilation Felt that her life was not worth living Asked doctors to switch off the ventilator – Doctors refused Court felt that she was competent Ventilator switched off at her request Passive assisted suicide allowed Passive assisted suicide allowed 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 refused Assisted suicide refused Incompetence Advance 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 Incompetence No advance directive The legal duty of the doctor is to act in the patients 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 Airedale Trust vs. Bland (1993) 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 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 Schiavo Feb 1990 May 1998 Cardiac arrest with severe brain damage (PVS) 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 Florida Supreme Court strikes down law Sept 2004 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 3/2002 3/2002 11/2002 12/2002 12/2002 SVC thrombosis – stented successfully Abnormal LFTs Bleeding GU L pleural effusion .. ?TB Recurrent SVC thrombosis (stented) 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 … Then – Discussions with her & family Palliative care team Competence involved – Was she competent to make Allowed to die the decision? – Yes, in my opinion – Psychiatrist also – by withdrawing fluids & nutrition – husband at her bedside Listen to the patient views sought Religious perspective Legal perspective – Assault to feed against her wishes Carers Advanced dementia 4 million cases in the USA  Frequently  – swallowing difficulties – Anorexia / loose interest in eating – aspiration  Decision to insert a feeding tube Advanced dementia feeding 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 dementia feeding 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 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