Artificial Nutrition and Hydration - Essay Example

Artificial Nutrition and Hydration Artificial Nutrition and Hydration Artificially provided nutrition and hydration (ANH) is a medical procedure that can be withheld or withdrawn like any other. A decade has passed since that heated discussion occurred. Today in Japan, end-of-life issues have become an even more urgent problem. Many people are living long lives and most of them die in hospitals connected to high-technology medical equipment. At the same time, the sanctity of life has begun to move from its central place to compete with quality of life issues in the health care arena as well as Japanese society. Earlier in Japan, as in many industrialized countries, the only ethical position in this situation was the sanctity of life and therefore the clinically right action was always to give treatment. Now, with more advanced medical technology and national decade on these issues, a more recent concept quality of life, especially for dying patients, has gained influence. The lack of knowledge that scientifically justifies giving or not giving AFF to terminally ill patients also prevails internationally (Konishi, Davis & Aiba, 2002). As controversial and sensitive ethical issues continue to challenge nurses and other health care professionals, many of them have begun to develop a unique appreciation for the diverse ethical viewpoints of others. ANH is not categorized as a treatment that must always be provided, and in coming to a decision about forgoing or continuing ANH, the patient's surrogates are allowed to either use their knowledge about the patient's desires and values or weigh the costs and benefits of tube feeding against the costs and benefits of waiving this treatment. At the same time, Americans still have a good deal of anxiety about the prospect of discontinuing food and fluids, both for themselves and for their loved ones. This is one reason why there are approximately 1.5 million patients being tube fed in the United States today. Half of this group is over the age of sixty-five, and many if not most of these patients are severely and irreversibly demented (OTA 1987). The clinical reality is that tube feeding is often provided as a matter of course and that the choice of whether to tube feed or not is never fully explored. This situation contrasts markedly with the situation just a few decades ago. Today, the modus operandi of physicians and families is turned on its head. In past decades and centuries, family members provided around-the clock palliative care in the home, and physicians occasionally stopped by to do what they could. Today, by contrast, caregivers provide various levels of technologically sophisticated care twenty-four hours a day, and family members drop by on occasion to do what they can. In the past, diseases were allowed to run their natural courses, largely because the technology had not been developed to accurately diagnose and treat mortal pathologies. Death was simply accepted as a natural and ultimate phase of living, an essential element of our humanity. Today, death tends to be regarded by many as a conquerable evil that must be resisted at all costs. With the widespread use of ANH and antibiotics, each of which can help to sustain the body in a vegetative or near-vegetative state for months and perhaps even years, dementia no longer has a terminal phase per se (Peck, Cohen, and Mulvihill 1990: 1195). A number of researchers have suggested that we return to the mind-set of the 1950s, when aggressive medical procedures were not blindly applied in the absence of thought about the ultimate goal of the intervention. Walshe and Leonard (1985: 1047) locate themselves squarely in this camp, arguing that "as in patients who develop the [vegetative] syndrome after acute injury, patients with progressive neurological disease should be treated without undue intervention to preserve a mindless life." Mark Wicclair ( 1993: 60) advances the same position: "The severely demented elderly constitute another category of patients about whom it might be claimed that they will receive no benefit from life-prolonging measures. Although they are not unconscious, it is nevertheless arguable that their quality of life is so low that extended life is of no benefit to them." The hypothetical clinical scenario of a terminally ill cancer patient was presented and physicians (n=1182) were asked about their decision-making regarding treatment as well as about their attitudes to certain ethical values. The results suggest that the treatments most often forgone were blood transfusions (82%) and thrombosis prophylaxis (81%). Least willingly abandoned were intravenous hydration (29%) and supplementary oxygen (13%) (Hinka et al, 2002). Female doctors were less likely to discontinue thrombosis prophylaxis and supplementary oxygen, but more readily X-ray and laboratory examinations. Young doctors were more likely to continue antibiotics, thrombosis prophylaxis, supplementary oxygen and laboratory tests. Oncologists comprised the specialty most ready to forgo all studied treatments except antibiotics and blood transfusions. Other factors in the physician's background were found to predict decisions to withdraw antibiotics or IV hydration (Hinka et al, 2002). If only we knew a bit more about what tube feeding entails and what death after forgoing ANH was like, then ANH might become more than something we say we would forgo in response to a public opinion poll. Methods of ANH Generally speaking, there are two kinds of ANH--enteral and parenteral. Enteral feeding (from the Greek term meaning intestines or entrails) delivers nutritional slurry directly into the gut through a plastic nasogastric tube, inserted through the nose and down through the throat or through a gastrostomy tube, inserted directly into the stomach or upper intestine. Home-enteral tube feeding (HETF) via percutaneous gastrostomy (PEG) has become an established method to support patients who cannot take in adequate nutrition. In Germany roughly 140 000 patients received HETF in 2000. Major indications for HETF in adults are neurologic disorders of swallowing (e.g., cerebro vascular disease, motor neuron disease) and obstructive lesions of the upper gastrointestinal tract (e.g., head and neck cancer, esophageal carcinoma). In a 4-y prospective study we recently showed that HETF can prevent weight loss and may even cause weight gain. The techniques of HETF are well established and safe, and procedure-related complication rates are low. However, because patients on HETF have high mortality because of the severity and/or terminal phase of the underlying disease, the benefits of HETF in terms of survival and quality of life (QOL) have been questioned (Chiu, 2004). In a retrospective study of 7369 patients, Rabeneck et al. found a median survival of 7.5 mo for the entire cohort. Based on analyses of different subgroups, those investigators recommended that physicians not offer PEG to patients with anorexia-cachexia syndrome (i.e., alterations in intermediary metabolism that are refractory to nutrition support, e.g., in advanced cancer or acquired immunodeficiency syndrome) and those who are in a permanent vegetative state. They argued that these patients cannot experience QOL. However, measurements of QOL were not performed systematically in their HETF patients. Using QOL measures in clinical practice may identify the main problem, facilitate communication, screen for hidden problems, facilitate shared clinical decision making, and monitor changes or responses to treatment. Measures of QOL are not a substitute for measures of disease outcome but may add to treatment planning and evaluation and thus clinical decision making (Chiu, 2004). It is concluded that the association between QOL and nutrition status is unclear in HETF patients, that there is a lack of prospective data, and that different instruments used in QOL research have not been investigated systematically in HETF-patients. These are important issues because objective measures of QOL may contribute to ethically justified decision making. Therefore, we assessed QOL and nutrition status in a consecutive group of 155 competent and non-competent HETF patients. In addition, 56 patients on HETF were followed prospectively for up to 4 mo (Chiu, 2004). Parenteral feeding delivers fluid and nutrients through a needle inserted in the patient's vein. This can be accomplished in one of two ways: intravenous feeding, using lines inserted into the veins of a patient's limbs, or total parenteral nutrition (TPN), which uses lines inserted into the central veins in the neck and upper chest area. Enteral and parenteral feeding--like any medical procedures--both has their drawbacks and potential complications. General Drawbacks of ANH Summarized Whatever the method used, artificial feeding (particularly NG feeding) is likely to add to a dying patient's distress rather than alleviate it. This sentiment, expressed over twelve years ago by Dr. Judith Ahronheim, has been echoed among clinicians in more recent years. Perhaps even more disconcerting than the distress caused by tube feeding is the need to restrain patients who are uncooperative or confused and demented (Peck, Cohen, and Mulvihill 1990: 1197). One study found that almost all of the fifty-two tube-fed patients in one skilled nursing facility required some form of continuous physical restraint to prevent self-extubation. Ninety percent of those patients with restraints had to have their hands enclosed in mittens, and 71 percent required some form of additional restraint (Peck, Cohen, and Mulvihill 1990). For patients who retain some level of awareness, restraints might be considered an affront to their dignity, and many patients who are aware of their situation tend to become depressed or angry over being tied down (Major 1989: 25). Restraints can also violate the dignity of demented and vegetative patients, for, legally, these individuals retain an interest in being cared for humanely regardless of their mental state. In addition to whatever indignity might be suffered, restraints can, over time, put the patient at increased risk for developing bedsores and pneumonia. According to one study, tube-fed patients were more than three times as likely to develop aspiration pneumonia (57 percent versus 15 percent in the control group). Restrained patients were also 50 percent more likely to suffer from painful decubitus ulcers (Peck, Cohen, and Mulvihill 1990: 1197). Tube feeding can also cause edema (swelling) in the abdomen and extremities. Accumulations of fluid in the upper respiratory tract can cause increased secretions, and accumulations in the lower tract can increase coughing and shortness of breath. Artificially provided food and fluids may also precipitate psychological problems for friends, family members, and caregivers. The feeding tubes and their associated apparatus may serve as a barrier between relatives and the patient and may divert the attention of caregivers from tending to the patient to maintaining the equipment. Ultimately, the relief of the patient's suffering, which should be the primary goal, can be overwhelmed by the drive to correct nutritional imbalances and restore electrolyte levels (Peck, Cohen, and Mulvihill 1990: 1197). In addition, artificial feedings provided to hopelessly ill patients may give them, their friends, and members of the family a false sense of hope (Sutcliffe 1994: 62). Palliation Dying and death have always been diabolically disruptive to individuals and to the societies they live in. Life is always fragile in the face of death but it is interesting to reflect upon the ways that we temper this fragility through our management of dying and death. The hospice movement and, more recently, the development of palliative care and palliative medicine, can be seen as part of a contemporary response to the medical management of dying. Hospice was originally conceived as part of a broader 'death awareness movement' which impacted upon Western advanced industrialized societies in the 1960s and 1970s. However, recent developments within palliative care and palliative medicine now reflect a specialization in dying and death. This specialization is framed by medicine and by mainstream health care, a move which has brought both benefits and disadvantages to terminally ill people, their families and those who care for them. It was unrealistic to expect that the original ideals of the hospice movement would survive intact, how the medical component of palliative care overrides the less scientific or the intuitive aspects of this potentially unique form of care. 'Postmodern death' typifies a fragmentation of ideas and behaviors, a multivocality of responses and, ultimately, an existential uncertainty. As society becomes "postmodern" it also becomes vulnerable to the attenuation or loss of beliefs, values, and communication patterns that had provided it with a sense of identity and continuity.' The palliative care philosophy recognizes the multiplicity of beliefs and communication patterns evident in the collective of dying patients. Nevertheless, care is organised scientifically by a process which categorizes different diseases through comparison and similarity. Using this framework, 'pathological normality' (disease is normalized around signs and symptoms) and routinised pharmacological responses appear to offer more certain answers to the uncertainty of dying than psychological, social and spiritual counseling and support. This argument is not at all straightforward because the pain associated with dying is complex and medicine is efficient in relieving some of that pain. Nevertheless, rational scientific approaches to pain and dying will not ultimately give meaning to the experience of suffering. The changes that are taking place in the practice of palliative care are therefore reflective of a broader social process which manifests in a tension between postmodern death and the medical management of death. Where postmodern dying finds us bereft of ways to approach death as a collective, medicalised dying pushes the phenomenon of death away through technology and pretence. The most common goals for a patient at advanced stages of a chronic disease are palliation of severe symptoms and discharge from a hospital to a regimen of home care. HETF (home enteral tube feeding) contributes to both goals. A pragmatic decision carries the risk of including a certain number of patients with unpredictable early mortality. Because these patients could not be reinvestigated, it is not known whether HETF was without any benefit or even reduced patients' independence and thus had the potential for prolonging a life of decreasing quality. The finding that important aspects of QOL (Quality of life) increased in response to HETF in competent and non-competent patients argues in favor of at least some relevant benefits and challenges in clinical comprehensive guidelines against PEG (percutaneous gastrostomy) placement in patients with anorexia-cachexia syndrome or in a permanent vegetative state. In clinical practice individual decisions for HETF via PEG should be considered earlier and more frequently in appropriate patients. The data provided evidence that HETF benefits the patient. The observed improvement in some aspects of QOL indices does not mean that enteral feeding is justified in all non-competent patients. Study showed that measures developed for QOL research including a specific PEG module can be used in clinical nutrition. The results are fair, based on research, and support the notion that subjective and objective experiences of patients receiving tube feeding should be measured with a health-related QOL tool (Loeser, Herz, Kchler, Rzehak & Manfred, 2003). Conclusions The utilization of ANH for patients at the end of life hardly ever restores nutritional status or extends life. In most patients with end-stage terminal illness, ANH has the likelihood for causing burdensome and distressful symptoms. The exceptions to this are those infrequent patients who complain of thirst unassuagable by ice chips or sips of liquids or who undergoes from opioid toxicity that cannot be comforted by reducing doses, switching drugs, or if not controlling side effects adequately. These patients may advantage from low-volume fluid administration via hypodermoclysis. In medical practice, the health care team must bear in mind that the sign for applying technology is not the plain accessibility of that technology. Rather, clinicians should have evidently defined goals as well as endpoints of therapy in mind when relating such therapy. While offering nutritional support may appear to be the right thing to do, health care professionals must frequently inspect the actual benefits as well as burdens of all therapies. Determining benefits or burdens of any dealing must include the patient as well as family's opinion of what comprises benefit or burden. Ethical principles of beneficence, nonmaleficence, independence, fairness, and virtue help providers recognize when ANH is an appropriate or inappropriate medical treatment. . References: Chiu, 2004. Journal of Pain and Symptom Management. Volume 27, Issue 3, Pages 206-214. Christian Loeser MD, Ulrike von Herz PhD, Thomas Kchler PhD, Peter Rzehak MDand Manfred J., 2003. Quality of life and nutritional state in patients on home enteral tube feeding. Volume 19, Issues 7-8, July-August 2003, Emiko Konishi, Anne J davis and Toshiaki Aiba, 2002. The Ethics of withdrawing Artificial food and fluid from terminally if patients: An end-of-life dilemma for Japanese Nurses and families. Nursing Ethics 9 (1). Hinka et al 2002, Medical Ethics 28 (2). Konishi 2002. Nursing Ethics 9 (1). Major David. 1989. "The Medical Procedures for Providing Food and Water: Indications and Effects." In Joanne Lynn, ed., By No Extraordinary Means: The Choice to Forgo Life-Sustaining Food and Water. Bloomington: Indiana University Press, pp. 21-28. Peck Arthur, Cohen Camille E., and Mulvihill Michael N. 1990. "Long-Term Enteral Feeding of Aged Demented Nursing Home Patients." Journal of the American Geriatrics Society. Vol. 38, pp. 1195-1198. Sutcliffe Jayne. 1994. "Palliative Care: Terminal Dehydration." Nursing Times. Vol. 90, pp. 60-63."To Suffer a Prolonged Illness or Elect to Die: A Case Study." 1984. New York Times. December 16. Walshe Thomas M., and Leonard Cheri. 1985. "PVS: Extension of the Syndrome to Include Chronic Disorders." Archives of Neurology. Vol. 42, pp. 1045-1047. Wicclair Mark R. 1993. Ethics and the Elderly. New York: Oxford University Press. Read More