Artificial Nutrition and Hydration and End of Life Decision Making - Term Paper Example

? Artificial Nutrition and Hydration and End of Life Decision Making al Affiliation Artificial Nutrition and Hydration and End of Life Decision Making There are end-of-life decisions that prove to be challenging, not only to the dying persons; but more so, to the family members tasked to make crucial life changing decisions. One of the more common decisions that need to be made involves a medical intervention known as artificial nutrition and hydration (ANH). According to Ersek (2003), “artificial nutrition is any non-oral means of administering nutrition to a person. Methods encompass both enteral and intravenous (i.e., total parenteral nutrition, TPN; also referred to as hyperalimentation) routes of administration” (2). The Hospice and Palliative Nurses Association (HPNA) emphasized that ANH was originally described as a means to effectively “provide short-term support for patients who were acutely ill and are often used to provide a bridge to recovery, or to meet therapeutic goals of prolonging life” (Hospice and Palliative Nurse Association (HPNA), 2011, p. 1). The current discourse hereby aims to present crucial ethical concerns or dilemma pertaining to AHN, especially during end of life (EOL) situations using support from evidence based sources. Ethical Concerns In an article written by Brody, et al. (2011), the authors explored controversial issues ranging from allegedly prolonging or sustaining unconscious human life, particularly that which was apparently categorized as patients in permanent vegetative state (PVS); also in terms of determining conformity to patients’ or relatives’ wishes in contrast to health care practitioners’ professional guidelines (Sampson, Candy, & Jones, 2009). Other ethical issues ensue from the religious beliefs and practices, specifically that which were defined under the early doctrines of the Roman Catholic church, to wit: “to value above all the ability of medical technology to extend life indefinitely was interpreted by the Church as idolatry” (Drane, 2006; cited in Brody, et al.: The 1950s, 2011, par. 2). This original belief apparently seemed to stem from the perspective that life and death is governed by the Supreme Being or God and that any intervention not considered within the natural course of life was therefore considered not within the Will of God. This belief was apparently changed in recent Catholic teachings which reportedly supported that “the position currently endorsed by the Church hierarchy stresses life prolongation based on fundamental human dignity. The two most recent Popes have each stated that administration of food and water, artificially or not, constitutes ordinary care “in principle;” ANH is to be considered not a medical technology, but rather a “natural means of preserving life.” Removing ANH is “euthanasia by omission” because the cause of death would be lack of sustenance rather than the underlying disease” (Brody, et al.:Recent Roman Catholic Teaching, 2011, par. 1). The new teachings support the belief that life should be preseved by all means, as a consistent paradigm towards provision of all methods and possible resources available and accessible to the family members and to the medical practitioners governing the patients’ lives. Concurrently, as expounded by Brody, et al. (2011), a transition in bioethics that acknowledged patients rights to refuse life extending medical care, consistent with patients’ rights and the obligation to allegedly respect patient autonomy has elevated application of ANH to face the following ethical concerns: “Bioethicists who supported mandatory ANH offered several arguments: terminating food or fluids made the physician causally responsible for death; the burdens of ANH seemed minor compared to the overriding good of life prolongation; food and fluids represented “care” at a basic, symbolic level; and in an environment dominated by cost containment, forgoing ANH might lead to the selective elimination of vulnerable patients” (Brody, et al.: The 1980s, 2011, par. 2). This belief focused on respecting the patients’ rights – either to avail of the recommended ANH or to refuse it. Although it was seen as compulsory, at the onset, patients’ preferences and decisions seem to override medical professionals’ recommendations, especially when seen to be futile for terminally ill patients. In addition, ethical concerns were noted to have confirmed that the provision of ANH was actually useless, especially for terminally ill patients, and in hopefully achieving an improvement in the quality of life. As asserted in various empirical and evidence based studies, “a high risk of bothersome complications—aspiration pneumonia, need for physical restraints, nausea, increased respiratory secretions, diarrhea, edema, and need for burdensome laboratory monitoring” (McClave and Chang, 2003; cited in Brody, et al.:Late 1990s, 2011, par. 1) all preclude preferences to apply ANH accordingly. Despite the challenges, there are still predominance in supporting evidences towards favoring the use of ANH, as clearly enumerated below. Likewise, although ANH in EOL situations usually pertain to dying adults, one study written by Rapoport, Shaheed and Newman (2013) who studied application of ANH to children encountering EOL instances. As asserted, “forgoing artificial nutrition and hydration (FANH) in children at the end of life (EOL) is a medically, legally, and ethically acceptable practice under specific circumstances” (par. 1). The findings revealed that parents have apparently welcomed ANH during the trying and difficult times facing EOL situations and were seen as instrumental in contributing to a peaceful and comfortable demise. Factors Favoring the Use of ANH The study written by Brody, et al. (2011) has clearly identified factors which reportedly favor the use of ANH according to family members, to physicians and to administrators, presented herewith as Table 1. Both physicians and administrators rationalized the fear of litigations as important reasons to favor the use of ANH. Concurrent, family members have continued to rationalize that ANH is preferred to avoid guilt; to find more time to accept the transition from life to impending death of the loved one; and in securing more credible information regarding ANH during the EOL decision making process. The therapeutic goals of ANH were likewise identified to include the following: “increased survival, prevention of aspiration and pressure sores, and increased comfort and amelioration of symptoms associated with malnutrition (e.g., hunger) and dehydration (e.g., thirst, delirium)” (Ersek, 2003, p. 3). These are traditionally emphasized by medical professionals to assert the benefits of ANH as a medical intervention that is consistent with the ethical standards stipulated in the health care profession. Table 1: Factors Favoring the Use of ANH Involved party Factors favoring ANH Family members Unwillingness to accept terminal prognosis Belief in cruelty of dying process if ANH not administered Need to demand interventions to avoid guilt Physicians Lack of familiarity with palliative care techniques and evidence Length of time required to educate families on true facts of ANH Reimbursement for insertion of PEG tube, etc. Desire to avoid controversial discussions Fears of litigation Administrators Reimbursement for tube feedings, etc. Fear of regulatory sanctions if ANH not administered (nursing homes) Extra time and staff needed to assist with oral feedings in weakened or demented patients Fears of litigation Source: Brody, et al., 2011 On the other hand, the complications associated with ANH were summarized by Ersek (2003) and presented herewith as Table 2, below. The results corroborated the study of McClave and Chang (2003), as briefly noted above, where aspiration, complications and restraints were found to be paramount concerns. From among the mentioned procedural complications, it was revealed that bleeding, preponderance for infection, sustained pain, tendencies for perforation and tube displacement, as well as bowel obstruction and even death could be sustained. Table 2: Burdens and Complications of ANH Source: Ersek, 2003, p. 4 Conclusion The current research has presented relevant issues pertaining to ethical dilemmas facing ANH during EOL decisions through the support of evidence based studies. The ethical concerns evolved through time as ranging from those spurring from religious Catholic doctrines, changing state regulations regarding EOL advanced directives, to asserting patients’ rights either to sustain life or to refuse prolonged treatment through ANH. The importance of open communication is crucial and paramount among and between the patients, the relatives, health care professionals with direct access to patient care, and those who are instrumental in EOL decision process who should be made aware of the implications and effects of ANH. Aside from ethical consideration, the decision makers should take into account the financial resources and capabilities of the family and the patient, as well as their cultural and religious beliefs. Given the factors favoring its use, as well as the burdens and potential complications, decision-makers must always balance pros and cons of each alternative course of action and select the option which serves the best interests of the patient and the relatives in the long run. References Brody, H., Hermer, L., Scott, L., Grumbles, L., Kutac, J., & McCammon, S. (2011, September). Artificial Nutrition and Hydration: The Evolution of Ethics, Evidence, and Policy. Retrieved October 7, 2013, from Journal of General Internal Medicine. Drane, J. (2006, April). Stopping nutrition and hydration technologies: a conflict between traditional Catholic ethics and church authority. Retrieved October 7, 2013, from Christian Bioethics. Ersek, M. (2003). Artificial Nutrition and Hydration: Clinical Issues. Retrieved October 6, 2013, from Journal of Hospice and Pallative Nursing. Hospice and Palliative Nurse Association (HPNA). (2011). HPNA Position Statement: Artificial Nutrition and Hydration in Advanced Illness. Hospice and Palliative Nurses Association. McClave, S., & Chang, W. (2003, November). Complications of enteral access. Retrieved October 7, 2013, from Gastrointestinal endoscopy. Rapoport, A., Shaheed, J., Newman, C., Rugg, M., & Steele, R. (2013, April 8). Parental Perceptions of Forgoing Artificial Nutrition and Hydration During End-of-Life Care. Retrieved October 7, 2013, from Pediatrics. Sampson, E., Candy, B., & Jones, L. (2009, April). Enteral tube feeding for older people with advanced dementia. Retrieved October 7, 2013, from The Cochrane database of systematic reviews. Read More