Ethics of Extraordinary Nutritional Support

Abstract

To the Editor:—I read with great interest the article, “Extraordinary Nutritional Support: A Case Study and Ethical Analysis,” by Watts and Cassel in the issue of March 1984. It concerned an 89-year-old man who had a history of senile dementia of the Alzheimer type. He suffered a cerebrovascular accident, which left him stuporous with a significant neurologic deficit. Quite reasonably over the following seven to ten days after admission he was treated with intravenous fluids to maintain hydration and was given appropriate nursing care. Over this period he showed only slight improvement and then reached a plateau characterized by episodes of aggression and refusal to eat. It is not made clear whether the difficulty with feeding was related to a neurologic problem or otherwise. On two occasions nasogastric tubes were removed by the patient, as was an intravenous line. His relatives had indicated that they did not wish the patient to be resuscitated, and they felt that his refusal of feeding was an indication that he wished to die. It was decided at a unit meeting of experts, a nutritionist, an internist, and so on, that if he could be given several weeks of hyperalimentation, his mental state might improve sufficiently for him to take fluid orally. This course of treatment was commenced. I believe that such a patient in the setting of an Australian Medical Ward would not have received this extraordinary method of treatment—namely, hyperalimentation feeding. I would take the view that an 89-year-old man, already demented, who had a quite profound neurologic deficit, very probably had an extremely poor prognosis for further recovery or even for life. I believe an appropriate course of action would have been to sedate the patient, to gently restrain him, and to continue the use of nasogastric feeding, with continued attempts at oral feeding, particularly by his relatives. I feel in this way the patient's dignity would have been preserved, and there would have been no undue suffering on his part. It seems a not unreasonable judgment that this man's life had run its course and, in the global view of the Christian tradition, his passing would have been in many ways a blessing. One cannot but feel that such a complex management plan may reflect the very different medicolegals climate that obtain in the United States and Australia.