Clinically Assisted Nutrition And Hydration Research Articles

The ethics of clinically assisted nutrition and hydration in adults and the role of the advanced clinical practitioner.

Clinically assisted nutrition and hydration (CANH) decision-making in adult patients presents complex ethical dilemmas that require careful consideration and navigation. This clinical review addresses the multifaceted aspects of CANH, emphasising the importance of ethical frameworks and the role of advanced clinical practitioners (ACPs) in guiding decision-making processes. The pivotal role of ACPs is highlighted, from their responsibilities and challenges in decision-making to the collaborative approach they facilitate involving patients, families and multidisciplinary teams. The article also explores ethical principles such as autonomy, beneficence, non-maleficence, and justice, elucidating their application in CANH decision-making. Legal and ethical frameworks covering CANH are examined, alongside case studies illustrating ethical dilemmas and resolutions. Patient-centred approaches to CANH decision-making are discussed, emphasising effective communication and consideration of cultural and religious beliefs. End-of-life considerations and palliative care in CANH are also examined, including the transition to palliative care and ethical considerations in withdrawal or withholding of CANH. Future directions for research and implications for clinical practice are outlined, highlighting the need for ongoing ethical reflection and the integration of ACPs in CANH decision-making.

Withdrawing Assisted Nutrition in Neonates: A Survey on Attitudes and Insights in Argentina.

This study aimed to assess beliefs and attitudes of Argentinean neonatologists and neonatal nurses regarding end-of-life care of newborn infants, including withdrawal of clinically assisted nutrition and hydration (CANH). A five-domain survey was sent to 465 neonatal health care workers, which included demographic data, general ethical concepts, participation in end-of-life decisions, beliefs about end-of-life care practices, and presentation of four clinical scenarios. Standard statistical tests were used, and a multivariable analysis was done to evaluate variables independently associated with rejecting the withdrawal of CANH. A total of 227 questionnaires were anonymously completed, 60% by physicians and 40% by nurses. More respondents agreed to withdraw mechanical ventilation in comparison to CANH in patients under certain circumstances (88 vs. 62%, p < 0.01). The most accepted variables when deciding to withdraw care were the quality of life perceived by parents (86%) and their religious beliefs (73%). A total of 93% agreed that parents should be included in the decision, but only 74% acknowledged they are included in real practice. Considering the scenario of a newborn with severe and irreversible neurological compromise, 46% of respondents were opposed to suspending enteral nutrition. No independent variables were found to be associated with opposing the withdrawal of CANH. Of those agreeing to withdraw enteral feeds under certain circumstances, for the severely neurologically affected neonate 58% would either refuse to limit enteral feeds or consult with an ethics committee before doing so. When given the scenario of their own severe and irreversible neurological compromise, 68% agreed to have enteral feeds withdrawn to themselves, and they were more likely to agree with withdrawing feeds for the severely compromised neonate (odds ratio: 7.2; 95% confidence interval: 2.7-24.1). While most health care providers agreed to withdraw life-sustaining support under certain conditions, many were reluctant to suspend CANH. Many responses differed when being asked as general statements versus actual clinical scenarios. · Withdrawal of assisted nutrition is supported by the American Academy of Pediatrics in certain scenarios.. · Many neonatal intensive care units health care providers from Argentina are reluctant to suspend assisted nutrition.. · There is a need to learn how to deal with complex bioethical issues..

End-of-life care for patients with prolonged disorders of consciousness following withdrawal of life-sustaining treatment: Experience and lessons from an 8-year cohort

National guidelines provide advice for end-of-life care in patients with prolonged disorders of consciousness (PDOC). Following a Supreme Court judgment in July 2018, updated guidelines set out requirements to ensure that decisions to withdraw clinically assisted nutrition and hydration (CANH) are made responsibly in the absence of a mandatory application to the court.This retrospective 8-year cohort analysis of prospectively collected clinical data examines the experience and lessons learned from implementing the guidelines in the 80 PDOC patients who have died in one tertiary centre since 2014. It also reports performance against the standards for elective withdrawal of CANH outside of court since July 2018.CANH was withdrawn in 39/80 (49%) of the patients, over half of whom were already imminently dying. Even in a centre where patients are referred for this purpose, elective CANH withdrawal is comparatively rare (just 14 patients since 2018). The requirements were met in all cases.

Life-threatening Malnutrition in very severe Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)

Patients with very severe Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome (ME/CFS) can experience difficulty maintaining their nutrition and hydration. In the most severe cases it is not uncommon. The commonest reason is simple debility. Dysphagia, severe gastrointestinal problems in tolerating food, possibly indicative of Mast Cell Activation Disorder, and conditions such as gastroparesis may also be contributing factors. These patients require enteral or parental nutrition. In our experience there is often a delay in implementing Clinically Assisted Nutrition and Hydration (CANH), until the malnutrition becomes life-threatening.

Spór o zaprzestanie daremnej terapii oraz sztucznego odżywiania i nawadniania na przykładzie sprawy polskiego pacjenta RS w Wielkiej Brytanii

The article describes and comments upon a recent decision of the British Court of Protection which authorised the cessation of futile life-sustaining therapy including clinically assisted nutrition and hydration (CANH) from RS, a middle-aged Polish patient who fell into the permanent vegetative state (PVS) caused by severe brain damage. The authors scrutinize the legal proceedings and discuss the “best interests” criterion applied by Mr. Judge Cohen (the famous Bland case as well as the Mental Capacity Act of 2005 are evoked in this context). Several terminological and ethical issues are also explained, including the concepts of “passive euthanasia”, “futile therapy”, “over-zealous treatment”, and CANH withdrawal. The authors reflect upon the role of family in decision-making concerning the withdrawal of futile treatment from PVS patients, recalling the notorious cases of Terri Schiavo, Vincent Lambert, and Eluana Englaro. Furthermore, in view of the public outrage caused by the RS case in Poland, the authors comment upon the alleged cultural differences in legal regulations and social attitudes towards the approach to the end of life treatment in Poland and United Kingdom, speculating on the possible way of handling RS’s case in his homeland.

Absence of monitoring in withdrawal of clinically-assisted nutrition and hydration (CANH) and other treatments: a cause for concern?

Since 2018, there has been no requirement to bring decisions about the withdrawal of clinically-assisted nutrition and hydration (CANH) in patients with persistent disorders of consciousness before the courts, providing that the requirements of the Mental Capacity Act 2005 (MCA) are fulfilled. Subsequent British Medical Association and Royal College of Physicians guidance on CANH withdrawal recommended standards of record keeping and internal and external audit to ensure local decision making was compliant with the MCA to safeguard patients. The scope of the guidance also included patients with stroke and neurodegenerative disorders.Freedom of Information requests made 2 years after the introduction of this guidance have shown that none of the NHS trusts or clinical commissioning groups who responded were undertaking any systematic monitoring of these decisions. Neither is the Care Quality Commission reviewing these decisions, as there is 'no statutory requirement' to do so. It appears there is a lack of organised scrutiny of these highly complex life-ending treatment decisions. This omission must surely be a cause for concern.

To What Extent Does Clinically Assisted Nutrition and Hydration Have a Role in the Care of Dying People?

The question over whether to administer clinically assisted nutrition and hydration (CANH) to a dying patient is controversial, with much debate concerning this sensitive issue. The administration of CANH poses clinical and ethical dilemmas, with supporting and opposing views. Proposed positive effects of CANH include preventing thirst, delirium, hypercalcemia, and opioid toxicity. However, CANH has been shown to increase the risk of aspiration, pressure ulcers, infections, and hospital admissions as well as potentially causing discomfort to the patient. Guidance from several national bodies generally advises that the risks and burdens of CANH outweigh the benefits in the dying patient. However, an individualized approach is needed, and the patient’s wishes regarding CANH need consideration if they have capacity and can communicate. Otherwise, sensitive discussions are required with the family, enquiring about the patient’s prior wishes if there is no advanced care plan and acting in the patient’s best interests. The ethical principles of autonomy, beneficence, non-maleficence, and justice need to be applied being mindful of any cultural and religious beliefs and potential misperceptions.

An NHS Trust and others v Y and another [2018] UKSC 46: Reducing the Role of the Courts in Treatment Withdrawal.

In An NHS Trust and others v Y and another, the Supreme Court was asked to address the question of whether a court order must always be obtained before clinically assisted nutrition and hydration (CANH), which is keeping alive a person with a prolonged disorder of consciousness (PDOC). This case note explores the Court's decision to dispense with the need for such a court order and analyses that important change in approach from the perspective of the right to life protected in Article 2 European Convention on Human Rights (ECHR) as well as in the broader context of end of life decision-making.

End-of-life Decision-making for People in a Minimally Conscious State: A Review of the Application of the Mental Capacity Act 2005.

The last 15 years has seen clarification of the terminology used to describe prolonged disorders of consciousness within the United Kingdom leading to the emergence of a new diagnosis – minimally conscious state (MCS) in 2002. MCS is distinct from vegetative states, in that a person demonstrates wakefulness with some degree of minimal awareness. The Mental Capacity Act (MCA) 2005 in England and Wales provides a legal framework for assessing an individuals’ capacity to make decisions for themselves. The Act also authorizes others to make decisions on behalf of an individual who is assessed as lacking capacity in their best interests. The Act has an accompanying Code of Practice which provides guidance and a best interests “test” to be applied when assessing best interests. Since the advent of the Act, approximately two cases each year go to the Court of Protection for final decisions regarding end-of-life care in people in an MCS. Currently, any decision involving the withdrawal of clinically assisted nutrition and hydration (CANH) for people in an MCS must be referred to the court. In each case, the courts analyze the application of the Act which has become central in the court's decision-making process, particularly when assessing best interests. This article provides an overview of key MCA sections applied in such end-of-life MCS cases and reviews seminal cases elucidating how the Act has been applied. It further describes the evolution of how courts have interpreted the doctrine of best interests when considering withholding or withdrawing CANH and other life-sustaining treatments.

Awake and (Only Just) Aware? A Typology, Taxonomy, and Holistic Framework for Withdrawing Clinically Assisted Nutrition and Hydration in the Minimally Conscious State.

Decisions to withdraw clinically assisted nutrition and hydration (CANH) from people in the minimally conscious state are predicated on the question as to whether it is in the individual's best interests to continue with CANH and determined traditionally using a 'balance sheet' approach. The emerging case law in this area suggests that decisions may appear inconsistent and lack sufficient certainty and clarity of process. Using an analysis of statute, common law and academic commentary we articulate a typology for the elements that tend to engage in these decisions. Next, we construct a taxonomy of overarching legal and ethical issues and then proceed to develop a novel framework for holistic decision-making. We validate this on the principle upon which it is grounded: coherent weighting of elements and theoretical proof of concept. The framework has potentially far-reaching benefits that include consistency and transparency of decision-making, thereby enabling a more uniform judicial approach. We suggest this as a foundational paradigm for decision-making in this context.

When ‘Sanctity of Life’ and ‘Self-Determination’ clash: Briggs versus Briggs [2016] EWCOP 53 – implications for policy and practice

In a landmark judgment in the English Court of Protection, the judge (Charles J) found it to be in the best interests of a minimally conscious patient for clinically assisted...

Withdrawing clinically assisted nutrition and hydration (CANH) in patients with prolonged disorders of consciousness: is there still a role for the courts?

Currently, in England and Wales, Court of Protection’s Practice Directive 9E (PD9E) requires all cases of proposed withdrawal or withholding of life-sustaining treatment in relation to adults in a permanent...

From Twilight to Breaking Dawn? Best Interests, Autonomy, and Minimally Conscious Patients.

In law, as in the alphabet, N comes after M. Like M, whose case was decided in 2011,1 N was in a minimally conscious state (MCS), a disorder of consciousness in which the patient nevertheless exhibits some signs of consciousness.2 The issue in N's case, as in M's, was whether or not clinically assisted nutrition and hydration (CANH) should continue to be provided. The MCS is distinguishable from the permanent vegetative state (PVS), in which sleep–wake cycles are observable, but the patient appears unaware, uncommunicative, and incapable of purposeful behaviour.3 Yet, if the patient occupies either of these ‘twilight world[s]’,4 the court must decide whether or not CANH can be withdrawn.5 In M's case, this treatment stayed in place; in N's case, Hayden J decided that the treatment could cease. Critics of Baker J's ruling in M's case had charged him with over-emphasising the intrinsic value of life.6 Those critics might welcome Hayden J's decision, with its orientation towards respect for the patient's autonomy. We might wonder, however, whether this is not a new dawn, but rather a false dawn, in healthcare law.