Withdrawal Of Artificial Nutrition Research Articles

Withdrawing Life Support and Medical Futility

Life support technologies have the potential to save many lives. However, in some cases – particularly when disease is advanced or incurable – the use of these interventions may simply prolong the dying process while causing significant pain and suffering. The ethical basis for withdraw of life support has been clearly elucidated in medical ethics and the law, but given the emotions surrounding these issues, it is not surprising that controversy still exists. This review discusses withdrawal of life support and withdrawal of artificial nutrition. Additionally, this review explores medical futility, including the historical background, futility and the law, focus on process: hospital futility policies and ethics committees, and current practice and the future of medical futility. Illustrative case reports are presented. The table lists some examples of responding to requests for non-beneficial care from patients or surrogates. This review contains 1 figure, 3 tables, and 27 references. Key Words: Withdrawal of life support; Withdrawal of care; Medical futility

Food as Love: Ethical and Moral Dilemmas in Withdrawal of Artificial Nutrition and Hydration in the Minimally Conscious State.

Supportive Palliative Care and Hospice professionals frequently attend to Minimally Conscious State (MCS) patients near the end of life and in so doing, face decisions over maintenance or withdrawal of artificial nutrition and hydration. Although both withholding and withdrawal of artificial nutrition and hydration (ANH) in such circumstances are considered by experts in ethics and law to be acceptable, not all families nor health care professionals agree. This paper will explore basic aspects of serious brain injuries, especially MCS, the psychological role of food in interpersonal relationships, and lessons from clinical ethics that can help in goals of care discussions about withdrawal of ANH.

FOOD FOR THOUGHT: VOLUNTARY PALLIATED STARVATION AND WITHDRAWAL OF ARTIFICIAL NUTRITION

Background: Voluntary palliated starvation (VPS) involves voluntarily stopping eating and drinking with the intention to die and subsequently receive palliative care1. This is different to the withdrawal of artificial nutrition and hydration, which involves a pre‐existing condition that necessitates a life sustaining therapy2. This distinction is not always evident and may lead to allegations of physician assisted suicide (PAS)2. Currently physician assisted suicide is a crime in all states and territories in Australia except for Victoria1. The following case study examines these contemporary issues. Case: Mr LT was a 64‐year‐old gentleman who had a 9‐month hospital admission following a motor vehicle accident which left him severely disabled with traumatic amputation of his right lower limb, blindness of his left eye and traumatic ischaemic bowel. This was then complicated by intra‐abdominal sepsis requiring further bowel resections, resulting in short gut syndrome and complete dependence on total parental nutrition (TPN). Mr LT wished to cease artificial nutrition due to on‐going physical and mental suffering and the prospect of a lifetime of complete nursing cares. The decision was complicated by allegations of potential PAS and conflicting legal opinion regarding the lawfulness of withdrawing artificial nutrition, obligating continuation of nutritional therapies, despite him being deemed to have capacity to make health related decisions. After multiple multidisciplinary assessments the artificial nutrition was lawfully discontinued, and his cares transferred to the palliative care team. Discussion: In Australia, withdrawal of artificial nutrition is supported by case law1,3. Cases are confounded by questions about capacity, mental health and associations with PAS. Complicating this further, there are differences in state law. Conflict within the Queensland Criminal Code as to the lawfulness of withdrawing life sustaining artificial nutrition and hydration led to the issues in the instant case1,4. Respect for autonomy is a fundamental principle in bioethics and extends to an individual's right to refuse treatment1. This case represents a legal and ethical grey area and clearly the association between PAS and VPS is not binary. Regardless of the distinction between withdrawal of life sustaining nutrition and VPS the provision of palliative care in either case is not PAS1. Conclusion: The withdrawal of artificial nutrition is lawful in a voluntary and competent individual. Uncertainty arises when VPS is implied and associated with PAS. It is an emerging issue and its legal status remains uncertain. Regardless, good medical practice and the provision of palliative care should overcome this uncertainty, as illustrated in this case study.

Dying with Dignity; Living with Laws (and Ethics).

An increasing number of jurisdictions allow individuals to obtain medication prescribed by their physicians for medical assistance in dying (MAID). But discussion of whether (and to what extent) individuals have the right to use the health care system to control the time and manner of their death is not limited to MAID. The right also exists in other contexts, such as directing the withdrawal of life-sustaining treatments. Palliative (or terminal) sedation involves medications to render a patient unconscious, coupled with either the withdrawal of artificial nutrition and hydration or their not being administered at all. In high-enough doses, these medications may further suppress already-weakened cardiopulmonary function even if there is no intent to hasten death. When teaching about these topics, I challenge students to consider whether there are meaningful differences between practices like euthanasia, MAID, aggressive use of morphine, terminal sedation, or the withdrawal of ventilator support. Whether their differences are morally, ethically, or legally meaningful can be difficult to tease out. After recently watching a loved one, whom I call "Stephan," direct the time and manner of his death within hospice care in a state that does not allow MAID, I am less inclined than ever to believe that the differences are meaningful in a way the law should recognize.

Argumentation for the Withdrawing or Withholding of Artificial Nutrition by the Mobile Palliative Care Team

<p class=MsoListParagraphCxSpFirst style=margin-left:0in;mso-add-space:auto; text-align:justify;tab-stops:179.25pt;mso-mirror-indents:yes> 1. Abstract <p class=MsoListParagraph style=margin-left:.25in;mso-add-space:auto; text-align:justify;text-indent:-.25in;mso-list:l0 level2 lfo1;tab-stops:179.25pt; mso-mirror-indents:yes> 1.1. <span style=font-size:10.0pt;mso-ansi-language: EN-US>Introduction: <span style=font-size:10.0pt;mso-ansi-language: EN-US>Palliative care practice confronts us with the dilemma of «equitable care», namely: when to treat, by what means and, above all, when to stop. The issue of artificial nutrition is the perfect example. The present study was conducted to identify the arguments used by the Mobile Palliative Care Team to discuss the introduction or withdrawal of artificial nutrition and compare these arguments according to the advice given. <p class=MsoListParagraph style=margin-left:.25in;mso-add-space:auto; text-align:justify;text-indent:-.25in;mso-list:l0 level2 lfo1;tab-stops:179.25pt; mso-mirror-indents:yes> 1.2. <span style=font-size:10.0pt;mso-ansi-language: EN-US>Methods: A descriptive, historical cohort-type epidemiological study was carried out on all medical files of patients followed by the mobile team of the Metz-Thionville Regional Hospital in 2013 and for whom a discussion had taken place regarding artificial nutrition. <p class=MsoListParagraph style=margin-left:.25in;mso-add-space:auto; text-align:justify;text-indent:-.25in;mso-list:l0 level2 lfo1;tab-stops:179.25pt; mso-mirror-indents:yes> 1.3. <span style=font-size:10.0pt;mso-ansi-language: EN-US>Results: The most commonly mentioned arguments were general patient condition (68.4% of cases), estimated life expectancy (67.3%) and the palliative nature of care management (55.1%). Advice for the withdrawal or withholding of artificial nutrition formulated by the mobile team was followed in 75.9% of cases while the advice for the introduction or continuation of artificial nutrition was followed in 93.3%. <p class=MsoListParagraph style=margin-left:.25in;mso-add-space:auto; text-align:justify;text-indent:-.25in;mso-list:l0 level2 lfo1;tab-stops:179.25pt; mso-mirror-indents:yes> 1.4. <span style=font-size:10.0pt;mso-ansi-language: EN-US>Conclusion: <span style=font-size:10.0pt;mso-ansi-language: EN-US> The decision to withdraw or pursue artificial nutrition is based on a body of arguments and a multidisciplinary evaluation with discussion encompassing an ethical dimension involving the patient and his/her relatives. <p class=MsoListParagraph style=margin-left:.25in;mso-add-space:auto; text-align:justify;text-indent:-.25in;mso-list:l0 level1 lfo1;tab-stops:179.25pt; mso-mirror-indents:yes> 2. Keywords: Artificial Nutrition; Collegial Discussion; Ethics; Palliative Care <p class=MsoListParagraph style=margin-left:.25in;mso-add-space:auto; text-align:justify;text-indent:-.25in;mso-list:l0 level1 lfo1;tab-stops:179.25pt; mso-mirror-indents:yes> 3. Abbreviations : SD: Standard Deviation

The withdrawal of artificial nutrition and hydration from PVS and MCS patients: the experiences and perceptions of allied health professionals

The withdrawal of artificial nutrition and hydration from PVS and MCS patients: the experiences and perceptions of allied health professionals

A matter of life and death

Cases concerning the withdrawal or withholding of artificial nutrition and hydration from patients in a vegetative or minimally conscious state raise difficult medical, legal and ethical questions including the diagnosis...

Late recovery of awareness in prolonged disorders of consciousness –a cross-sectional cohort study

Purpose: To detect any improvement of awareness in prolonged disorders of consciousness in the long term.Methods: A total of 34 patients with prolonged disorders of consciousness (27 vegetative state and seven minimally conscious state; 16 males; aged 21–73) were included in the study. All patients were initially diagnosed with vegetative/minimally conscious state on admission to our specialist neurological rehabilitation unit. Re-assessment was performed 2–16 years later using Coma Recovery Scale-Revised.Results: Although remaining severely disabled, 32% of the patients showed late improvement of awareness evidenced with development of non-reflexive responses such as reproducible command following and localization behaviors. Most of the late recoveries occurred in patients with subarachnoid hemorrhage (5/11, 45.5%). The ages of patients within the late recovery group (Mean = 45, SD = 11.4) and non-recovery group (Mean = 43, SD = 15.5) were not statistically different (p = 0.76).Conclusions: This study shows that late improvements in awareness are not exceptional in non-traumatic prolonged disorders of consciousness cases. It highlights the importance of long-term follow up of patients with prolonged disorders of consciousness, regardless of the etiology, age, and time passed since the brain injury. Long-term follow up will help clinicians to identify patients who may benefit from further assessment and rehabilitation. Although only one patient achieved recovery of function, recovery of awareness may have important ethical implications especially where withdrawal of artificial nutrition and hydration is considered.Implications for rehabilitationLong-term regular follow-up of people with prolonged disorders of consciousness is important.Albeit with poor functional outcomes late recovery of awareness is possible in both traumatic and non-traumatic prolonged disorders of consciousness cases.Recovery of awareness has significant clinical and ethical implications especially where withdrawal of artificial nutrition and hydration is considered.

Withdrawal of artificial nutrition and hydration in neonatal intensive care: parents' and healthcare practitioners' views.

Withdrawing Artificial Nutrition and Hydration (WANH) in the neonatal intensive care units (NICUs) has long been controversial. In France, the practice has become a legal option since 2005. But even though, the question remains as to what the stakeholders' experience is, and whether they consider it ethically appropriate. In order to contribute to the debate, we initiated a study in 2009 to evaluate parental and health care professionals (HCP) perspectives, after they experienced WAHN for a newborn. The study included 25 cases from 5 different clinical neonatology departments. We interviewed both the parents and some of the HCP who cared for the baby, at least 6months after this latter deceased. We proceeded through in-depth individual qualitative interviews. Content was analyzed for themes and patterns that emerged from the data. Some parents expressed that WANH offered an opportunity to the family to spend a few demedicalized days with the baby before she dies, without any tubes and machines, and to be well supported by the HCP during this palliative stage. But others evaluated the practice in retrospect as a terrible ordeal. All said that, at least, the time of waiting for death to ensue should not last too long. After a few days, it becomes unbearable because of the transformation of the baby's appearance and because they, as parents, began to wonder if she was not dying from starvation rather than from her initial disease. An important proportion of HCP also expressed some kind of ethical unease. This was due to the psychological violence involved in the decision for a human being to stop feeding a little one, and also to the difficulty to deal with the fundamental intention behind the decision of WANH: indeed, could it be claim that it does not presuppose the intention of provoking the infant's death? The discussion focuses on the point to know if WANH can be considered as a source of progress from an ethical point of view, particularly in comparison with earlier practices-that in France could involve active euthanasia by lethal injection. We argue that when HCP are merely focused on avoiding that WAHN could be construed as a way of intending to hasten the baby's death, the practice is at risk to be implemented in a way that becomes ethically counterproductive. Focusing on this intention easily distract the clinical teams from what should be their ultimate concern, namely the baby's comfort during the dying process, as well as the support owned to her parents. To conclude, we suggest that the ethical priorities, when WANH is decided, should be the support due to the patient and her family on the one hand, and, on the other hand to implement it in such a way that at least the baby seems to have died of her initial disease and never of starvation. This means that HCP have a duty to control the timing of death, even though this might be incompatible with the worry to avoid the intention of hastening the baby's death.

Pain Perception in Unresponsive Wakefulness Syndrome May Challenge the Interruption of Artificial Nutrition and Hydration: Neuroethics in Action.

The voluntary withdrawal of artificial nutrition and hydration (ANH) in patients with severe disorders of consciousness (DoC, e.g., permanent vegetative states) constitutes a fundamental ethical issue extending beyond the boundaries of end-of-life decisions. The term “Vegetative State” was originally adopted to define “an organic body capable of growth and development but devoid of sensation and thought” (1). In this frame, the traditional approach toward the suspension of ANH rested upon the view that patients in the Vegetative State had no residual capability to perceive pain (2, 3). However, over the past few decades, an increasing number of studies (4–11) have shown that strong claims about awareness in patients without behavioral responses to commands are unwarranted. Furthermore, there is again a high percentage of misdiagnoses in the assessment of these patients (12–14). Recently it was proposed the alternative name “unresponsive wakefulness syndrome” (VS/UWS) (15), to define a condition characterized by the absence of response to commands or oriented voluntary movements in the presence of wakefulness. Neuroimaging studies demonstrated the existence of distinctive cerebral responses to noxious stimuli in conditions like VS/UWS and minimally conscious state (MCS) (16–18). Yet, there is no univocal consensus about pain perception in patients with DoC. In a study by Demertzi and colleagues (19), 2,059 medical and paramedical professionals from 32 European countries were asked the following question: “can a patient in vegetative state feel pain?” Over 40% of those surveyed replied that these patients do not feel pain. The percentage was higher among medical doctors compared to paramedical caregivers (54 and 32%, respectively). This view was substantiated by the idea that, in the absence of consciousness, patients were not capable of experiencing and reporting a painful experience. However, recent advances in the pathophysiology of DoC, debunking the original tenet that patients with DoC do not perceive pain, suggest a reconsideration of the voluntary withdrawal of ANH (20). In this manuscript, we will briefly review the recent literature indicating that some patients with DoC reveal a form of residual awareness (21) and that they are capable of perceiving painful stimuli and exhibiting consistent responses to them. Furthermore, empirical evidence in the literature suggests that, when tested with the appropriate tools, these patients can exhibit consistent reactions to emotionally salient stimuli (5, 10, 22–27). Based on these findings, we propose that the voluntary withdrawal of ANH should be carefully reconsidered on medical and ethical grounding.

Vincent Lambert, Dignity in Dying and the European Court: A Critical Evaluation and the Global Reflections.

In this article I analyse the verdict of the European Court of Human Rights in the Case of Lambert and Others v. France, delivered on 5 June 2015, affirming the Conseil d'État's decision holding that the withdrawal of artificial nutrition and hydration from Vincent Lambert, a French national lying in tetraplegia and persistent vegetative state, was consistent with French domestic law and the European Convention for the Protection of Human Rights and Fundamental Freedoms. In order to make a comparative evaluation I give an account of judicial decisions across the world and find that the European Court's decision is an affirmative pronouncement, in the prevailing milieu of judicial heterogeneity, as it recognizes a person's right to die with dignity in the face of conflicting claims and arguments, by giving supremacy to a person's autonomy and right of self-determination over the deep-rooted religious beliefs and undue paternalistic postures. I conclude that right to die with dignity is a profound area where judge-made law is not the answer. The situation calls for greater consensus and uniformity by evolving suitable legislative strategies.

Caregivers Confronted With the Withdrawal of Artificial Nutrition at the End of Life: Prevalence of and Reasons for Experienced Difficulties.

Withdrawing artificial nutrition in palliative care is an issue that often leads to ethical dilemmas among health care providers, despite clinical guidelines. To describe the experience of health care providers confronted with the withdrawing of artificial nutrition at the end of life and identifying the factors related to the level of ethical dilemmas. Cross-sectional survey questionnaire of all the nurses and nurses' aides working in medicine, surgery, and palliative care departments of a regional hospital and who have already been confronted with the withdrawal of artificial nutrition. Of 818 questionnaires sent, 274 were returned (response rate 33.5%); 60% (163) of the care providers who responded were involved in withdrawing artificial nutrition at the end of life. Among these, 42 (25.8%) had always or often been affected with ethical dilemmas, and 97 (60%) responded that withdrawing artificial nutrition had always or often been preceded by a multidisciplinary discussion. Items significantly associated with a high level of ethical dilemmas were (1) existence of differences in opinion within the health care team, (2) lack of information regarding the indication of the withdrawal of artificial nutrition, (3) feeling uncomfortable with the patient and his or her relatives, (4) guilt, (5) feeling of abandonment of care, and (6) uneasiness. Health care providers seem to have a lack of information and consensus regarding the withdrawal of artificial nutrition at the end of life. The ethical dimension of withdrawing artificial nutrition in palliative care has a strong impact on care providers, regardless of the circumstances of the withdrawal.

Withdrawal of Artificial Nutrition

In spite of the existence of clinical guidelines and a legal framework in France, the withdrawal of artificial nutrition (AN) in palliative care remains a difficult situation for caregivers who are confronted with this reality. To describe the perception of caregivers on the withdrawal of AN and to compare this perception between caregivers who have already been confronted with this situation and those who have not. Cross-sectional survey questionnaire of nurses and nurses' aides (n = 274) working in medicine, surgery, and palliative care departments of a regional hospital. Of the caregivers, 59.5% declared having been confronted with the withdrawal of AN in their professional practice. This was associated with a better perception by these caregivers even if their knowledge on the criteria to be considered in the decision was not significantly modified. The coherence of the withdrawal of AN with the personal beliefs of the caregivers, already high in the absence of being confronted with this practice, is better among caregivers who have been confronted with this situation. The lack of information perceived by caregivers should prompt us to develop additional training on the withdrawal of AN, its objectives, and its clinical consequences.

Opinions des soignants des réanimations pédiatriques françaises sur l’application de la loi Léonetti

To identify the knowledge of caregivers of pediatric intensive care units (PICUs) on the French law related to patients' rights and end of life, their views on withholding/withdrawing life-sustaining treatment (WWLST) decisions, and their feelings about how these decisions were made and implemented. A multicenter survey in 24 French PICUs during the fourth trimester 2010. One thousand three hundred and thirty-nine professional healthcare workers (1005 paramedics and 334 physicians) responded. Over 85% of caregivers had good knowledge of the WWLST decision-making processes required by law. More than 80% of caregivers accepted mechanical ventilation, hemodiafiltration, or hemodynamic support withdrawal or withholding. Nevertheless, the withdrawal of artificial nutrition and hydration generated reluctance or opposition for the majority of respondents. While paramedics' participation in the decision-making process was deemed necessary by all caregivers, paramedics found more often than physicians that they were insufficiently involved. The quality of end-of-life care was judged very positively by caregivers. The answers on how WWLST was applied suggest very different interpretations of the law. Some caregivers respect the principles of palliative care as stated in the public health code and 40% of doctors and 64% of caregivers consider it "acceptable" to hasten death if resulting from a collaborative decision-making process. This study is the first to show that caregivers of French PICUs have good knowledge of the French law concerning the end of life. Yet, there is still confusion about the limits of practice during the end-of-life period.

End of life neonatal care: withdrawal of artificial nutrition and hydration

End of life neonatal care: withdrawal of artificial nutrition and hydration

The weight attributed to patient values in determining best interests

In W v M and Others (Re M) the Court of Protection considered whether withdrawal of artificial nutrition and hydration was in the best interests of a person in minimally...

Withdrawing and withholding artificial nutrition and hydration from patients in a minimally conscious state: Re: M and its repercussions

In 2011 the English Court of Protection ruled that it would be unlawful to withdraw artificial nutrition and hydration from a woman, M, who had been in a minimally conscious...

Classic Cases Revisited: Anthony Bland and Withdrawal of Artificial Nutrition and Hydration in the UK

Artificial nutrition and hydration (ANH) in the context of end-of-life care generates strong emotions. For some, it may be considered burdensome treatment, while others see ANH as an essential aspect of basic or comfort care. The case of Anthony Bland, which was appealed before the House of Lords in February 1993, has become the test case for the lawfulness of ‘elective’ withdrawal of life support in the form of artificial nutrition and hydration in an adult patient in the UK. While the case has been debated previously, 1,2 it is worthwhile revisiting it, given that it informs current practice concerning end-of-life care. It is hard to envisage evidence-based ethics, but cases such as that of Anthony Bland and others inform our practice. The topic of ANH remains controversial to this day and keeping abreast of ethical and legal debate surrounding it, is essential.

Pain Perception in Disorders of Consciousness: Neuroscience, Clinical Care, and Ethics in Dialogue

Pain, suffering and positive emotions in patients in vegetative state/unresponsive wakefulness syndrome (VS/UWS) and minimally conscious states (MCS) pose clinical and ethical challenges. Clinically, we evaluate behavioural responses after painful stimulation and also emotionally-contingent behaviours (e.g., smiling). Using stimuli with emotional valence, neuroimaging and electrophysiology technologies can detect subclinical remnants of preserved capacities for pain which might influence decisions about treatment limitation. To date, no data exist as to how healthcare providers think about end-of-life options (e.g., withdrawal of artificial nutrition and hydration) in the presence or absence of pain in non-communicative patients. Here, we aimed to better clarify this issue by re-analyzing previously published data on pain perception (Prog Brain Res 2009 177, 329–38) and end-of-life decisions (J Neurol 2010 258, 1058–65) in patients with disorders of consciousness. In a sample of 2259 European healthcare professionals we found that, for VS/UWS more respondents agreed with treatment withdrawal when they considered that VS/UWS patients did not feel pain (77%) as compared to those who thought VS/UWS did feel pain (59%). This interaction was influenced by religiosity and professional background. For MCS, end-of-life attitudes were not influenced by opinions on pain perception. Within a contemporary ethical context we discuss (1) the evolving scientific understandings of pain perception and their relationship to existing clinical and ethical guidelines; (2) the discrepancies of attitudes within (and between) healthcare providers and their consequences for treatment approaches, and (3) the implicit but complex relationship between pain perception and attitudes toward life-sustaining treatments.

Case Law on Artificial Nutrition and Hydration Since Bland

The legal basis and principles for the lawful withdrawal of artificial nutrition and hydration (ANH) from people in a persistent vegetative state (now termed permanent vegetative state), was laid out in the case of Anthony Bland, who sustained catastrophic and irreversible brain damage as a result of being crushed during the Hillsborough stadium disaster in 1989. Anthony Bland was medically diagnosed as being in a persistent vegetative state with no hope of recovery or improvement. Since the Bland case the Mental Capacity Act 2005 and the Human Rights Act 1998 have been introduced and must be considered in all such cases. This article provides an update of the legal basis for the withdrawal of ANH from people in a permanent vegetative state or a minimally conscious state. In this regard, it analyses the cases of Re C [2010] and W vs M & Ors [2011]. Analysis of these cases demonstrates the decision-making process and current legal basis for the lawful withdrawal or withholding of ANH from people in a permanent vegetative state or a minimally conscious state. Conflicts of interest: none