Withdrawal Of Nutrition Research Articles

Nutrient timing and metabolic regulation.

Daily (circadian) rhythms coordinate our physiology and behaviour with regular environmental changes. Molecular clocks in peripheral tissues (e.g. liver, skeletal muscle and adipose) give rise to rhythms in macronutrient metabolism, appetite regulation and the components of energy balance such that our bodies can align the periodic delivery of nutrients with ongoing metabolic requirements. The timing of meals both in absolute terms (i.e. relative to clock time) and in relative terms (i.e. relative to other daily events) is therefore relevant to metabolism and health. Experimental manipulation of feeding–fasting cycles can advance understanding of the effect of absolute and relative timing of meals on metabolism and health. Such studies have extended the overnight fast by regular breakfast omission and revealed that morning fasting can alter the metabolic response to subsequent meals later in the day, whilst also eliciting compensatory behavioural responses (i.e. reduced physical activity). Similarly, restricting energy intake via alternate‐day fasting also has the potential to elicit a compensatory reduction in physical activity, and so can undermine weight‐loss efforts (i.e. to preserve body fat stores). Interrupting the usual overnight fast (and therefore also the usual sleep cycle) by nocturnal feeding has also been examined and further research is needed to understand the importance of this period for either nutritional intervention or nutritional withdrawal. In summary, it is important for dietary guidelines for human health to consider nutrient timing (i.e. when we eat) alongside the conventional focus on nutrient quantity and nutrient quality (i.e. how much we eat and what we eat).

Compulsively Moral: OCD, Ethics, and the Law.

Compulsively Moral: OCD, Ethics, and the Law.

Lidocaine as an element of multimodal analgesic therapy in major spine surgical procedures in children: a prospective, randomized, double-blind study

BackgroundIntroducing the principles of multimodal analgesic therapy is necessary to provide appropriate comfort for the patient after surgery. The main objective of the study was evaluating the influence of perioperative intravenous (i.v.) lidocaine infusion on postoperative morphine requirements during the first 48 h postoperatively in children undergoing major spine surgery.Materials and methodsProspective, randomized, double-blind study: 41 children, qualified to multilevel spine surgery, were randomly divided into two treatment groups: lidocaine and placebo (control). The lidocaine group received lidocaine as a bolus of 1.5 mg/kg over 30 minutes, followed by a continuous infusion at 1 mg/kg/h to 6 hours after surgery. The protocol of perioperative management was identical for all patients. Measurements: morphine demand, intensity of postoperative pain (the Numerical Rating Scale), oral feeding initiation time, first attempts at assuming erect position, postoperative quality of life (the Acute Short-form /SF-12/ health survey).ResultsPatient data did not differ demographically. Compared to the control group, lidocaine treatment reduced the demand for morphine during the first 24h [95% CI 0.13 (0.11-0.28) mg/kg, p = 0.0122], 48h [95% CI 0.46 (0.22-0.52) mg/kg, p = 0.0299] after surgery and entire hospitalization [95% CI 0.58 (0.19-0.78) mg/kg, p = 0.04]; postoperative pain intensity; nutritional withdrawal period [introduction of liquid diet (p = 0.024) and solid diet (p = 0.012)], and accelerated the adoption of an upright position [sitting (p = 0.048); walking (p = 0.049)]. The SF-12 generic health survey did not differ between groups before operation, 2 months and 4 years after surgery.ConclusionsPerioperative lidocaine administration, as a part of the applied analgesic therapy regimen, may decrease postoperative opioid demand and accelerates convalescence of children undergoing major surgery.

Neuroznanstvena dekonstrukcija ideologiziranog »beznađa« vegetativnoga stanja

Recentna neuroznanstvena istraživanja propituju dosadašnju predrasudu o vegetativnom stanju kao »beznadnom« stanju. Rezultati ovih otkrića ne samo da ruše već postojeće predrasude prema osobama u vegetativnom stanju, već daju i nov uvid u epistemološku problematiku točnosti dijagnosticiranja aktualnog stanja, popraćenu etičkim i društvenim implikacijama. Pružajući bolje razumijevanje same naravi svijesti i svjesnosti, upućuju na oblik moralne i socijalne odgovornosti prema tim osobama ne ostavljajući mjesta za »beznađe«. Stoga je prvotni cilj ovoga rada prikazati kako se uz razvitak uvida u stanje osoba s poremećajem svijesti, na samom početku paralelno razvijala i predrasuda »beznađa« kao nuspojava nedovoljnog i neadekvatnog znanja o naravi svijesti kod osoba u vegetativnom stanju. Ova ustaljena predrasuda imala je direktan utjecaj na donošenje kliničkih odluka o mjerama održavanja na životu: od povlačenja nutricije i hidratacije – do pitanja kardio-pulmonarnog oživljavanja pa onda do odvajanja od respiratora, smatrajući da osoba nema nade za oporavak nakon uspostave dijagnoze vegetativnog stanja. Stoga, ova predrasuda »beznađa« ne samo da nije ostavila duboko utaban, moralno upitan put za izvođenje pasivne eutanazije, već je, štoviše, bila iskorištena i ispolitizirana kao jedan od glavnih argumenata i primjera pro-eutanazijskih pokreta u borbi za ozakonjenje same eutanazije.

Assisted Dying in Australia and Limiting Court Involvement in Withdrawal of Nutrition and Hydration

Assisted Dying in Australia and Limiting Court Involvement in Withdrawal of Nutrition and Hydration

Death by Withdrawal of Nutrition and Hydration

Death by Withdrawal of Nutrition and Hydration

L’arrêt de l’alimentation et de l’hydratation dans les états de conscience altérée: Différence et répétition

Interruption of nutrition and hydration in states of altered consciousness: differences and repetitions Against the backdrop of the Vincent Lambert case in France, we examined three cases of withdrawal of nutrition and hydration for patients in states of altered consciousness (PVS, MCI) which raised debates: the case of Terri Schiavo in the United States, the case of Eluana Englaro in Italy, and the case Re M in the United Kingdom. Taking the relevant legal, political, and societyl contexts into account, we present the arguments that played out at the time of these decisions. We hope that this comparative study will help future reflection

Effects of Nitrogen and Calcium Nutrition Withdrawal Before Harvesting on Biomass and Nutritive and Safety Quality in Spinach (Spinacia Oleracea L.)

A hydroponic culture was used to study different nitrogen and calcium supply patterns on biomass, nutritive, and safety quality of spinach seven days before harvesting. The results showed that the complete or partial withdrawal of nitrogen (N) and calcium (Ca) nutrient decreased spinach biomass compared to control (CK). At the same time, the withdrawal of N and Ca supply before harvesting increased vitamin C contents and decreased nitrate and oxalate content in edible parts of spinach. The decrease in spinach biomass could be partially compensated by the increase of the nutritive and safety quality of spinach and the reduced use of N and Ca nutrients.

Detecting awareness after severe brain injury

Recent developments in functional neuroimaging have provided a number of new tools for assessing patients who clinically appear to be in a vegetative state. These techniques have been able to reveal awareness and even allow rudimentary communication in some patients who remain entirely behaviourally non-responsive. The implications of these results extend well beyond the immediate clinical and scientific findings to influencing legal proceedings, raising new ethical questions about the withdrawal of nutrition and hydration and providing new options for patients and families in that decision-making process. The findings have also motivated significant public discourse about the role of neuroscience research in society.

The Roman Catholic Church, Biopolitics, and the Vegetative State

Compelled by recent public and politicized cases in which withdrawal of nutrition and hydration were at issue, this essay examines recent Church statements and argues that the distinction between private and public forms of human life is being lost. Effacing the distinction between the sphere of the home (oikos), where the maintenance of life (zoē) occurs, and the city (polis), where political and public life (bios) occurs, may have unforeseen and unwanted consequences. Through their well-intentioned efforts to preserve the sanctity of life, certain bishops and the Congregation for the Doctrine of the Faith have unfortunately brought political considerations into the home, taking decision-making authority away from those most intimately related to the patient. Thus, the question of removing nutrition and hydration in the case of patients such as Schiavo and Englaro becomes politicized and abstract, in contrast with the Church’s previous positions on the importance of proportionate means in the maintenance of life, local decision making, and its recognition of life as a penultimate end.

Nothing's Settled

If That Ever Happens to Me: Making Life and Death Decisions after Terri Schiavo. By Lois Shepherd. The University of North Carolina Press, 2009. 192 pages. Hardcover. $28.00 Lois Shepherd's book If That Ever Happens to Me: Making Life and Death Decisions after Terri Schiavo demonstrates a great appreciation for the unresolved conflicts over end-of-life care revealed by the Schiavo case. Through detailed analysis, this book debunks the claim that the controversy defied an established concerning the appropriateness of withdrawing medically administered nutrition and hydration. Arguments that settled legal standards provided a stalwart framework for that failed to appreciate the variations and limitations of those norms. Shepherd challenges the notion that we professionals--doctors, lawyers, judges, and bioethicists--had authoritatively resolved the moral and social significance of withdrawal of nutrition and hydration. In fact, law is where we have kept our conflicts alive. The controversy over Terri Schiavo's care demonstrated the startling capacity of the legal system to be used to extend disputes beyond reasonable bounds. Observed more closely, the case shows how our laws have embedded unresolved tensions within the framework for surrogate decision-making relating to end-of-life care. Legal standards for surrogate decision-making in the United States require a highly individualized inquiry into a particular patient's desires in anticipated and unanticipated medical situations as she may or may not have communicated them to others. Much of the judicial crafting around life-sustaining treatment decisions has focused on establishing a particular evidentiary standard for determining the particular patient's choice. This approach reflects respect for individual liberty in intimate decisions, as well as deference to America's moral and religious pluralism. In focusing on variation among individuals and in failing to establish a substantive rather than process norm for withdrawing treatment, however, the current legal framework ensures continuing battles over the morality of specific decisions and clashes over significant facts in particular cases. Most states still have discrete threads rather than a full fabric of law that is applicable to end-of-life decision-making. States often have only one or two appellate cases addressing such issues, and the rulings in them are usually confined to the facts of the case before the court or to closely related situations that the court can imagine and address in dicta. And much of existing case law involves persons in a permanent vegetative state, relying on reasoning stemming from the condition's irreversibility and the patient's absence of awareness--so much so, in fact, that some states have what amounts to PVS law, rather than case law on life-sustaining treatment generally. Furthermore, living will and durable power of attorney statutes in many states reflect the compromise of principles that occurs in the legislative process and refer to particular medical conditions, like terminal illness or irreversible coma, and to nutrition and hydration as distinct from other treatment. Legal academics meld general common law principles, constitutional theory, and various state laws into a consensus on legal standards. Practicing attorneys, however, must focus on particular decisions for particular patients in a particular state and in many circumstances can't tell their clients with certainty what the law is. This indeterminacy can be a problem in situations where interpersonal conflict persists and escalates, but it may not be particularly concerning in most cases. When treatment decisions proceed without conflict, law tends to stay in the background. For example, the high standard for clear and convincing evidence established by Cruzan v. Director, Missouri Department of Health does not make it impossible for surrogates to decide to withdraw nutrition and hydration in Missouri, even where evidence of the patient's choice fails to meet the standard. …

Permanent vegetative state: comparing the law and ethics of two tragic cases from Italy and England.

In April 1989, in England, Tony Bland aged 17 was trampled and crushed by a stampede at the Hillsborough football stadium ground – a disaster in which 95 people were killed. His lungs were crushed and punctured and the supply of oxygen to his brain was temporarily interrupted. Nearly three years later, in January 1992, in Italy, Eluana Englaro aged 21 lost control of her father's car whilst driving at night on an icy road and crashed into a lamp post, fracturing her skull and neck. When these young people were admitted to hospital, both of them were found to have suffered devastating anoxic brain damage and both were later diagnosed as being in a persistent vegetative state. Their illness narratives have several commonalities, but they also diverge in significant ways. In this article we shall be exploring the views of the relatives, the public, and the health professionals, how their voices were heard, and how the values underpinning these differing accounts were interpreted by the courts of law. We shall critically evaluate the ethical and legal justifications for the final decision to allow these unfortunate young people to die from the withdrawal of nutrition and hydration. We shall also consider the influence and interventions of the Church and the State in these two countries and how the law in England and in Italy resolved the moral and legal issues. From this analysis we shall reflect on what would appear to be the most humane and reasonable way forward.

Access and Conscience: Principles of Practical Reconciliation

There are many situations in which conflicts arise between health care professionals who have religious objections to certain medical services and their employers or patients who want them to provide those services. The services that are generally controversial include delivery or support of abortion, sterilization, contraception, assisted reproduction techniques (ART), withdrawal of life support, withdrawal of nutrition and hydration, autopsies, or assisted suicide.

The nuclear ceramide/diacylglycerol balance depends on the physiological state of thyroid cells and changes during UV-C radiation-induced apoptosis

Intranuclear lipid metabolism modifications in relation to cell proliferation and/or apoptosis were demonstrated in hepatocytes. The aim of this study was to establish whether nuclear lipid metabolites influence cell function in different experimental models using a rat thyroid cell line (FRTL-5) treated with UV-C radiation. After UV-C irradiation cells proliferate and undergo apoptosis in the presence of thyrotropin, are quiescent and resistant to radiation-induced apoptosis in its absence and finally are proapoptotic for nutrition withdrawal. In nuclei purified from proliferating cells, irradiation stimulates neutral-sphingomyelinase activity and inhibits sphingomyelin-synthase, phosphatidylcholine-specific phospholipase C and phosphatidylinositol-specific phospholipase C activity with a consequent increase in the ceramide/diacylglycerol ratio. This effect is marked in proapoptotic cell nuclei and low in quiescent cell nuclei. In conclusion, UV-C radiation induces apoptosis, modifying nuclear lipid metabolism in relation to the physiological state of cells.

Farnesoid X Receptor Protects Liver Cells from Apoptosis Induced by Serum Deprivation in Vitro and Fasting in Vivo

The farnesoid X receptor (FXR) is a key metabolic regulator in the liver by maintaining the homeostasis of liver metabolites. Recent findings suggest that FXR may have a much broader function in liver physiology and pathology. In the present work, we identify a novel role of FXR in protecting liver cell from apoptosis induced by nutritional withdrawal including serum deprivation in vitro or starvation in vivo. Two FXR ligands, chenodeoxycholic acid (CDCA) and GW4064, rescued HepG2 cells from serum deprivation-induced apoptosis in a dose-dependent manner. This effect of FXR on apoptotic suppression was compromised when FXR was knocked down by short interfering RNA. Similarly, the effects of both CDCA and GW4064 were abolished after inhibition of the MAPK pathway by a specific inhibitor of MAPK kinase 1/2. Immunoblotting results indicated that FXR activation by CDCA and GW4064 induced ERK1/2 phosphorylation, which was attenuated by serum deprivation. In vivo, FXR(-/-) mice exhibited an exacerbated liver apoptosis and lower levels of phosphorylated-ERK1/2 compared to wild-type mice after starvation. In conclusion, our results suggest a novel role of FXR in modulating liver cell apoptosis.

Initial efficacy and tolerability of early enteral nutrition with immediate or gradual introduction in intubated patients

To compare the initial (D7) calorie intake and tolerability of two early enteral nutrition protocols in which the optimal flow rate was introduced either immediately or gradually. Open, prospective, randomized study. Two medical-surgical intensive care units. One hundred consecutive intubated and mechanically ventilated patients. Early enteral nutrition was started within 24 h following intubation, and the optimal flow rate (25 Kcal/kg day(-1)) was either introduced immediately or reached in increments. Flow rate of the nutritional solution was adapted to the residual gastric volume, measured every 8 h, and the use of prokinetic agents was encouraged. Vomiting, regurgitation, colectasia, and suspected aspiration were defined as serious adverse events requiring withdrawal of enteral nutrition. When introduced immediately at optimal flow rate, early enteral nutrition led to a significant improvement in actual calorie supply (p < 0.0001). Although high residual gastric volume (>300 ml) was more frequent when optimal flow rate was introduced immediately (p=0.04), frequency of serious adverse events necessitating withdrawal of enteral nutrition was similar in the two groups (p=0.64). When residual gastric volume is measured regularly and prokinetic agents are used, enteral nutrition can be started early and be introduced at optimal dose regimen, thereby providing better calorie intake. Serious adverse events required early enteral nutrition withdrawal in only 15 patients, with no difference in frequency between the groups.

Guidelines for Quality Management of Apallic Syndrome / Vegetative State.

Epidemiology in Europe shows constantly increasing figures for the apallic syndrome (AS)/vegetative state (VS) as a consequence of advanced rescue, emergency services, intensive care treatment after acute brain damage and high-standard activating home nursing for completely dependent end-stage cases secondary to progressive neurological disease. Management of patients in irreversible permanent AS/VS has been the subject of sustained scientific and moral-legal debate over the past decade. A task force on guidelines for quality management of AS/VS was set up under the auspices of the Scientific Panel Neurotraumatology of the European Federation of Neurological Societies to address key issues relating to AS/VS prevalence and quality management. Collection and analysis of scientific data on class II (III) evidence from the literature and recommendations based on the best practice as resulting from the task force members' expertise are in accordance with EFNS Guidance regulations. The overall incidence of new AS/VS full stage cases all etiology is 0.5-2/100.000 population per year. About one third are traumatic and two thirds non traumatic cases. Increasing figures for hypoxic brain damage and progressive neurological disease have been noticed. The main conceptual criticism is based on the assessment and diagnosis of all different AS/VS stages based solely on behavioural findings without knowing the exact or uniform pathogenesis or neuropathological findings and the uncertainty of clinical assessment due to varying inclusion criteria. No special diagnostics, no specific medical management can be recommended for class II or III AS treatment and rehabilitation. This is why sine qua non diagnostics of the clinical features and appropriate treatment of AS/VS patients of "AS full, remission, defect and end stages" require further professional training and expertise for doctors and rehabilitation personnel. Management of AS aims at the social reintegration of patients or has to guarantee humanistic active nursing if treatment fails. Outcome depends on the cause and duration of AS/VS as well as patient's age. There is no single AS/VS specific laboratory investigation, no specific regimen or stimulating intervention to be recommended for improving higher cerebral functioning. Quality management requires at least 3 years of advanced training and permanent education to gain approval of qualification for AS/VS treatment and expertise. Sine qua non areas covering AS/VS institutions for early and long-term rehabilitation are required on a population base (prevalence of 2/100.000/year) to quicken functional restoration and to prevent or treat complications. Caring homes are needed for respectful humane nursing including basal sensor-motor stimulating techniques. Passive euthanasia is considered an act of mercy by physicians in terms of withholding treatment; however, ethical and legal issues with regard to withdrawal of nutrition and hydration and end of life discussions raise deep concerns. The aim of the guideline is to provide management guidance (on the best medical evidence class II and III or task force expertise) for neurologists, neurosurgeons, other physicians working with AS/VS patients, neurorehabilitation personnel, patients, next-of-kin, and health authorities.

An Evaluation of Nutrition Support for Terminal Cancer Patients at Teaching Hospitals in Korea

We wanted to analyze the use of nutrition support for terminal cancer patients, the effect of discussing withdrawal of nutrition support and do-not-resuscitate (DNR) consent on the use of intravenous nutrition during the patient's last week of life and at the time of death. The study involved 362 patients with terminal cancer from four teaching hospitals, and they all died between January 1 2003 and December 31 2005. The basic demographic data, the use of intravenous nutrition during the patient's last week of life and at death, discussion of terminal nutrition withdrawal and DNR consent were evaluated. In the week before death, the patients received artificial nutrition such as total parenteral nutrition (31%), intravenous albumin infusion (25%), and feeding tube placements (9%). A discussion concerning withdrawal of nutrition support was limited to 25 (7%) patients. DNR consent was obtained from 294 (81%) patients. None of the patients were directly involved in any of these decisions. The discussion about withdrawal of terminal nutrition and DNR consent with the patient's surrogates did not have any effect on reducing the use of parenteral nutrition. The majority of patients dying of terminal cancer were still given potentially futile nutritional support. Modern clinical guidelines and ethical education about nutritional support at the end of life care is urgently needed in Korean medical practice to provide proper administration of terminal nutrition for end of life care.

Death after withdrawal of nutrition and hydration

Death after withdrawal of nutrition and hydration

The withdrawal of nutrition and hydration in the vegetative state patient: Societal dimension and issues at stake for the medical profession

The withdrawal of assisted nutrition and hydration (ANH) is increasingly supported by scientific societies, by hospitals and by some families, once the condition of vegetative state could be considered permanent. In the first part of this article, the authors present the factors used to support the decision to withdraw ANH: a) the prognostic evaluation about outcome transformed into a clinical diagnosis of permanency; b) basic health care transformed into a medical treatment, subject to refusal by the patient; c) the human life (an undisposable good) transformed into a disposable one, open to decisions made by surrogates; d) the evaluations about quality of life transformed into judgments about the indignity of human life to be lived. In the second part, the authors outline the changes that this attitude can provoke in the integrity and the juridical status of the medical and nursing professions, and its potential impact on the society at large.