Statement on Artificial Nutrition and Hydration Near the End of Life
Approved by the Board of Directors
Artificial nutrition and hydration (ANH) were originally developed to provide short-term support for patients who were acutely ill. When used in patients near the end of life, the available data suggest these measures are seldom effective in preventing suffering or prolonging life. Patients with advanced, life-limiting illness often lose the capacity to eat and drink and/or the interest in food and fluids. Ethical issues may arise when patients, families, or caregivers request ANH even if there is no prospect of recovery from the underlying illness.Statement
The AAHPM endorses the ethically and legally accepted view that artificial nutrition and hydration, whether delivered parenterally or through the gastrointestinal tract via a tube, is a medical intervention. Like other medical interventions, it should be evaluated by weighing its benefits and burdens in light of the patient's clinical circumstances and goals of care. ANH may offer benefits when administered in the setting of acute, reversible illness. Near the end of life, some widely assumed benefits of ANH, such as alleviation of thirst, may be achieved by less invasive measures including good mouth care or providing ice chips. The potential burdens of ANH depend on the route used, and include sepsis (with total parenteral nutrition) and diarrhea (with tube feeding). In addition, agitated or confused patients receiving ANH may suffer the indignity of physical restraints, which are often instituted to prevent them from removing a gastrostomy tube or central intravenous line.
The AAHPM advocates respectful and informed discussions of the effects of ANH near the end of life among physicians, other health care professionals, patients, and families, preferably before the patient is actively dying. Ideally, the patient will make his or her own decision about the use of ANH based on a careful assessment of potential benefits and burdens, consistent with legal and ethical norms that permit patients to accept or forgo any medical interventions. Such choices are best made in concert with family, and should routinely be communicated to the patient's health care proxy. For patients who are unable to make decisions, the evaluation of benefits and burdens should be carried out by the patient's designated surrogate or next of kin, using substituted judgment whenever possible, in accordance with local laws.
The AAHPM recognizes that for some patients and families, ANH is of symbolic importance, beyond any measurable effects on the patient's physical well-being. Such views should be explored, understood, and respected, in keeping with patient and family values, beliefs, and culture. Good communication is necessary to allow caregivers to learn about patient and family fears about "starvation" and other frequently expressed concerns. At the same time, communication is essential to clarify the patient's clinical condition and explain that inability to eat and drink can be a natural part of dying that is generally not associated with suffering. In some situations, particularly if there is uncertainty about whether a patient will benefit from ANH, a time-limited trial may be useful. The caregiving team should explain that, as with other medical therapies, ANH can be withdrawn if it is not achieving its desired purpose.Key Elements
Recognize that ANH is a form of medical therapy which, like other medical interventions, should be evaluated by weighing its benefits and burdens in light of the patient's goals of care and clinical circumstances
Acknowledge that ANH, like other medical interventions, can ethically be withheld or withdrawn, consistent with the patient's wishes and the clinical situation
Establish open communication between patients/families and caregivers, to assure that their concerns are heard and that the natural history of advanced illness is clarified
Respect patient's preferences for treatment, once the prognosis and anticipated trajectory with and without ANH have been explainedKey References
D Casarett, J Kapo, and A Caplan, "Appropriate Use of Artificial Nutrition and Hydration-Fundamental Principles and Recommendations," New England Journal of Medicine 2005; 353: 2607-12.
MP Fuhrmann and VM Herrmann, "Bridging the Continuum: Nutrition Support in Palliative and Hospice Care," Nutrition in Clinical Practice 2006; 21: 134-41.
L Ganzini, ER Goy, LL Miller et al, "Nurses' Experiences with Hospice Patients who Refuse Food and Fluids to Hasten Death," N Engl J Med 2003; 349:359-65.
MR Gillick, "Rethinking the Role of Tube-Feeding in Patients with Advanced Dementia," N Engl J Med 2000; 342:206-10
R McCann, W Hall, A Groth-Juncker, "Comfort Care for Terminally Ill Patients," JAMA 1994; 272: 1263-6.
J Slomka, "What do Apple Pie and Motherhood Have to do with Feeding Tubes and Caring for the Patient?" Arch Int Med 1995; 155: 1258-63.