Artificial Nutrition and Hydration

by Mark Hughes, MD, MA

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    00:01 Another issue that we might encounter in palliative care ethics is artificial nutrition and hydration.

    00:08 So this is generally considered when patients either have an advanced life limiting illness, they've lost the ability to eat or drink, or perhaps they've lost interest in food and fluids.

    00:21 It may also happen when they have a critical illness and they are on you know, life sustaining treatments and can't take nutrition themselves.

    00:32 So artificial nutrition hydration is a means of giving them that nutrition and fluids, it can be done parenterally.

    00:40 So intravenous or IV, it could be done enterally through a tube that goes into the gastrointestinal tract, either an nasal gastric tube, a gastric tube, or jejunal tube, and delivers the nutrition by that means.

    00:54 So artificial nutrition hydration, you know, in an acute reversible illness can certainly offer benefits, you know, provide the nutrition to the person while they're recovering from this reversible illness.

    01:06 It may also be used for people that have more chronic disease.

    01:11 For instance, short bowel syndrome, if they've had primary prior surgery, they've got inflammatory bowel disease, other conditions where their GI tract can't be used.

    01:21 The artificial nutrition hydration is a means for them to get the nutrition they need for their body to be sustained.

    01:27 So there are certainly roles for artificial nutrition and hydration.

    01:33 When we're thinking about its use, for patients near the end-of-life, may really have uncertain benefits.

    01:40 And you know, for persons that are really dying or near, you know, clearly near the end-of-life, there may be significant burdens associated with artificial nutrition hydration.

    01:51 And that's why this becomes an ethics issue for palliative care of is it appropriate to use artificial nutrition hydration in those situations.

    02:01 So, the general expectation when a person is ill, you know, a sign that we are trying to take care of them is that we will provide them food fluids, routine nursing care, that's just a fundamental matter of comfort and dignity, that we should expect to give to all patients.

    02:19 Giving them nourishment also holds symbolic significance that we're connected to this person, there's a there's a human solidarity with them.

    02:28 We gather around dinner tables, you know, we have holidays that are focused on you know, meals and, and being with others.

    02:35 So there's lots of significance to nutrition and providing nutrition to another person.

    02:40 But when we're talking about artificial nutrition hydration, it's been felt that this is a life sustaining treatment that should undergo the same sort of calculation that we would for a ventilator dialysis, when it may be more burdensome than beneficial.

    02:57 It's not something that automatically has to be offered to a person, it should undergo that same you know, discussion, debate, you know, consideration as to whether or not it's appropriate for a particular patient.

    03:12 This really comes to light in conditions such as persistent vegetative state.

    03:16 So there have been some famous cases in the United States where artificial nutrition hydration for patients that were in PVS, persistent vegetative state, needed to be considered because the family thought that it might be a life sustaining treatment that they could decide to withdraw and not automatically have to give to the person.

    03:41 So one of the famous court cases in the United States was the Cruzan case in 1990.

    03:48 This was a woman that was in persistent vegetative state after a car accident.

    03:52 And the court ruling at that time said, artificial feeding cannot readily be distinguished from other forms of medical treatment.

    03:59 The techniques used to pass food and water into the patient's alimentary tract, all involve some degree of intrusion and restraint and therefore, it should be a decision, a medical decision as to whether or not to pursue it, the family can have informed refusal that this is not something that the person would have wanted.

    04:21 So there are certain concerns with use of artificial nutrition hydration and some of the burdens that have to be considered.

    04:28 So when we're thinking about parenteral, artificial nutrition and hydration, so when it's being delivered intravenously, you're going to need an intravenous catheter.

    04:37 And that means that there's a possibility of introducing infection.

    04:40 So the person could develop sepsis, there's concerns about either developing venous thrombosis or thrombophlebitis from the catheter insertion.

    04:50 There's concerns about the amount of fluid that might need to be given intravenously and leading to fluid overload.

    04:57 For enteral nutrition, there's also concerns about certain burdens, there's the possibility of aspiration, so an aspiration pneumonia could develop.

    05:07 Sometimes when a person is not able to swallow themselves, there's concerns about aspiration, but putting a tube, a gastro tube, also has that same as associated concerns for aspiration.

    05:20 Because this is being delivered into the GI tract, and it's a liquid nutrition, there's concerns about developing diarrhea, you might develop pressure sores that could be skin breakdown.

    05:32 So other concerns, other burdens with the use of enteral nutrition.

    05:36 And it likewise, might have concerns about fluid overload, especially if a person's medical condition is such they really can't handle that additional fluid.

    05:48 So it really requires especially for patients at the end-of-life, the discussion and informed consent process to decide whether or not to pursue artificial nutrition hydration.

    05:59 And there may be three rationales not to provide artificial nutrition hydration.

    06:04 First, it's unlikely to improve nutrition and fluid levels.

    06:08 And certainly, when people are at the end-of-life, you know, in the dying process, that is clear that it's not really going to improve their nutrition or, or make a difference in how their bodies sort of shutting down in the dying process.

    06:24 It may be that you know, artificial nutrition hydration does improve nutrition and fluid levels for certain patients, but the patients themselves will not actually benefit.

    06:33 You know, a patient that is anencephalic.

    06:36 So, infant born that that has no functioning brain, a person that's gone into a permanent coma or persistent vegetative state, like some of these famous cases in the United States, the family may say, well, really, that's not a benefit to them, it might be sustaining the body's living, but it's not actually benefit to the person, and therefore may not be something we want to offer.

    06:59 And then lastly, you know, there might be the possibility that artificial nutrition hydration, improves nutrition and fluid levels.

    07:06 But the calculation is that it's too burdensome, that the burdens outweigh the benefits for a person with end stage dementia, if they, you know, might be pulling at a gastric tube, you know, they might need to be restrained, that's additional burden to them.

    07:25 And then all the other burdens that we talked about, weighed against the benefits.

    07:30 There may be family members who choose not to pursue the artificial nutrition hydration.

    About the Lecture

    The lecture Artificial Nutrition and Hydration by Mark Hughes, MD, MA is from the course Ethical Considerations in Palliative Care.

    Included Quiz Questions

    1. Nasogastric
    2. Gastric
    3. Jejunal
    4. Intravenous
    5. Rectal
    1. Sepsis
    2. Aspiration
    3. Diarrhea
    4. Pressure sores
    5. Fluid overload
    1. Aspiration
    2. Sepsis
    3. Thrombophlebitis
    4. Venous thrombosis
    5. Fluid overload
    1. Unlikely to improve the nutrition or fluid levels of the patient
    2. The patient will not benefit from the intervention.
    3. The burdens of treatment outweigh the benefits.
    4. The patient's family will not benefit from the treatment.
    5. The intervention is time-intensive.

    Author of lecture Artificial Nutrition and Hydration

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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