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.