When discussing life sustaining measures artificial nutrition is not immediately considered as a measure. Nutrition and hydration are viewed as a basic human necessity. Although it is a necessity, during end-of-life care it may not be viewed as such. Artificial nutrition and hydration (ANH) can be provided to a patient that isn’t eating through enteral feeding (via nasogastric intubation) or total parenteral feeding (via central lines). In this case study the mother was no longer tolerating oral feedings, and the daughter wanted a tube feed placed.
The placement and delivery of artificial nutrition and hydration has risks that raise the concern on whether it is beneficial to the patient or a burden and whether providing it would promote quality versus quantity of live. The summary will elaborate the ethical principles affected, laws involved, legal and ethical responsibility, and suggestions on resolution of issue.
This article by Coyle and Todaro-Franecschi (2012), discusses the ethical principle of nonmaleficence vs beneficence, autonomy and justice.
Nonmalfeasance is the obligation of placing the patient first and minimizing harm to the patient, while beneficence is ensuring good measures are taken in benefit of the patient (Westrick, 2014). When trying to uphold the ethical principles of nonmaleficence and beneficence, the nurse may inadvertently disregard the patient’s autonomy. This is why it was essential for the healthcare team to consider all the ethical and legal aspects before agreeing to place the tube, or not doing it all. Advance directives can essentially protect the patient’s autonomy, though it should be explicit on issue of artificial nutrition and hydration.
In this situation there was not an advanced directive to follow, however the daughter and the team were aware of the woman’s wishes of not being a burden.
Artificial nutrition and hydration are seen as medical interventions and can be refused by the patient or the Power of attorney, if that is respectful to the patient’s wishes. To develop a case, Cruzan vs director resulted in the supreme court ruling that a competent person has the constitutionally protected right to refuse lifesaving hydration and nutrition (Westrick, 2014). In the instance the patient is not competent, evidence should be presented on the patient’s condition and an informed decision can be made by the power or attorney of the patient. Based on these laws the care team should make the decision according to what the woman would have wished; due to her advanced dementia and end stage cancer she was unable. Fortunately, the daughter was able to honor her mother’s beliefs as her advocate and was supported by the hospice team.
The health care provider and nurses are accountable to reduce the possibility of harm to the patient, place the patient first in care, and provide detail to allow an informed decision to be made. Nurses should individualize their care by respecting patient’s rights while upholding the ethical principles discussed previously. The patient is not to be harmed and should be placed first in regard to their end-of-life care wishes. Information on how the disease progresses can inform the patient’s family about why artificial nutrition may be implemented or not. The body would normally need nutrition to heal and recover, however this would appear differently in end-of-life care. During end-of-life care, the body would shutdown and require less and less nutrients and the patient would eventually stop eating (Coyle & Todaro-Franceschi, 2012). This is the course the woman’s life has taken, her daughter is encouraged to continue to offer her oral feeding but educated and supported by the team if she does refuse to eat. Withdrawing of nutrients and hydration can be viewed as abandonment or neglect. The nurse has a legal and ethical responsibility to document and discuss with health care professionals the changes in diet.
There are instances in which the progression of the illness prevents the adequate nutrition and hydration a patient would normally need; it is up to the healthcare professionals to inform the patient and their family about the progression and how the nutritional interventions would affect it. Providing thorough information on the patient’s illness during end-of-life care can allow families or the patient to make informed decisions. According to Artificial Nutrition and Hydration (2012), It was crucial for the healthcare team to have this discussion with the patient’s daughter so that she felt comfortable with the decision and did not feel like her mother was being starved. The decisions about ANH at the end-of-life should be made in the same way as any other medical decisions at the end of life, on a case-by-case basis.
As stated in Artificial Nutrition and Hydration (2012), the vast majority of evidence about dying patients shows that burden and risks of ANH at the end-of-life far outweigh the benefits. in this case the decision was made for the benefit of the patient. Ultimately, patients with decision-making capacity can decide on whether they would like ANH in their end-of-life care (ANA Center for Ethics and Human Rights, 2017). Nurses are required to respect and uphold that decision but also be informative to the patient and their families, should the families be part of their decision-making. It is important that the patient is supported and rights are respected.