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Chairman and Editor: Professor J Lennard-Jones.
There is increasing realisation that malnutrition is a complication of many illnesses, as well as being a consequence of inadequate food intake for social, psychological or other reasons. The caring professions have an ethical duty to recognise and treat malnutrition, usually by attention to drinking and eating, as part of optimal care for patients. Only in certain circumstances when such care prolongs the period of dying or maintains an unacceptable quality of life should positive nutritional treatment to provide a normal intake be re-considered and possibly withdrawn. Even so, patients who can swallow should still be encouraged and assisted to drink and eat as much as they wish if there is no contraindication.
Tube feeding permits maintenance of tissue metabolism and structure even though a patient cannot eat anything, or enough to sustain or regain health, or cannot absorb adequate nutrients. Ethical problems arise because these techniques are only part of the care of the whole person. They are active medical treatments for which permission is required from
competent patients. Adequate consultation is needed when such treatments are started, stopped, or continued in the long-term for incompetent patients.
It is likely that patients and their relatives will increasingly expect good nutritional care as part of medical treatment to prolong life and improve its quality. It is also likely that the public will increasingly accept that hydration or nutrition via a tube should not be used when it impairs the dignity and comfort of those who are dying, or prolongs the life of anyone
who has permanently lost, or will never achieve, any of the attributes of a person due to severe irreversible brain injury or disorder.
Findings and Recommendations
- Care of the sick entails the basic duty of providing adequate and appropriate fluid and nutrients.
- As long as a patient can swallow, and expresses a desire or willingness to drink or eat, fluid and nutrients should be given, provided that there is no medical contraindication.
- A treatment plan for any patient with an existing or probable future fluid or nutrient deficit should include a policy regarding fluid and/or nutrient provision. Health carers concerned with nutrition should work together as a team, each discipline involved can contribute a different skill
- If the plan is to maintain an adequate intake, the ethical duty is to provide, with the-patient's consent, appropriate measures to achieve this aim. A patient who is unable to consume or absorb adequate fluid or nutrients, despite all dietary and other measures to increase oral intake, should be considered for administration of supplementary or total fluid replacement, with or without nutrients, via a tube.
- If the plan is to provide compassionate care for relief of symptoms, because the illness is regarded as in a terminal phase, ethical considerations indicate that oral fluid and food should be given according to the patient's wishes and/or ability to swallow; fluid given via a tube should be given only if it is needed to relieve symptoms.
- Fluid given via a tube is regarded in law as a medical treatment. Some professionals regard tube feeding, especially of infants, as part of basic medical care.
- Consent of a competent adult patient must be sought for any treatment, especially an invasive measure such as hydration or feeding via a tube, and refusal is binding. Competence depends on adequate thought processes to make the decision needed. It is ethically and legally wrong for a carer to under estimate the capacity of a patient in order to achieve what the carer believes to be in the patient's best interest.
- For an incompetent adult patient, the doctor undertaking care is responsible in law for any decision to withhold, give or withdraw a medical treatment. The doctor's duty is to act in a way which he or she believes to be in the patient's best interest. Before making a decision about starting, stopping or continuing treatment, the doctor should seek to ascertain the patient's previously expressed views about the type of treatment he or she would wish to receive should the present state of incompetence occur. Full consultation with the family and the health care team is needed from the outset, but at present in England relatives or a nominated proxy cannot make a decision on behalf of an adult patient.
- Special considerations apply regarding the responsibility of parents to make a decision on behalf of their child, and consent for treatment by adolescents.
- Application to the court should be made regarding the legality of withdrawing artificial hydration and nutrition from a patient in a vegetative state.
- Under carefully specified circumstances, it can be legal to enforce nutritional treatment for an unwilling patient with mental disorder, including anorexia nervosa.
- When tube feeding is continued outside hospital there is an ethical duty to ensure that the patient, daily carers and the community health team are adequately instructed in the technique and possible complications.