ETHICAL
ISSUES IN NUTRITION SUPPORT
Artificial nutrition
support is fraught with ethical and legal difficulties and all prescribers of
IVN should be familiar with these. In general, providing adequate and
appropriate fluid and nutrients is a basic duty to sick patients and while a
patient can swallow and expresses a desire or willingness to drink or eat,
fluid and nutrients should be given unless there is a medical contraindication.
If the patient cannot safely consume or absorb adequate amounts orally, administration
of nutrients and/or fluid via a tube or vein must be considered. Legally,
however, this becomes a ‘medical treatment’ and hence can be withheld or
withdrawn if providing or continuing such support is not in the patient’s best
interests.
If, for example, an
illness is regarded as being in the terminal phase and the plan is to provide
only compassionate and palliative care, ethical considerations indicate that a
tube/vein supply of nutrients or fluid need only be given to relieve symptoms
and should not necessarily be used to prolong survival. In cases where benefits
are in doubt, a planned time limited trial of artificial feeding may be useful.
Whenever nutrition support
is used, patients should give their consent and a competent patient’s refusal
is binding. If a patient lacks the competence to make a decision, the patient’s
doctor should seek to ascertain whether the patient expressed previous views about
the type of treatment that he or she would wish to receive if the present state
of incompetence occurred. If no such views can be identified, any decisions on
tube or vein provision of food and/or fluids should involve consultation with
the family and all members of the health care team.
However, under current
English law, relatives or a nominated proxy cannot make a decision on behalf of
an adult patient and so cannot override the clinician’s decision. Special
considerations apply in relation to children and application to the court
should be made regarding the legality of withdrawing artificial hydration and
nutrition from a patient in a persistent vegetative state.
Under specified
circumstances, it can be legal to enforce nutritional treatment for an
unwilling patient with a mental disorder. This includes anorexia nervosa, in
which it is considered that severe malnourishment per se can render patients incompetent of making rational decisions regarding
their care.
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