Artificial Hydration and Nutrition

What is artificial nutrition and hydration?

Artificial nutrition and hydration is a form of life-sustaining treatment. It is a chemically balanced mix of nutrients and fluids, provided by placing a tube directly into the stomach, the intestine or a vein. It is very common for doctors to provide fluids and food to people who are very sick or recovering from surgery. This is called “artificial nutrition and hydration” .Artificial nutrition and hydration is given to a person who for some reason cannot eat or drink enough to sustain life or health. Without nutrition and fluids a person will eventually die. Artificial nutrition and hydration is a medical treatment that allows healthcare providers to bypass whatever may be preventing a person from eating or drinking. It may be used for a variety of conditions.

Short-term artificial nutrition and hydration often is given to patients recovering from surgery, greatly improving the healing process. It may also be given to people with increased nutritional requirements, such as burn victims, or to someone who cannot swallow because of an obstructing tumor. A highly sophisticated form of artificial nutrition and hydration (total parenteral nutrition or TPN) can be given indefinitely. For example, TPN can be given to patients with serious intestinal disorders that impair their ability to digest food, enabling them to live fairly normal lives. However, long-term artificial nutrition and hydration also is commonly given to people with irreversible neurological disorders, such as advanced Alzheimer’s disease or severe stroke, although it cannot reverse the condition or change the course of the disease itself.

Artificial nutrition and hydration may be given in several ways. Usually it is provided through a flexible tube inserted through the nasal passage into the stomach (nasogastric or NG tube), through the wall of the abdomen into the stomach (gastrostomy, G tube or PEG) or into the intestine (jejunostomy). Insertion through the wall of the abdomen requires a minor surgical procedure. TPN requires the surgical insertion of a special catheter or port, usually into a vein below the collar bone. Fluid with limited amounts of nutrients (or fluids alone) can be supplied directly into a vein in the arm through an intravenous (IV) line. Nutrition and hydration may be supplied temporarily, until the person recovers the ability to eat and drink, or indefinitely. If artificial nutrition is likely to be given for a long time or permanently, a surgically implanted tube is generally more comfortable for the patient and has fewer side effects.

Providing artificial nutrition and hydration requires technical skill and has many serious risks. Professional skill and training are necessary to insert the tube, to make decisions about how much and what type of nutrition to give, and to monitor for side effects. Artificial nutrition and hydration do not offer the comforts that come from the taste and texture of food and liquids. Doctors and nurses control when and how much will be given rather than the person artificial nutrition and hydration is given to patients who are at the end of life? 

Medical treatments, it can be helpful or harmful depending on the situation.

When there is no hope of recovery from an illness or an injury, decisions about artificial nutrition and hydration at the end of life can be very difficult, especially for loved ones.

If the person who is ill or injured can not communicate, families can have different opinions and be torn apart.

In order to make an informed decision about artificial nutrition and hydration at the end of  life, it is essential to understand how the body processes food and fluids. The information below explains the medical facts about artificial nutrition and hydration at the end of life so that you can make informed decisions for yourself or a loved one.someone with a serious, life-limiting illness is no longer able to eat or drink it usually means that the body is beginning to stop functioning. Artificial nutrition and hydration will not bring the person back to a healthy state. Most doctors agree that artificial nutrition and hydration can increase suffering in patients who’re dying and no longer have the ability or interest to eat food and drink liquids themselves.

Artificial nutrition and hydration can add more discomfort to a dying person’s physical symptoms such as: bloating, swelling, cramps, diarrhea, and shortness of breath.

It is important to remember that the person’s body is beginning to shut down because of the disease and dying process, not because of the absence of food and liquid. There are ways to ensure a person’s comfort at the end of life by treating dry lips and mouth. Hospice and palliative care professionals are experts in providing comfort treatments.suicide to refuse artificial nutrition and hydration?

A number of side effects may occur, especially with the long-term use of artificial nutrition and hydration. Tubes can damage and erode the lining of the nasal passage, esophagus, stomach, or intestine. If tube placement requires surgery, complications such as infection or bleeding may arise. Intravenous lines can become uncomfortable if the insertion site becomes infected or if fluid leaks into the skin causing inflammation or infection. Intravenous fluids must be given with extra care to frail patients in order to avoid fluid overload and serious breathing difficulties. TPN requires particular skill and care to ensure that dangerous infections do not enter the blood stream.

Many patients receiving artificial nutrition and hydration by NG or G-tube have brain disease and are unable to report that they feel full or unwell, so abdominal bloating, cramps, or diarrhea may occur. Regurgitation is common, and the feed (the nutritional substance inserted through the tube) may be inhaled into the lungs causing pneumonia.

With careful attention by healthcare providers, many side effects can be avoided or managed fairly well. However, confused patients also can become anxious over a tube’s presence and try to pull it out. is often leads to the use of restraints – tying the patient’s arms down – or to sedation, which can have a serious effect on patients’ mental state and their ability to interact or to perform any small activities they might be capable of such as changing position in bed. As with any other medical treatment, stopping treatment is both legally and ethically appropriate if treatment is of no benefit to the patient or it is unwanted. In fact, the law requires that treatment be stopped if the patient does not want it. If it were not possible to stop treatment once started, patients might not receive treatment that might be helpful for fear it could not be stopped later.

In practice, however, caregivers often have a more difficult time stopping a treatment that has been started than simply not starting it. Stopping a treatment makes some caregivers feel as if they are in some way “killing” the patient. It is important for health caregivers, family members, and surrogates to remember that it is the underlying disease that is causing death.  treatment is prolonging the dying process.

Conflicts about stopping artificial nutrition and hydration often arise because the patient’s wishes are not clearly known or the patient has not designated an agent to make decisions for him. Some state laws also may create obstacles to stopping treatment. In situations of uncertainty, the usual fallback position is to continue treatment. Conflicts also may occur because the patient’s healthcare provider believes that it is never appropriate to stop or withhold artificial nutrition and hydration. It is important that individuals talk to their doctors and loved ones about their wishes regarding the use of artificial nutrition and hydration at the end of life so they will be honored.

Some Points To Think About When Making Decisions About The Use Of Artificial Nutrition And Hydration

• What are the patient’s wishes?
• What quality of life is important to the patient?
• What is the goal or purpose for providing artificial nutrition and hydration?
• Will it prolong the patient’s life? Will it bring about a cure or arrest the disease?
• Will it maintain an acceptable quality of life for the patient?
• Will it contribute to the patient’s comfort?
• Does the patient have religious, cultural, or personal values that would affect a decision to continue or stop treatment?
• Are there any benefits that artificial nutrition and hydration offer this patient?
• What burdens will artificial nutrition and hydration create?
• Are there issues such as depression, inability to let go, guilt, unresolved issues from the past or unfinished business, affecting the decision-making process of the patient, the surrogate decision-maker, or the healthcare provider?
• Does the state law affect the decision to stop treatment?

Patients family viewpoints and fears ,Emotions

The decision to withhold artifical fluid  and nutrition is frequently an unexpected one. When made without full knowledge of the basic physiology of dying, it often elicits strong emotional reactions in patients and families. Families often times believe that withholding AHN increases the patient’s suffering. They may be concerned that the patient will experience hunger and thirst and that the patient will “starve to death.” In fact, anorexia and decreased oral intake of calories are natural accompaniments of  terminal illness. Patients near the end of life rarely express hunger.2 Even in the  setting of poor oral intake, patients may live for many months.

Providing food and drink is often of  symbolic importance to patients, loved ones, and caregivers. The act is a sign of love, compassion, loyalty, steadfastness, and concern. Withholding food and drink implies the reverse of these traits. Recognizing and responding to the family’s need to care for the patient when food and drink is withdrawn can be accomplished by encouraging alternative nurturing activities, such as touching, communicating, comforting, and providing physical care needs like bathing and mouth care. These activities may be particularly helpful  in relieving the family’s sense of helplessness. Indeed, providing  emotional nurturing is essential for both patients and families.

The story of Terri Schiavo should be disturbing to  all of us. How can it be that medicine, ethics, law, and family could work so poorly together in meeting the needs of this woman who was left in a persistent vegetative state after having a cardiac arrest?

Ms. Schiavo had been sustained by artificial hydration and nutrition through a feeding tube for 15 years, and her husband, Michael Schiavo, was locked in a very public legal struggle with her parents and siblings about whether such treatment should be continued or stopped. Distortion by interest groups, media hyperbole, and manipulative use of videotape characterized this case and demonstrate what can happen when a patient becomes more a precedent-setting symbol than a unique human being. 

The right of competent patients to refuse unwanted  medical treatment, including artificial hydration  and nutrition, is a settled ethical and legal issue in this country — based on the right to bodily integrity. In the Nancy Cruzan case, the Supreme

Court affirmed that surrogate decision makers have this right when a patient is incapacitated, but it said that states could set their own standards of evidence about patients’ own wishes. Although both the Schiavo and Cruzan cases involved the potential  withdrawal of a feeding tube from a patient in a persistent vegetative state, the family was united in believing that Nancy Cruzan would not want to be kept alive in such a state indefinitely. Their challenge, under Missouri law, was to prove to the court in a clear and convincing manner that this would have been Nancy Cruzan’s own wish. The Schiavo case raises much more challenging questions about how to define family and how to proceed if members of the immediate family are not in agreement

Medical & Legal aspects 

A decrease in food and fluid intake  at the end of life is normal and appears to be part of the natural physiology of dying. The dehydration of the natural dying process is frequently isotonic, with the only attending symptom consistently being the complaint of dry mouth.1 This symptom may be readily palliated through the use of lubricants and ice chips. The symptom is not relieved by parenteral hydration. Nutritional deficiency at the end of life produces a metabolic state of ketosis that reinforces the lack of desire for food intake. Together, isotonic dehydration and ketonemia can be understood as adaptive physiologic responses within the natural dying process. Altered endorphins in the central nervous system have been postulated to be responsible in part for the frequently observed appearance of calm, peacefulness, and serenity. Such observations suggest that, in some patients, a state of mild euphoria occurs.

Some situations in end-of-life care warrant the administration of artificial hydration and nutrition. One is when the gastrointestinal tract can no longer function normally, for example, in patients with both acquired immune deficiency syndrome (AIDS) and AIDS-associated enteropathy and wasting. In these patients weight loss and wasting is caused by protein energy malnutrition and the diarrhea of malabsorption. Death in these cases appears to be determined more by nutritional status than by the presence of opportunistic infection.4 This is in contrast to patients with terminal cancers, cardiopulmonary disease, and neurologic diseases, whose gastrointestinal function is normal. Another potential indication of AHN is the management of acute delirium associated with dehydration.

Legally, artificial nutrition and hydration is considered a medical treatment that may be refused at the end of life. If the patient still has the capacity to make decisions, the patient can tell the physician what he or she wants. However, for patients who are too sick to communicate, certain states demand strong evidence that a patient would choose to refuse treatment before the state will permit treatment to be stopped.

Every state law allows individuals to refuse artificial nutrition and hydration through the use of an advance directive such as a living will or durable power of attorney for health care, which is used to appoint an agent or surrogate to speak for the patient. However, state laws vary as to what must be done to make wishes known. In many states nutrition and hydration is simply considered a medical treatment that may be refused in an advance directive. But in some states individuals are required to state specifically whether or not they would want artificial nutrition and hydration at the end of life. When there is uncertainty or conflict about whether or not a person would want the treatment, treatment usually will be continued.

Because caregivers’ own views may be very different from the patient’s views, it is wise for people to make their wishes about the use of artificial nutrition and hydration known in advance and to be sure that caregivers will honor them. is advance planning is important even if state law does not require it. Some states prohibit caregivers or agents from making decisions to stop the use of artificial nutrition and hydration unless they specifically know the patient’s own wishes. Carefully read the instructions that come with the advance directives or contact Caring Connections for information about the state’s law.

en a person is refusing life-sustaining treatment at the end of life, including artificial nutrition and hydration, it is not considered an act of suicide. A person at the end of life is dying, not by choice, but because of a particular condition or disease. Continuing treatment may delay the moment of death but cannot change the underlying condition.  Because death is not the result of suicide, life insurance policies are not affected when medical treatments are stopped and the patient is allowed to die naturally.

Does the medical community agree that it is ethically permissible to stop artificial nutrition and hydration?

Professional organizations such as the American Academy of Neurology, American Medical Association, American Nurses Association, American oracic Society and Society of Critical Care Medicine have affirmed through policy statements that artificial nutrition and hydration are medical treatments and their use should be evaluated in the same way that any other treatment would be. Other major organizations that have issued similar policy statements or treatment guidelines include e American Dietetic Association and the Alzheimer’s Association. However, some doctors and nurses personally believe that it is never appropriate to with-hold or stop artificial nutrition and hydration. It is therefore important that individuals discuss their wishes with their physician and confirm that their wishes will be honored. Can anything be done if the doctor insists on providing artificial nutrition and hydration?

If individuals have made their wishes known, the doctor must honor those wishes or transfer their care to another doctor who will honor them. To keep this kind of conflict from developing, it is wise for people to talk with their physicians before a medical crisis arises, if possible, so they know their physician will honor their end-of-life choices. Everyone has the right to refuse or discontinue a medical treatment. A person at the end of  life is dying, not by choice, but because of a particular disease. It is not considered suicide to refuse or stop a medical treatment that cannot bring back health. The concept of AHN implies any form     of nutrient intake by an individual beyond assisted oral placement (putting a cup to someone’s mouth or spooning/syringing liquid into the oral  cavity). Specifically, AHN is defined as “nutritional and hydration support of an invasive nature requiring placement of a tube into the alimentary tract (enteral) or parenterally, via intravenous or subcutaneous means (hypodermoclysis).”

Please look at the unfortunate episode of Terri Schiavo life

Terri Schiavo — A Tragedy Compounded

Let us begin with some medical facts. On February 25, 1990, Terri Schiavo had a cardiac arrest, triggered by extreme hypokalemia brought on by an eating disorder. As a result, severe hypoxic–ischemic encephalopathy developed, and during the subsequent months, she exhibited no evidence of higher cortical function. Computed tomographic scans of her brain eventually showed severe atrophy of her cerebral hemispheres, and her electroencephalograms were flat, indicating no functional activity of the cerebral cortex. Her neurologic examinations were indicative of a persistent vegetative state, which includes periods of wakefulness alternating with sleep, some reflexive responses to light and noise, and some basic gag and swallowing responses, but no signs of emotion, willful activity, or cognition. There is no evidence that Ms. Schiavo was suffering, since the usual definition of this term requires  conscious awareness that is impossible in the absence of cortical activity. There have been only a few reported cases in which minimal cognitive and motor functions were restored three months or more after the diagnosis of a persistent vegetative state due to hypoxic–ischemic encephalopathy; in none of these cases was there the sort of objective evidence of severe cortical damage that was present in this case, nor was the period of disability so long.

Having viewed some of the highly edited videotaped material of Terri Schiavo and having seen other patients in a persistent vegetative state, I am not surprised that family members and others unfamiliar with this condition would interpret some of her apparent alertness and movement as meaningful. In 2002, the Florida trial court judge conducted six days of evidentiary hearings on Ms. Schiavo’s condition, including evaluations by four neurologists, one radiologist, and her attending  physician. The two neurologists selected by Michael Schiavo, a court-appointed “neutral” neurologist, and Ms. Schiavo’s attending physician all agreed that her condition met the criteria for a persistent vegetative state. The neurologist and the radiologist chosen by the patient’s parents and siblings, the Schindler family, disagreed and suggested that

Ms. Schiavo’s condition might improve with unproven therapies such as hyperbaric oxygen or vasodilators — but had no objective data to support their assertions. The trial court judge ruled that the diagnosis of a persistent vegetative state met the legal standard of “clear and convincing” evidence, and this decision was reviewed and upheld by the Florida Second District Court of Appeal. Subsequent appeals to the Florida Supreme Court and the U.S. Supreme Court were denied a hearing. So what was known about Terri Schiavo’s wishes and values? Since she unfortunately left no written advance directive, the next step would be to meet with her closest family members and try to understand what she would have wanted under these medical circumstances if she could have spoken for herself, drawing on the principle of “substituted judgment.” Some families unite around this question, especially when there is a shared vision of the patient’s views and values. Other families unravel, their crisis aggravated by genuine differences of opinion about the proper course of action or preexisting fault lines arising from long-standing family dynamics. Here Ms. Schiavo’s story gets more complex. Michael Schiavo was made her legal guardian under Florida law, which designates the spouse as the decision maker above other family members if a patient becomes irreversibly incapacitated and has not designated a health care proxy.

After three years of trying traditional and experimental therapies, Mr. Schiavo accepted the neurologists’ diagnosis of an irreversible persistent vegetative state. He believed that his wife would not want to be kept alive indefinitely in her condition, recalling prior statements that she had made, such as “I don’t want to be kept   alive on a machine.” The Schindler family, however,  did not accept the diagnosis of a persistent vegetative state, believing instead that Ms. Schiavo’s condition could improve with additional rehabilitative  treatment. The relationship between Mr. Schiavo and the Schindler family began breaking down in 1993, around the time that a malpractice lawsuit revolving around the events that led to Ms. Schiavo’s cardiac arrest was settled. In 1994, Mr. Schiavo attempted to refuse treatment for an infection his wife had, and her parents took legal action to require treatment. Thus began wide-ranging, acrimonious legal and public-opinion battles that eventually involved multiple special-interest groups who saw this case as a for their particular issue. Michael Schiavo was criticized for being motivated by financial greed, and his loyalty to his wife was questioned because he now lives with another woman, with whom he has two children. The Schindlers were criticized for not accepting the painful reality of their daughter’s condition and for expressing their own wishes and values rather than hers.

The right of competent patients to refuse unwanted medical treatment, including artificial hydration and nutrition, is a settled ethical and legal issue in this country — based on the right to bodily integrity. In the Nancy Cruzan case, the Supreme Court affirmed that surrogate decision makers have this right when a patient is incapacitated, but it said that states could set their own standards of evidence about patients’ own wishes.

Florida legislature created “Terri’s Law” to override the court decision, and the tube was again reinserted. This law was subsequently ruled an unconstitutional violation of the separation of powers. On March 18, 2005, Ms. Schiavo’s feeding tube was removed for a third time. The U.S. Congress then passed an “emergency measure” that was signed by the President in an effort both to force federal courts to review Ms. Schiavo’s case and to create a legal mandate to have her feeding tube reinserted yet again. The U.S. District Court in Florida denied the emergency request to reinsert the feeding tube, and this decision was upheld on appeal.

Multiple subsequent legal appeals were denied, and Ms. Schiavo died on March 31, 2005, 13 days after the feeding tube was removed. This sad saga reinforces my personal belief that the courts — though their involvement is sometimes necessary — are the last place one wants to be when working through these complex dilemmas. Although I did not examine her, from the data I reviewed, I have no doubt that Terri Schiavo was in a persistent vegetative state and that her cognitive and neurologic functions were unfortunately not going to improve. Her life could have been further prolonged with artificial hydration and nutrition, and there is some solace in knowing that she was not consciously suffering. I also believe that both  her husband and her family, while seeing the situation in radically different ways, were trying to do what was right for her. Her family and the public should be reassured and educated that dying in this way can be a natural, humane process (humans died in this way for thousands of years before the advent of feeding tubes).

In considering such profound decisions, the central issue is not what family members would want for themselves or what they want for their incapacitated loved one, but rather what the patient would want for himself or herself. The New Jersey Supreme Court that decided the case of Karen Ann Quinlan got the question of substituted judgment right: If the patient could wake up for 15 minutes and understand his or her condition fully, and then had to return to it, what would he or she tell you to do? If the data about the patient’s wishes are not clear, then in the absence of public policy or family consensus, we should err on the side of continued treatment even in cases of a persistent vegetative state in which there is no hope of recovery. But if the evidence is clear, as the courts found in the case of Terri Schiavo, then enforcing life-prolonging treatment against what is agreed to be the patient’s will is both unethical and illegal. Let us hope that future courts and legislative bodies put aside all the special interests and distractions and listen carefully to the patient’s voice as expressed through family members and close friends. This voice is what counts the most, and in the Terri Schiavo case, it was largely drowned out by a very loud, self-interested public debate. This article has been modified

The Cathilic Churches teaching in relationship to ethical moral principles and the Ethical and Religious Directives   

Christ’s redemption and saving grace embrace the whole person, especially in his or her illness, suffering, and death.³⁵ The Catholic health care ministry faces the reality of death with the confidence of faith. In the face of death—for many, a time when hope seems lost—the Church witnesses to her belief that God has created each person for eternal life.³⁶

Above all, as a witness to its faith, a Catholic health care institution will be a community of respect, love, and support to patients or residents and their families as they face the reality of death. What is hardest to face is the process of dying itself, especially the dependency, the helplessness, and the pain that so often accompany terminal illness. One of the primary purposes of medicine in caring for the dying is the relief of pain and the suffering caused by it. Effective management of pain in all its forms is critical in the appropriate care of the dying.

The truth that life is a precious gift from God has profound implications for the question of stewardship over human life. We are not the owners of our lives and, hence, do not have absolute power over life. We have a duty to preserve our life and to use it for the glory of God, but the duty to preserve life is not absolute, for we may reject life-prolonging procedures that are insufficiently beneficial or excessively burdensome. Suicide and euthanasia are never morally acceptable options.

The task of medicine is to care even when it cannot cure. Physicians and their patients must evaluate the use of the technology at their disposal. Reflection on the innate dignity of human life in all its dimensions and on the purpose of medical care is indispensable for formulating a true moral judgment about the use of technology to maintain life. The use of life-sustaining technology is judged in light of the Christian meaning of life, suffering, and death. Only in this way are two extremes avoided: on the one hand, an insistence on useless or burdensome technology even when a patient may legitimately wish to forgo it and, on the other hand, the withdrawal of technology with the intention of causing death.³⁷

Some state Catholic conferences, individual bishops, and the USCCB Committee on Pro-Life Activities (formerly an NCCB committee) have addressed the moral issues concerning medically assisted hydration and nutrition. The bishops are guided by the Church’s teaching forbidding euthanasia, which is “an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated.”³⁸ These statements agree that hydration and nutrition are not morally obligatory either when they bring no comfort to a person who is imminently dying or when they cannot be assimilated by a person’s body. The USCCB Committee on Pro-Life Activities’ report, in addition, points out the necessary distinctions between questions already resolved by the magisterium and those requiring further reflection, as, for example, the morality of withdrawing medically assisted hydration and nutrition from a person who is in the condition that is recognized by physicians as the “persistent vegetative state” (PVS).³⁹

Directives

1. Catholic health care institutions offering care to persons in danger of death from illness, accident, advanced age, or similar condition should provide them with appropriate opportunities to prepare for death. Persons in danger of death should be provided with whatever information is necessary to help them understand their condition and have the opportunity to discuss their condition with their family members and care providers. They should also be offered the appropriate medical information that would make it possible to address the morally legitimate choices available to them. They should be provided the spiritual support as well as the opportunity to receive the sacraments in order to prepare well for death.
2. A person has a moral obligation to use ordinary or proportionate means of preserving his or her life. Proportionate means are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community.⁴⁰
3. A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patient’s judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.⁴¹
4. There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient.
5. The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life-sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching.
6. Euthanasia is an action or omission that of itself or by intention causes death in order to alleviate suffering. Catholic health care institutions may never condone or participate in euthanasia or assisted suicide in any way. Dying patients who request euthanasia should receive loving care, psychological and spiritual support, and appropriate remedies for pain and other symptoms so that they can live with dignity until the time of natural death.⁴²
7. Patients should be kept as free of pain as possible so that they may die comfortably and with dignity, and in the place where they wish to die. Since a person has the right to prepare for his or her death while fully conscious, he or she should not be deprived of consciousness without a compelling reason. Medicines capable of alleviating or suppressing pain may be given to a dying person, even if this therapy may indirectly shorten the person’s life so long as the intent is not to hasten death. Patients experiencing suffering that cannot be alleviated should be helped to appreciate the Christian understanding of redemptive suffering.
8. The determination of death should be made by the physician or competent medical authority in accordance with responsible and commonly accepted scientific criteria.
9. Catholic health care institutions should encourage and provide the means whereby those who wish to do so may arrange for the donation of their organs and bodily tissue, for ethically legitimate purposes, so that they may be used for donation and research after death.
10. Such organs should not be removed until it has been medically determined that the patient has died. In order to prevent any conflict of interest, the physician who determines death should not be a member of the transplant team.
11. use of tissue or organs from an infant may be permitted after death has been determined and with the informed consent of the parents or guardians.
12. Catholic health care institutions should not make use of human tissue obtained by direct abortions even for research and therapeutic purposes.⁴³

Furthe it can be noted that

Ethical decision making is the generic term for the process of making a decision within an ethical context in a specific setting: business, education, or medicine. Ethics may be defined in a variety of ways, but simply put, it is the principles upon which one has a foundation of right conduct and how to live as a good person. Morality is the practical application of those ethical principles. clearly, JCAHO has outlined that hospitals should have defined policies and procedures allowing patients to create and modify advance directives. The 2000 JCAHO Standards regarding patients’ rights to formulate an advance directive, to have a mechanism in place to deal with ethical issues, and for their rights to accept or refuse care, is found in This form has since been replaced with an entire section titled “Ethics, Rights and Responsibilities,” which appears in the 2004 revision of the “Comprehensive

Accreditation Manual for Hospitals: The Official Handbook” published by the Joint

Commission on Accreditation of Healthcare Organizations. This section outlines the standards that healthcare organizations must follow in order to obtain or maintain accreditation. It contains a revised numbering system extending from “Organizational Ethics,” RI.1.10 to RI.1.40, where ethical behavior and review processes are addressed.

“Individual Rights,” RI.2.10 to RI.2.20, follows, which includes the topics of the hospital respecting the rights of patients, informed consent, refusal of care, and requiring hospitals to have policies that define situations in which patients work. The final portion, numbered RI.3.10 on “Individual Responsibilities,” requires hospitals to provide information to patients about their personal responsibilities while receiving care, treatment and services. The expanded section makes it easier for healthcare organizations to test their compliance and for reviewers to rate them.  Because the information in presents so many useful concepts in a single page, we decided to keep it as part of this course although it is no longer contained in the current JCAHO manual [30].

The JCAHO requires healthcare organizations to follow their state laws. If a person is from out of state, they may have an advance directive that does not comply with the state laws where the patient is hospitalized. Quoin Frazer JD, of Garner, Carton & Douglas in Chicago, advises hospitals treating patients who do bring advance directives from outof- state to ask them to complete an advance The Veterans Administration recommends that, unless the person is unresponsive, confused, or otherwise unable to make a rational decision due to a clinical condition, it should be assumed that the person has the decisional capacity to consent to or refuse assessment or treatment. (http://www.guidelines.gov/summary/ summary.aspx?doc_id=5632&nbr=003794.

Last accessed February 1, 2006.)

Level of Evidence: Consensus Statement

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EVIDENCE-BASED _

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RECOMMENDATION

#705 Ethical Decision Making

By whom and how was it decided what constituted those ethical principles of right conduct in any given situation? The foundation fro m which ethical principles originated began from debates and discussions from ancient times. These ethical principles then became the theoretical framework upon which we base our actions as individuals and societies. Most prominently, it was the Bible and Greek philosophers, such as Plato and Aristotle, that created most of the familiar ethics and morals we use today.

How do we then go from theoretical ethics to the day-to-day practical application of those principles in today’s high tech society? It really boils down to a deductive reasoning process. The process starts with the broad and general, often abstract global ideas of how people should act rightly within society. Then, the process narrows in focus to a smaller group or individual situation in which the ethical principles act as a guide for daily living. Further, when a situation presents itself that contradicts “the norm,” it may cause a dilemma. When these dilemmas are of an ethical nature, we often say the situations are controversial, called into question, or infringe upon a group or individual’s rights based upon accepted ethical theories and moral practices.

How does one move from the general concepts, based on religious or philosophical theoretical frameworks discussed in this course, and practically apply them to patient/society healthcare decision making? Generally, an ethical conflict presents itself when a person’s or group’s ethical values or principles are challenged or conflict with one another. It is imperative to identify what principles are in conflict so that an appropriate resolution can be made. A dilemma occurs when one is faced with what is perceived (or is in reality) to be no alternative, only one alternative, or an either/or choice situation. This dilemma scenario leaves the individual with limited, often painful choices.

“Have the surgery or die,” may be the only two alternatives given to a patient. This can leave the patient immobilized, powerless, feeling subservient  and victimized, with no sense of control. Providing options may assist the individual by giving him a sense of freedom and participation in the decision-making process. The nurse is often the person who can act as an advocate and resource to the patient. Whether an ethical dilemma exists or not should be the first question the nurse asks. It may simply be conflict arising out of poor communication, usually resolved when clarification and information gathering occurs. Once an ethical dilemma or conflict is determined to exist, one can begin a step by step process to open the discourse and begin the decision-making process.

There are a myriad of ethical issues facing patients, families of patients and healthcare professionals today. Some of these issues are organ transplantation, fetal surgeries, infants with severe anomalies and lifesaving surgery, neglect, trauma, inability to reach and/or the rationing of healthcare. Still other issues involve competency of healthcare workers, nurse-physician relationships, treating non-compliant patients, and many more situations applying to individuals and to those facing our nation on a societal level. One of the most common ethical issues facing healthcare professionals in patient care settings is the withholding or withdrawing of treatment.

Most healthcare institutions are required to have policies and procedures in which the rights of the patient/ family and the duties of the healthcare professionals are outlined. It is only when there is a conflict between the parties involving value or moral principle differences that a dilemma may arise. Often, the real problem may be one of three nonethical related issues: poor communication between the involved parties, or an administrative or legal ambiguity. The first step that should be taken is to gather information about the patient’s diagnosis, prognosis and treatment options, and the best medical judgments regarding life expectancy and quality of life with or without treatment. This must include discussion of the risks and the side effects of such treatment. Of equal importance, the patient (if legally competent) needs to be fully informed and have his statement of wishes

 Conclusion 

The decision to forego AHN does  not come easy to clinicians, patients, and families. The intervention causes no distressful physiologic phenomena nor does it increase suffering.

What’s more, no ethical or legal barriers exist to preclude withholding or withdrawing AHN.

The burdens and complications induced by AHN frequently outweigh the benefits of the intervention. Individual decisions must take into account all factors. A therapeutic trial of AHN to achieve clearly defined goals may be useful in cases of conflict. This “final effort” can lessen the guilt family members might experience during the bereavement process, as it allows them to feel every effort was made to comfort their loved one. Supporting the patient and family in their decision making to forego

AHN includes educating them about the normal dying process and allaying their fear that a lack of food and fluid will increase suffering. Nurturing is not equivalent to nutrition.

It can further noted that  

Watching someone we love die makes us feel powerless. But even when “nothing can be done” to cure the disease, there is a great deal that can be done to make the person’s last days comfortable and even productive and meaningful. As we broaden our understanding of providing care to dying people, we are improving the management of pain and other symptoms. rough the exceptional work of the hospice movement, we have come to recognize that care of people who are dying requires medical expertise and a collaborative approach among all of a patient’s caregivers. its collaboration allows caregivers to consider the total needs of the patient. Because of the powerful symbolism that associates the provision of food and water with caring, we as caregivers (family and professional) may be uncomfortable about withholding artificial nutrition and hydration. It is important to remember that, when we are entrusted with decisions about the care of someone who is dying, the patient’s comfort and wishes must guide our decision making, not our own.