The complex ethical debate about artificial feeding Essay
The complex ethical debate about artificial feeding
The decision to withdraw or withhold medical procedures associated with end-of-life care is an exceptionally difficult choice for family members, individuals with terminal and/or debilitating conditions, and medical practitioners - The complex ethical debate about artificial feeding Essay introduction. Artificial nutrition and hydration (ANH), or tube feeding, is a particularly controversial intervention that has been hotly debated by ethicists for years. To consider the treatment from an objective stance, it is imperative to remove emotionally-laden language and review the medical evidence for the intervention’s effectiveness (Lipman, 2004). The cultural and historical significance of food and nurturing has clouded the view of many on the more precise definition of ANH (Casarett, Kapo, & Caplan, 2005). ANH is not simply an alternative method of feeding, but a highly invasive medical procedure associated with substantial risks and few empirically-tested benefits (Finucane, Christmas, & Travis, 1999).
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A review of empirical evidence conducted by Finucane, Christmas, and Travis (1999) identifies a small subgroup of patients for which tube feeding seems appropriate. These include, but are not limited to, growth deficiencies in children and cancer of the mouth and throat. Although empirical evidence does not support the use of ANH for patients with dementia, it is a commonly applied intervention to these patients (Finucane et al., 1999). In addition to few documented benefits, the high morbidity rates shortly after placement of a tube are a strong indicator to reconsider this form of treatment (Casarett et al., 2005). No evidence suggests ANH improves survival rates among patients with dementia. Decreased risks of bedsores or aspiration have also not been shown (Finucane et al, 1999). Patients with dementia continue to have trouble with aspiration following the placement of a tube and their functional capacity isn’t markedly improved (Finucane et al., 1999).
With so many negative side effects associated with ANH, why is it still the treatment of choice for so many patients with dementia? This answer is made further complex with social, economical, and religious considerations. Many doctors and ethicists argue that tube feeding is not really feeding at all (Lipman, 2004). Family members should not equate the withdrawal or withholding of a feeding tube with the denial of food or the initiation of starvation. More comprehensive medical information and training is necessary for families to understand the alternative treatments available. Patients and families should be provided support and education to give truly informed consent (Casarett et al., 2005). Economical ties also seem related to the increased use of ANH in nursing homes for patients with dementia. Despite the fact hand-feeding is much more expensive, nursing homes receive financial incentives for patients being tube fed. They can also be reported if patients lose weight who are not receiving ANH (Lipman, 2004). These imbalanced standards and reimbursements weigh heavily against any ethical decision-making that might be involved in this process. Religious constraints can also play an important role in whether or not ANH is the best option for an individual (Casarett et al., 2005). Chaplains and patient advocates should be welcomed into the discussion about ANH, but their opinions should not immediately override the clinical advice from medical experts.
Ethical decision-making prioritizes autonomy, a patient’s right to make his or her own decisions, over the paternalism of doctors or family members. Unfortunately, many medical conditions render a person unable to make their own decisions. Advance directives, or instructions about a person’s preferences regarding ANH, seem the most logical way to avoid uncertain situations and often heated family disagreements. However, as pointed out by Lipman (2004), these documents rarely serve their intended purpose. Even further, is it realistically possible to foresee one’s wishes before the entirety of a situation is experienced? Many people have responded drastically different than they might have imagined when they were actually faced with the adversity of a situation. Doctors caution that advanced directives, even those thoroughly documented, may still be a limiting factor to the careful decision-making that should correspond with the choice of whether or not to initiate ANH.
Discussions surrounding the use of ANH should be conducted on an individualized basis with consideration of numerous complex variables. The medical literature base provides no indication that it is an appropriate treatment for people with dementia (Finucane et al., 1999). Families need to be informed of this finding during the decision-making process. Healthcare policies need reforms to more appropriately assess and reward nursing homes that provide evidenced-based care. There are a number of alternatives to ANH, especially for patients with dementia. Constructing a distraction-free eating area paired with hand-feeding could improve nutritional intake without the potentially deadly complications associated with ANH. If ANH is the option suggested, a short waiting period to thoroughly consider other options may decrease the impulsive and emotional aspects of this decision for families. Further research is needed to examine the less visible aspects of decision-making related to ANH. Alternative methods of feeding should also be allocated more attention in the literature.
Casarett, D., Kapo, J., & Caplan, A. (2005). Appropriate use of artificial nutrition and hydration—fundamental principles and recommendations. NEJM, 353, 2607- 2612.
Finucane, T.E., Christmas C., & Travis, K. (1999). Tube feeding in patients with advanced dementia, a review of the evidence. JAMA, 282, 1365-1370
Lipman, T.O. (2004). Ethics and gastrointestinal artificial feeding. Current Gastroenterology Reports, 6, 314-315.