Artificial nutrition and hydration in end-of-life Geriatric Care : medical treatment or basic care?

Abstract

The topic of withdrawing life-prolonging treatment especially in patients in a persistent vegetative state has been discussed quite extensively in the literature and in the circles of bioethicists, theologians and philosophers since the first such case that of Karen Anne Quinlan ended up in the New Jersey courts between 1975 and 1976. The life-support in question this time was the mechanical ventilator, which the New Jersey Supreme Court allowed to be stopped in 1976 but Quinlan lived for another 9 years on artificial nutrition and hydration as she was breathing spontaneously. What started off as the legality of withdrawing or not of a mechanical ventilator, within years moved on to the legality of withdrawing or not artificial nutrition and hydration as in the case of Tony Bland, who was crushed to near death in the Hillsborough tragedy 25 years ago. In my practice of hospital geriatric medicine I rarely meet with patients in such a state, but it is fairly common to encounter patients in the terminal stage of an illness where the faculties of eating or drinking through the oral route become compromised for some reason or other. It is here that the dilemma often arises whether ANH should be started or not. The issue though is not of whether ANH should be withheld or not, but rather whether it should be considered as a basic care, as if though feeding the patient through the oral route, or a medical treatment. It is here that disagreements arise between the different health care providers since if considered a basic care one considers such treatment to be continued up to the end. The scope of this thesis is to look into what is available in the literature to support the notion of ANH as a treatment or not. The general feeling, that of the non-medical individual but also that of a good number of healthcare providers is that ANH is a basic care since it is involved with providing food and drink. During my years of training when being on call after hours, I did have calls from the nurses to see a patient suffering from dementia whose nutritional intake was inadequate. The request in the majority of cases would be for a naso-gastric tube to be inserted because of concern by the family that the patient will become malnourished or dehydrated. Although no harm is ever intended by the healthcare professional, I think that such decisions should not be taken in such circumstance that is without discussion with the multi-disciplinary team, after hours and by junior doctors. The insertion of a naso-gastric tube carries with it the risks and complications as any other treatment and the administration of special food preparations through such a medical device also carries with the risks and possible adverse effects. I will be starting my thesis by giving a look at the clinical aspect of ANH in the first chapter. I will be giving a short historical background to the development of ANH which goes back thousands of years, together with a look at some of the guidelines used to help healthcare professionals with their decisions in regard to the commencement of ANH. Chapter one will also give a brief overview of the different forms of ANH since this does not only involve tube feeding but even the simple intravenous infusion which is widely used in hospital practice is a form of ANH. In chapter two I will be dealing with three cases involving elderly patients that have been in the headlines of news in their respective countries. The cases occurred in England, United States of America and Canada. The first two cases involved elderly women in their terminal stages of their life because of various pathologies. The American case ended up in the New Jersey Supreme Court that had ordered the withdrawal of Quinlan’s mechanical ventilator a few years before. This time the court had decided in favour of withdrawing ANH because of the patient’s previous wishes and her poor quality of life, with which her nephew could not associate her aunt with. The English case did not end up in court but had caused a stir in the British papers after the general practitioner had withdrawn syringe feeding of a frail elderly patient with dementia. The reasoning behind it was that the feeding was inhumane and too laborious for the patient and with agreement of the family decided in favour of stopping the feeding. No tube feeding was involved in this case. The third case revolves more around the religious obligation of not terminating life through the withdrawal of life-sustaining treatment. Hasan Rasouli’s wife who is his surrogate decision maker, who also happens to be a physician qualified from the country of origin, Iran, was refusing removal of the mechanical ventilator and stopping other life-prolonging treatment since this would not be in compliance with their religion and should her husband been able to decide would have refused. The last case is pending a decision from the Consent and Capacity Board after the Canadian Supreme Court decided that the life-sustaining treatment should be kept in place. These three cases have not led to any change in legislation but together with the emerging evidence from the literature about the burdens of ANH in terminally ill patients, which I think does not apply for Rasouli, the practice about the institution of ANH by healthcare professionals would be done with more discussion between the different stakeholders involved. The third chapter then deals with the ethical issues surrounding ANH in end-of-life care. The medical literature undoubtedly deals with ANH as a medical treatment, with which definition a lot of physicians agree in view of the possible adverse effects and complications that can arise from the procedure. On the other hand the debate about the use of ANH in PVS patients became even more alive after the late Pope John Paul II’s allocution ten years ago during an international conference for doctors. He had stated that food and drink even when given through artificial means, that is naso-gastric or percutaneous gastrostomy tubes, remains a natural way of providing food and drink. The statement which practically is saying that ANH is a medical basic care rather than a treatment had caused a furore not only outside the Church but also within the church with some criticising the Pope openly like Kevin O’Rourke, a Dominican theologian. The use of ANH in end-of-life care is questioned even further after when looking at the data coming out from the use of ANH in advanced dementia. Such data indicates that the use of ANH in such patients carries with it a worse prognosis and the literature goes even further since it indicates that patients with such an advanced dementia do not experience hunger or thirst and therefore starting ANH is not appropriate. The problem is that such studies are limited because of the ethical issues involved like consent since these patients are at this point unable to consent for medical research to be carried out. In the last chapter I will be dealing with the situation in Malta regarding guidance for healthcare professionals. There have been no cases dealing with the status of ANH in end-of-life situations which have ended up in court or have been brought to the attention of the general public. The local healthcare professionals, mainly doctors, follow the guidelines used by the United Kingdom and no local guidelines have been developed by the local medical community. Is it time to develop such guidelines for the local doctors or are the foreign ones available enough for local use? Undoubtedly our health care service is amongst the best in the European Union. This can be seen from documents recently published by the European Commission which for example show Malta having the highest healthy life years at birth in the EU and is among the lower fourth of countries with self-reported unmet need for medical examination. Therefore considering the good practice by the local medical community in general, is there a need to re-invent the wheel and develop guidelines specific for the local practice? Such guidelines might be required because of laws which might be specific for Malta. Speaking about legislation, the next step should be to enact laws to regulate advance healthcare directives and durable power of attorneys which might affect decisions by healthcare professionals in end-of-life care. I will be going into further detail about this topic in my concluding chapter which will also include recommendations. I would like to conclude this introduction with this quote from an article by a lawyer and a doctor in their article The milk and the honey: ethics of artificial nutrition and hydration of the elderly on the other side of Europe: “The distinction – and the confusion – between the nature of ANH as medical treatment or as the simplest form of care that must be provided to a human being in suffering, is controversial as the two notions, once used in a parallel and complementary sense have now become the two opposite ends of the spectrum”.