SB physiology (ICSM BSc)

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  • It may be our duty to prolong life but not to prolong dying.
  • A legal judgement has been quoted (Ashby and Stofell, 1995) that expressed clearly this concept of the role and limitation of medicine. "Medical science and technology has advanced for a fundamental purpose: the purpose of benefiting the life and health of those who turn to medicine to be healed. It surely was never intended that it be used to prolong biological life in patients bereft of the prospect of returning to an even limited exercise of human life". These quotations I use to illustrate that it must be remembered that medicine has its limitations. No more important is the limitation around the issue of death.
  • Food is essential to sustain life. It is as important as oxygen and water. There are many debatable issues within nutrition, including some of the key ethical issues. The most important aspect about nutrition is, as it is essential for the maintenance of life, a duty to provide nutrition when caring for a patient.
  • Nutrition is a common thread between all medical and surgical specialities, community medicine, nursing, paediatrics and psychiatry. One dichotomy that is evident between hospitals and the community is that in the community obesity is a major problem - to the extent that that part of government health policy is to decrease the 'weight' of the population as it continues to rise to the same extent as in the USA. In hospitals, malnutrition is a major problem, which is largely unrecognised - probably as we are more aware of obesity being a problem, we are not tuned into recognising malnutrition. In addition, it is quite amazing that while the general topic of nutrition is of considerable interest to the general public and media, it seems to be of little interest to a large body of the medical profession. I think that the reason for this is that nutritional science is perceived as a rather inexact science and thus does not have the same profile as molecular science, for instance. Fashion has also a part to play.
  • But is the duty absolute, one to be discharged without exception, without regard to consequence or circumstance? What if the body cannot tolerate nutrition, however administered. It would then cease to be in the patients best interest to infuse nutrition (unless the rejection were temporary with a good prognosis beyond) The leading criterion is the patients best interest The duty to feed is presumptive not absolute. It is rebuttable in certain circumstances: Patients refusal of consent - English law forbids the forcible feeding of hunger strikers. To administer medical treatment to an adult of sound mind without consent constitutes a civil wrong and the crime of battery or assault. A patient in a persistent vegetative state has sufficient function of the brainstem to sustain a heartbeat and respiration so long a sufficient nutrients are supplied…
  • Unwell since return from Portugal x 2 months. Lost 1,5 stone in 2/12. Weight loss of 1,5 stone in 2 months Symptons began following holiday in Portugal, after eating a plate of ‘dodgy’ prawns Family hx: both parents – stomach CA, sister – breast CA Nil known allergies
  • SB physiology (ICSM BSc)

    1. 1. Ethical Issues in Nutrition Support Dr Simon Gabe Consultant Gastroenterologist St Mark’s Hospital London
    2. 2. Religion
    3. 3. Human Rights
    4. 4. Human Rights <ul><li>Fundamental right to life </li></ul><ul><ul><li>Does not mean bare existence </li></ul></ul><ul><ul><li>Existence that has a minimum quality & as free as possible from distress & pain </li></ul></ul><ul><li>Right to die </li></ul><ul><ul><li>When individuals decide that their life is below the minimum </li></ul></ul><ul><ul><li>Considerations of humanity imply a right to assistance (medical) to die painlessly & easily </li></ul></ul>
    5. 5. Death & Dying <ul><li>Death, like birth, is a natural event </li></ul><ul><li>A professional carer </li></ul><ul><li>has a duty to prolong life but not to inappropriately prolong dying </li></ul><ul><li>The difficulty … </li></ul>to recognise when death is occurring to recognise when death is occurring
    6. 6. Dying <ul><li>Sudden / final event of deterioration </li></ul><ul><li>When deterioration is quick – dying </li></ul><ul><li>Appropriate to: </li></ul><ul><ul><li>Basic human support </li></ul></ul><ul><ul><li>Compassion </li></ul></ul><ul><ul><li>Emotional support </li></ul></ul><ul><ul><li>Medical treatment </li></ul></ul><ul><ul><li>Withdraw medical treatment </li></ul></ul>
    7. 7. Ashby & Stofell, 1995 <ul><li>“The purpose of medical science is to benefit the life and health of those who turn to medicine. </li></ul><ul><li>It surely was never intended that it be used to prolong biological life in patients bereft of the prospect of returning to an even limited exercise of human life.” </li></ul>
    8. 8. <ul><li>I'm not afraid to die… </li></ul><ul><li>I just don't want to be there when it happens! </li></ul>
    9. 9. Essentials for life <ul><li>Oxygen - minutes </li></ul><ul><li>Water - days </li></ul><ul><li>Food - weeks </li></ul><ul><li>Reproduction - years </li></ul>
    10. 10. Nutrition Medicine Nursing Surgery Psychiatry Community Paediatrics
    11. 11. When is it lawful to withhold or withdraw life-prolonging treatment?
    12. 12. Ethics & Nutrition Support <ul><li>Hippocratic Tradition </li></ul><ul><li>Reduce violence or disease </li></ul><ul><li>Do no harm </li></ul><ul><li>Do away with suffering </li></ul><ul><li>Refuse to treat where medicine powerless </li></ul>
    13. 13. Duty to provide nutrition <ul><li>Is the duty absolute, without exception or regard to consequence or circumstance? </li></ul><ul><ul><li>If the body cannot tolerate nutrition </li></ul></ul><ul><ul><li>The leading criterion is the patients best interest </li></ul></ul><ul><li>The duty to feed is presumptive not absolute. It is rebuttable in certain circumstances: </li></ul><ul><ul><li>Patients refusal of consent </li></ul></ul><ul><ul><li>A persistent vegetative state? </li></ul></ul>
    14. 14. Ethics & Nutrition Support <ul><li>Does the provision of nutritional support constitute a medical treatment? </li></ul><ul><li>Does removal of an IV line or feeding tube ‘cause’ the death of a patient? </li></ul><ul><li>Is discontinuation of feeding, murder? </li></ul>
    15. 15. Murder <ul><li>The wilful killing of any subject whatever, with malice aforethought … </li></ul><ul><li>Can be a deliberate act or neglect </li></ul>
    16. 16. Competence <ul><li>Patients are competent to consent to treatment, or to refuse consent, if they have capacity to arrive at the decision </li></ul><ul><li>All adults are presumed competent, although this can be rebutted </li></ul><ul><li>A doctor who overrides a competent patients refusal of treatment can be liable in battery </li></ul>
    17. 17. Mrs B <ul><li>43 year old lady </li></ul><ul><li>Paralysed from the neck down </li></ul><ul><li>Kept alive by ventilation </li></ul><ul><li>Felt that her life was not worth living </li></ul><ul><li>Asked doctors to switch off the ventilator </li></ul><ul><ul><li>Doctors refused </li></ul></ul><ul><li>Court felt that she was competent </li></ul><ul><li>Ventilator switched off at her request </li></ul>Passive assisted suicide allowed Passive assisted suicide allowed Autonomy Rules!
    18. 18. Diane Pretty <ul><li>43 year old, MND </li></ul><ul><li>Paralysed from the neck down </li></ul><ul><ul><li>Not on a ventilator </li></ul></ul><ul><li>Virtually unable to speak </li></ul><ul><li>Enteral tube feeding </li></ul><ul><li>Wanted to die in a humaine & dignified manner (assisted by her husband) </li></ul><ul><li>Court refused </li></ul>Assisted suicide refused Assisted suicide refused
    19. 19. Incompetence Advance directive <ul><li>Anticipatory refusal of treatment </li></ul><ul><li>Can be written or oral </li></ul><ul><li>An advance refusal is legally binding if: </li></ul><ul><li>“ clearly established & applicable to the circumstances” </li></ul><ul><li>However, may not be directly applicable to current circumstances </li></ul><ul><li>A doctor who overrides a binding advance directive is liable for battery </li></ul>
    20. 20. Incompetence No advance directive <ul><li>The legal duty of the doctor is to act in the patients best interests </li></ul>
    21. 21. “ Best interests” ?
    22. 22. Airedale Trust vs. Bland (1993) <ul><li>Anthony Bland </li></ul><ul><li>Age 17 </li></ul><ul><li>Crushed in the Hillsborough stadium disaster </li></ul><ul><li>Persistent vegetative state for over 3 years </li></ul><ul><li>Completely insensate with no hope of recovery </li></ul><ul><li>His doctors, with the full agreement of his parents, wished to withdraw the means of intensive care </li></ul>
    23. 23. <ul><li>High Court: declared that the withdrawal of hydration and feeding would be unlawful </li></ul><ul><li>Court of Appeal: supported the High Court </li></ul><ul><li>House of Lords: dismissed the Court of Appeal judgement </li></ul><ul><ul><li>The provision medical treatment could no longer provide the chance of recovery </li></ul></ul><ul><ul><li>Therefore medical treatment could be withdrawn </li></ul></ul>Airedale Trust vs. Bland (1993)
    24. 24. Important rulings after Bland <ul><li>Best interests </li></ul><ul><ul><li>Medical decisions for a mentally incapable patient should be made in the best interests of the patient </li></ul></ul><ul><ul><li>If a decision to withdraw or withhold life prolonging treatment is in best interests of the patient then it is lawful (i.e. best interests can include death ) </li></ul></ul><ul><li>Feeding </li></ul><ul><ul><li>Artificial nutrition & hydration are medical treatments </li></ul></ul><ul><ul><li>Feeding against a patients wishes constitutes assault </li></ul></ul><ul><li>Withholding and withdrawing treatment </li></ul><ul><ul><li>There is no legal difference </li></ul></ul>
    25. 25. Terri Schiavo <ul><li>Feb 1990 Cardiac arrest with severe brain damage (PVS) </li></ul><ul><li>May 1998 Mr Schiavo files petition to remove feeding tube </li></ul><ul><li>Oct 2003 Feeding tube removed & Florida lower house passes &quot;Terri's Law&quot;, allowing the Governor to order doctors to feed Mrs Schiavo </li></ul><ul><li>Sept 2004 Florida Supreme Court strikes down law </li></ul><ul><li>18 Mar 2005 Florida court allows removal of tube </li></ul><ul><li>22 Mar 2005 Federal judge rejects appeal </li></ul><ul><li>23 Mar 2005 Appeals court backs federal ruling </li></ul><ul><li>29 Mar 2005 Federal court grants parents leave to appeal </li></ul><ul><li>30 Mar 2005 Federal court & Supreme Court reject parents' appeal </li></ul><ul><li>31 Mar 2005 Terri Schiavo dies </li></ul>
    26. 28. Passive Euthanasia <ul><li>The intentional hastening of a patients death by withholding or withdrawing treatment: where causing death is the doctors aim </li></ul>
    27. 29. Pauline <ul><li>61 year old lady </li></ul><ul><li>2001 Ileal resection then EC fistula Massive intestinal infarction </li></ul><ul><ul><li>Residual duodenal stump (then fistulated) </li></ul></ul><ul><ul><li>HPN established </li></ul></ul><ul><li>1/2002 SVC thrombosis – stented successfully </li></ul><ul><li>3/2002 Abnormal LFTs </li></ul><ul><li>3/2002 Bleeding GU </li></ul><ul><li>11/2002 L pleural effusion .. ?TB </li></ul><ul><li>12/2002 Recurrent SVC thrombosis (stented) </li></ul><ul><li>12/2002 Recurrent GI bleed (small) </li></ul>
    28. 30. Enough! <ul><li>After mentioning about the possibility of an endoscopy for her GI bleed </li></ul><ul><li>“I can’t cope any longer” </li></ul><ul><li>Wants to stop her treatment </li></ul><ul><ul><li>Including her IV fluids and nutrition </li></ul></ul>What would you do now?
    29. 31. What we did … <ul><li>Listen to the patient </li></ul><ul><ul><li>Discussions with her & family </li></ul></ul><ul><li>Competence </li></ul><ul><ul><li>Was she competent to make the decision? </li></ul></ul><ul><ul><li>Yes, in my opinion </li></ul></ul><ul><ul><li>Psychiatrist also </li></ul></ul><ul><li>Carers views sought </li></ul><ul><li>Religious perspective </li></ul><ul><li>Legal perspective </li></ul><ul><ul><li>Assault to feed against her wishes </li></ul></ul><ul><li>Then </li></ul><ul><li>Palliative care team involved </li></ul><ul><li>Allowed to die </li></ul><ul><ul><li>by withdrawing fluids & nutrition </li></ul></ul><ul><ul><li>husband at her bedside </li></ul></ul>
    30. 32. Advanced dementia <ul><li>4 million cases in the USA </li></ul><ul><li>Frequently </li></ul><ul><ul><li>swallowing difficulties </li></ul></ul><ul><ul><li>Anorexia / loose interest in eating </li></ul></ul><ul><ul><li>aspiration </li></ul></ul><ul><li>Decision to insert a feeding tube </li></ul>
    31. 33. Advanced dementia feeding tubes <ul><li>Often difficult to provide adequate nutrition </li></ul><ul><li>Disputed whether aspiration is reduced by NG or PEG tubes </li></ul><ul><li>Morbidity & mortality with PEG insertion </li></ul><ul><li>Little evidence to suggest that tube feeding prolongs life </li></ul><ul><li>Purpose of tube usually unclear for the patient (resulting in tube withdrawal) </li></ul>
    32. 34. Advanced dementia feeding tubes <ul><li>Increasing view that artificial nutrition should not be used in patients with advanced dementia </li></ul><ul><li>But there will always be exceptions </li></ul><ul><ul><li>Vascular disease (cognitive function may improve) </li></ul></ul><ul><li>Patient autonomy paramount </li></ul><ul><li>Requires close discussion with family </li></ul>
    33. 35. Advanced Dementia <ul><li>Cultural variations in treatment </li></ul><ul><ul><li>Germany / UK </li></ul></ul><ul><li>Nursing homes insist on PEG over NG </li></ul><ul><ul><li>Dementia, CVA </li></ul></ul>Ethical issues?
    34. 36. Should I tube feed this patient? <ul><li>If in doubt </li></ul><ul><li>A trial of treatment is recommended </li></ul><ul><li>NG or PEG? </li></ul><ul><li>NG feeding may be more appropriate than PEG in this setting </li></ul><ul><li>However, trial of PEG feeding possible </li></ul>
    35. 37. Hippocratic or Hypocritical? <ul><li>The law & the BMA guidance relating to withholding & withdrawal of treatment & tube feeding are ethically incoherent </li></ul><ul><li>The intentional shortening of a patients life </li></ul><ul><ul><li> P assive euthanasia (by omission) </li></ul></ul><ul><ul><li> A ctive euthanasia </li></ul></ul><ul><li>Assisted suicide </li></ul><ul><li>  Passive assisted suicide </li></ul><ul><li>  Active assisted suicide </li></ul>
    36. 39. Medical Ethics <ul><li>moral obligations which govern the practice of medicine </li></ul>Autonomy Non-maleficence Beneficence Justice
    37. 40. <ul><li>Autonomy </li></ul><ul><li>principle of self-determination </li></ul><ul><li>recognition of the patients rights </li></ul><ul><li>Non-maleficence </li></ul><ul><li>Deliberate avoidance of harm </li></ul><ul><li>Beneficence </li></ul><ul><li>Provides the patient with some benefit </li></ul><ul><li>Justice </li></ul><ul><li>The fair and equitable provision of available medical resources to all </li></ul>
    38. 41. Justifiable conditions of non-treatment <ul><li>Imminent or irreversible closeness to death </li></ul><ul><li>Extensive neurological damage leading to destruction of self-awareness & intentional action </li></ul><ul><li>Little self-awareness accompanied by severe motor disability </li></ul><ul><li>Destruction of short & long-term memory </li></ul><ul><li>Limited understanding by patient </li></ul>Doyal et al . BMJ 1994;308:1689

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