Nonmaleficence

ESPEN Congress Cannes
2003
Organised by the Israel Society for Clinical
Nutrition
Education and Clinical Practice Programme
Session: Nutrition and Palliative Care
Ethical Issues: Refusal to Eat in the Elderly
Doctor Esther Lee Marcus and Professor Elliot M. Berry
Jerusalem, Israel
email
[email protected]
Ethical Principles
v Autonomy
v Beneficence
v Nonmaleficence
v Justice
v Sanctity of Life
© ESPEN 2003. For personal use only.
1
American Medical Association
Code of Medical Ethics
“The principle of
patient autonomy
requires that
physicians respect the
decision to forgo lifesustaining treatment
of a patient who
possesses decisionmaking capacity.”
capacity.”
American Medical Association
Code of Medical Ethics
“Life-sustaining treatment is any
treatment that serves to prolong
life without reversing the
underlying medical
condition…..may include
…mechanical ventilation….and
artificial nutrition and hydration.”
© ESPEN 2003. For personal use only.
2
Iris Murdoch &
John Bayley
“November 1998: Iris won’
won’t eat, is barely
drinking…
…
..I
I
try
a
method
that has always worked
drinking ..
before – putting little pieces or spoonfuls in her
mouth. Now she doesn’
doesn’t push them away, but her
mouth remains closed…
closed….Without bother or fuss,
as if someone she trusted had helped her to come
to a decision, she stopped eating and
drinking. Gentle pressure from those kind nurses,
but no insistence. No horror of being put on a
drip”
drip”
John Bayley,
Bayley, Iris and Her Friends, 2000
Jury M, Jury D.
Gramp.
Gramp.
© ESPEN 2003. For personal use only.
The grandfather, 81,
one day “removed
his false teeth and
announced that he
was no longer
going to eat or
drink.
drink. Three weeks
later, to the day, he
died...to die was a
decision his inner
force had obviously
decided upon.”
upon.”
3
Is Tube feeding
medical treatment
or basic care ?
Tube feeding – Basic care
v Food is essential for life
v Cultural, religious and
symbolic meaning of food
v Healthcare
professionals are
reluctant to deny their
patients food and fluid.
v Family members do not
want their loved ones to die
from hunger
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4
Tube feeding - Medical
therapy
v Invasive
v Requires skilled medical, nursing
and nutritional expertise
v Associated with complications
v Consent of a competent patient
must be given
What do apple
pie and
motherhood
have to do with
feeding tubes
and caring for
the patient?
Slomka J. Arch Intern Med 1995; 155: 1258-1263.
1258-1263.
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5
Ethical Principles
v Autonomy
v Beneficence
v Nonmaleficence
v Justice
v Sanctity of Life
Objectives of therapy
v Prolonging life
v Improving health
v Preventing disease
v Improving quality of life
v Palliating terminal illness
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6
Beneficence
Evidence
v Stroke
v ALS
vCatabolic States
No evidence
vTerminal dementia
vTerminally-ill cancer patients
Gillick M R
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7
Ethical Principles
v Autonomy
v Beneficence
v Nonmaleficence
v Justice
v Sanctity of Life
Nonmaleficence
v Complication of tube feeding
v Lack of enjoyment of food
v Prolongation of suffering
v Need to restrain the patient
v Death from starvation “good death”
death”
Ganzini L et al. Nurses' experiences with
hospice patients who refuse food and fluids to
hasten death. N Engl J Med 2003;349:359-65.
© ESPEN 2003. For personal use only.
8
Ethical Principles
v Autonomy
v Beneficence
v Nonmaleficence
v Justice
v Sanctity of Life
Justice
v Elderly patients should have
equal access to treatment
regardless of age.
v Percutaneous gastrostomy
(PEG) is sometimes inserted
for administrative reasons to
facilitate discharge of patients
or to reduce nursing burden.
v This may not necessarily be
in the interests of the patient.
© ESPEN 2003. For personal use only.
9
Ethical Principles
v Autonomy
v Beneficence
v Nonmaleficence
v Justice
v Sanctity of Life
Sanctity of life
The preservation of life
takes precedence over
all other considerations.
© ESPEN 2003. For personal use only.
10
Cultural Differences in the
Attitude Towards Food
Refusal and Tube Feeding
India
The “natural” death while not
eating: a type of palliative care in
Banaras, India.
Justice C. J Palliat Care 1995; 11: 38-42.
Cultural Differences in the
Attitude Towards Food
Refusal and Tube Feeding
England
Fluid given by a tube is regarded by
law as medical treatment
Lennard-Jones
Lennard-Jones J E. Ethical and legal aspects of
clinical hydration and nutritional support. A
report
for the British Association for Parenteral
.
and Enteral Nutrition, 1998.
© ESPEN 2003. For personal use only.
11
Cultural Differences in the
Attitude Towards Food
Refusal and Tube Feeding
Greece
The milk and the honey: ethics of
artificial nutrtition and hydration
of the elderly on the other side of
Europe.
Garanis-Papadatos T. J Med Ethics 1999; 25: 447-450.
Cultural Differences in the
Attitude Towards Food
Refusal and Tube Feeding
Spain
Ethical problems of artificial nutrition
withdrawal: reflections from the
perspective of Mediterranean culture
Gomez Rubi J A. Nutr Hosp 2000: 15:169-174. .
© ESPEN 2003. For personal use only.
12
Cultural Differences in the
Attitude Towards Food
Refusal and Tube Feeding
Israel
Unlimited human autonomy
- a cultural bias?
.
Glick S M. N Engl J Med 1997; 336: 954-956.
954-956.
Percent of nurses who would feed
a terminally-ill competent 75-year old
woman with cancer who refuses to eat
100
90
80
70
60
50
40
30
20
10
0
Davidson B & al.
Cancer Nurs
1990;13: 286-292.
en
ed
Sw
l
ae
Isr
d
an
nl
Fi
a
in
Ch
da
na
Ca
a
ni
or
lif
Ca
lia
ra
st
Au
a
on
iz
Ar
© ESPEN 2003. For personal use only.
13
Percent of Nurses who would Feed
a Severely Demented Patient
100
90
80
70
60
50
40
30
20
10
0
Norberg A & al.
Nurs Ethics
1994; 1: 3-13.
n
ede
Sw
el
Isra
d
lan
Fin
ina
Ch
a
nad
Ca
a
rni
lifo
Ca
lia
stra
Au
a
zon
Ari
Ethical Conflict
v Autonomy
v
v
v
v
Beneficence
Nonmaleficence
Justice
Sanctity of Life
When ethical principles imply
different care actions, the problem
can be solved & ethical dilemmas
handled by giving priority to one or
more of these considerations.
© ESPEN 2003. For personal use only.
14
Open Discussion
vPatient
vFamily
v Staff
There is no one answer !
“Go the way, eat thy
bread with joy and
drink thy wine with
a merry heart”
heart”
Ecclesiastes
lesiastes 9,7
“.. and the years drew
nigh, when thou shalt
say ‘I have no pleasure in
them’”
them’”
Ecclesiastes 12,1
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15
References
v Angus F, Burakoff R. The percutaneous endoscopic
gastrostomy tube: medical and ethical issues in placement.
Am J Gastroentrol 2003; 98: 272-277.
v Asch D A, Faber-Langendoen
Faber-Langendoen K, Shea J A, Christakis N A.
The sequence of withdrawing life-sustaining treatment from
patients. Am J Med 1999; 107: 153-156.
v Council of Ethical and Judicial Affairs. American Medical
Association. Opinion E.220: Withholding or withdrawing lifesustaining medical treatment. In: Code of medical ethics:
current opinion with annotations. Southern Illinois University
School of Law. Chicago: American Medical Association,
2002-2003.
v Davidson B, Vander Laan R, Davis A, et al. Ethical reasoning
associated with the feeding of terminally ill elderly cancer
patients. An international perspective. Cancer Nurs 1990;
13: 286-292.
v Fergusson A. Letting vegetative patients die. BMJ 1992;
305: 1506.
© ESPEN 2003. For personal use only.
16
References
v Ganzini L, Goy E R, Miller L L, Harvath T A, Jackson A, Delorit M
A. Nurses' experiences with hospice patients who refuse food
and fluids to hasten death. N Engl J Med 2003; 349:359-365.
v Garanis-Papadatos T, Katsas A. The milk and the honey: ethics
of artificial nutrition and hydration of the elderly on the other
side of Europe. J Med Ethics 1999; 25: 447-450.
v Gillick M R. Rethinking the role of tube feeding in patients with
advanced dementia. N Engl J Med 2000; 342: 206-210.
v Glick S M. Unlimited human autonomy - a cultural bias? N Engl
J Med 1997; 336: 954-956.
vGomez Rubi JA. Ethical problems of artificial nutrition
withdrawal: reflections from the perspective of Mediterranean
culture. Nutr Hosp 2000: 15:169-174.
v Huang Z-B, Ahronheim J C. Nutrition and hydration in
terminally ill patients: an update. Clin Geriar Med 2000;
16: 313-325.
v Hughes N, Neal RD. Adults with terminal illness: a literature
review of their needs and wishes for food. J Adv Nurs
2000; 32 : 1101-1107.
v Justice C. The “natural”
natural” death while not eating: a type of
palliative care in Banaras,
Banaras, India. J Palliat Care 1995; 11: 38-42.
References
vLennard-Jones
Lennard-Jones J E. Ethical and legal aspects of clinical
hydration and nutritional support. A report for the British
Association for Parenteral and Enteral Nutrition. 1998.
vLennard-Jones
Lennard-Jones J E. Giving or withholding fluid and nutrients:
ethical and legal aspects. J R Coll Physicians Lond 1999; 33: 39-45.
v Marcus E- L, Berry E M. Refusal to eat in the elderly. Nutr Rev
1998; 56: 163-171.
v Norberg A, Hirschfeld M, Davidson B, et al. Ethical reasoning
concerning the feeding of severely demented patients: an
international perspective. Nurs Ethics 1994; 1: 3-13.
v Quill T E, Byock I R. Responding to intractable terminal suffering:
the role of terminal sedation and voluntary refusal of food and
fluids. ACP-ASIM End-of-Life Care Consensus Panel. American
College of Physicians – American Society of Internal Medicine.
Ann Intern Med 2000; 132: 408-414.
v Skelly R H. Are we using percutaneous endoscopic gastrostomy
appropriately in the elderly? Curr Opin Clin Nutr Metab Care
2002; 5: 35-42.
v Slomka J. What do apple pie and motherhood have to do with
feeding tubes and caring for the patient? Arch Intern Med 1995;
155: 1258-1263.
© ESPEN 2003. For personal use only.
17