End-of-life nutrition therapy poses many ethical issues. However, there is a new evidence-based resource to help clinicians with these cases.1
“The paper is intended to help clinicians understand what medically assisted nutrition and hydration [MANH] can and cannot accomplish for different groups of patients,” says lead author Katie L. Bower, MD, MSc, FACS. The authors’ recommendations are based on the available scientific evidence, expert opinion, and ethical principles.
Making a recommendation for medical interventions often is straightforward (e.g., prescribing antibiotics to treat an infection). “In contrast, making a recommendation for MANH is complicated,” says Bower, associate professor of surgery at Virginia Tech Carilion School of Medicine.
Many disease processes that result in a patient losing the ability to eat and drink enough to sustain life are not curable. In all cases, MANH is a supportive intervention only, meaning it does not do anything to treat the root cause. “If the root cause is reversible with other interventions or time, MANH can provide benefit by sustaining a patient through the period of treatment, if they are expected to recover the ability to eat,” Bower explains.
On the other hand, if there is no treatment for the root cause and a patient is not expected to recover the ability to eat, MANH can sustain the patient in an undesirable condition with poor quality of life.
“Worse, it can cause harm with no benefit if their body is in a state where it cannot process food and fluid,” Bower warns.
Losing the ability to eat and drink is part of the natural process of dying. Yet gauging where a patient is along a life-limiting disease trajectory, and predicting life expectancy with and without treatment, is uncomfortable for many clinicians. “Thus, it’s avoided, even though this information is born of our education and expertise, and critical to a patient achieving autonomy in medical decision-making,” Bower adds. The authors offered these recommendations:
• Clinicians should offer end-of-life nutrition therapy if there is a reasonable expectation of benefit for the patient, but clinicians are not ethically obligated to offer nonbeneficial treatment;
• Clinicians should base the decision on whether to proceed on the patient’s values and preferences, taking into account disease trajectory and functional status;
• Clinicians should remember MANH is contraindicated for patients with advanced dementia. The concept of patient autonomy often is oversimplified in medical curricula, according to Bower. “Ethicists can help clinicians to understand the difference between absolute and relational autonomy in the context of shared decision-making,” Bower suggests.
Closing this gap in knowledge can empower clinicians to alleviate some of the burden placed on patients and surrogates making difficult medical decisions. “This can be achieved with formal case-based education sessions — or in real-time, by facilitating communication between the patient and clinician with open-ended questions,” Bower offers.
REFERENCE
1. Bower KL, Shilling DM, Bonnes SL, et al. Ethical implications of nutrition therapy at the end of life. Curr Gastroenterol Rep 2023;25:69-74.
The guidance is intended to help clinicians understand what medically assisted nutrition and hydration can and cannot accomplish for different groups of patients.
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