Hydration and Nutrition: Clinical and ethical issues Hydration: Cochrane review 2014...

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Transcript of Hydration and Nutrition: Clinical and ethical issues Hydration: Cochrane review 2014...

  • Visit: www.pilgrimshospices.org pilgrimshospices @PilgrimsHospice

    Hydration and Nutrition:

    Clinical and ethical issues Andrew Thorns

    Consultant in Palliative Medicine

    East Kent Hospitals University Trust

    Medical Director Pilgrims Hospice in East Kent

    athorns@nhs.net

    @thornsandrew

    mailto:athorns@nhs.net

  • What the Papers Say “The end when it comes is distressing for all who witness it. When a patient is starved of food and water there is no question of lapsing peacefully into that good night. Dying becomes a misery of convulsions, bleeding and – if there is consciousness – fear and pain.”

    Daily Mail Editorial. Dec 8th 2004

  • Why are ethical problems around hydration and nutrition so challenging?

    • Media attention • Poor evidence base for decision-making • Difficulties of predicting prognosis • Team decision making and relations with colleagues • Understanding moral theory and the law • Challenging or finely balanced cases require a lot of resources • Serious consequences if handled badly • Having effective communication skills

  • • Ethics is concerned with how we ought to react to each other. What is good and what is bad, what is right and what is wrong when acting toward another individual.

    • Within the study of medical ethics, these questions are often equated with dramatic decisions about life and death, or the consequences of the latest advances within medical technology and research.

    • Ethics, however, is not only concerned with the spectacular or with questions of life and death. In general wards of hospitals and nursing homes, particularly in the daily care of the elderly, lies a type of everyday ethics with countless small down to earth decisions concerning the various aspects of care. These actions are not subject to analysis every time they are performed. Rather, they reflect consciously or unconsciously the fundamental attitudes which carers express in their everyday actions.

    • In seeking assistance in concrete situations, it is therefore imperative that we are aware of the values upon which we base our reflection.

    • (Mattiason and Hemberg 1997 p1; The Cambridge Medical Ethics Workbook. Parker M and Dickenson D. Cambridge University Press 2001)

  • Objectives

    • To be able to describe the ethical challenges of hydration and nutrition as patients and families approach the end of life

    • To identify the relevant research and guidance in helping make the best decisions

    • To evaluate how we need to adapt our practice as a result of this

  • Definitions and key resources

    • Clinically assisted nutrition and hydration (CANH)

    Clinically-assisted nutrition and

    hydration (CANH) and adults who

    lack the capacity to consent

    Guidance for decision-making in

    England and Wales

    BMA and Royal College of

    Physicians

  • How would you respond to this situation?

    Mr A has advanced incurable cancer. He is in his last few weeks of life

    and there are no more oncological treatment options. He has no

    appetite, has lost a great deal of muscle bulk and he and his family ask

    about tube feeding to help him feel better and live longer

    a) Tube feeding should be trialled for a short period to see if it helps

    b) Tube feeding will not help his life expectancy or quality of life at this

    stage of his life

    c) Tube feeding is likely to help and therefore should be implemented

    as per their request

  • How would you respond to this situation?

    Mrs B has advanced dementia so she lacks capacity for almost all decisions. On most days she does not get out of bed or maybe transferred to the chair for short while. Her swallow is unreliable and she has episodes of aspiration pneumonia. The question is being raised whether to arrange for a PEG tube

    a) As there is no advance decision by the patient it is up to the next of kin to decide

    b) A PEG tube insertion is the right course of action to help prolong the life of Mrs B

    c) Once someone with dementia can’t swallow they are close enough to

    the end of life that we should not supplement their fluids in a clinically assisted means

  • How would you respond to this situation?

    Mr C is dying in the next hours or days. He is comfortable with no signs of distress or respiratory secretions. He appears neither over or underhydrated. He is no longer able to take anything by mouth. His family are asking about setting up some fluids for his comfort and to stop him dehydrating. Having listened to the family’s concerns your response would be

    a) To agree and start some fluids with a plan to check they do not cause any complications

    b) To explain the risks in terms of increased secretions, discomfort and complications from the cannula and that fluids at the end of life are not needed by the body. But agreeing to monitor the situation and offer exemplary mouth care

    c) To explain that in your organisation the policy is not to give fluids at the end of life

  • Would you agree with this statement?

    • As people approach the end of their lives the enjoyment they get from their food is more important than the calorific content or

    nutritional quality

  • 10 things 1. We do not need to prolong life at all costs

    2. People cannot insist on CANH but if there is doubt we should act to prolong life

    3. The evidence is not clear about fluids at the end of life – but we all agree we need more research

    4. When people are approaching the end of their lives there are many reversible causes of poor appetite and weight loss which should be carefully looked at

    5. Once people can’t swallow with advanced dementia then CANH is not likely to help

    6. People with advanced cancer aren’t starving: distinguishing between starvation and cachexia

    7. To focus on enjoyment from food rather than nutritional value is often a better approach

    8. Religious and cultural aspects should be considered and each decision made on an individual basis

    9. An approach to withholding and withdrawing CANH is helpful remembering a 2nd opinion is required if not in last hours or days of life

    10. Communication is most important

  • 10 things 1. We do not need to prolong life at all costs

    2. People cannot insist on CANH but if there is doubt we should act to prolong life

    3. The evidence is not clear about fluids at the end of life – but we all agree we need more research

    4. When people are approaching the end of their lives there are many reversible causes of poor appetite and weight loss which should be carefully looked at

    5. Once people can’t swallow with advanced dementia then CANH is not likely to help

    6. People with advanced cancer aren’t starving: distinguishing between starvation and cachexia

    7. To focus on enjoyment from food rather than nutritional value is often a better approach

    8. Religious and cultural aspects should be considered and each decision made on an individual basis

    9. An approach to withholding and withdrawing CANH is helpful remembering a 2nd opinion is required if not in last hours or days of life

    10. Communication is most important

  • We do not need to prolong life at all costs: GMC guidance • “…decisions concerning potentially life-prolonging treatment must not be

    motivated by a desire to bring about the patient’s death, and must start from a

    presumption in favour of prolonging life.”

    • “This presumption will normally require you to take all reasonable steps to prolong a patient’s life.”

    • “However, there is no absolute obligation to prolong life irrespective of the consequences for the patient, and irrespective of the patient’s views, if they are

    known or can be found out.”

    Treatment and care towards the end of life: good practice in decision making. General Medical Council 2010

  • 10 things 1. We do not need to prolong life at all costs

    2. People cannot insist on CANH but if there is doubt we should act to prolong life

    3. The evidence is not clear about fluids at the end of life – but we all agree we need more research

    4. When people are approaching the end of their lives there are many reversible causes of poor appetite and weight loss which should be carefully looked at

    5. Once people can’t swallow with advanced dementia then CANH is not likely to help

    6. People with advanced cancer aren’t starving: distinguishing between starvation and cachexia

    7. To focus on enjoyment from food rather than nutritional value is often a better approach

    8. Religious and cultural aspects should be considered and each decision made on an individual basis

    9. An approach to withholding and withdrawing CANH is helpful remembering a 2nd opinion is required if not in last hours or days of life

    10. Communication is most important

  • People cannot insist on CANH but if there is doubt we should act to prolong life • An advance request to receive CANH should carry significant weight

    as evidence of a patient’s past wishes and preferences, but cannot be

    determinative of the doctor’s decision on best interests

    • Burke v General Medical