Penn researchers provide recommendations for artificial nutrition and hydration

December 15, 2005

For two decades, doctors have followed an ethically-established agreement about the appropriate use of artificial nutrition and hydration (ANH) for patients who are seriously ill or in a persistent vegetative state. Generally, patients or their surrogates have been able to accept or refuse ANH based upon considerations that guide most treatment decisions, i.e., potential benefits, risks, burden, religious and cultural beliefs. The Terri Schiavo case - which included very open, dramatic disagreements among family members over such considerations - publicly challenged long-held agreements about ANH and caused many to question its proper use.

In response to such challenges, researchers from the University of Pennsylvania's Institute on Aging and Center for Bioethics, and the Philadelphia VA's Center for Health Equity Research and Promotion review and clarify ethical principles regarding the use of ANH. According to the authors, the five ethical principles that should guide decisions about ANH are:These recommendations are the result of a national conference held at the University of Pennsylvania in early 2005, and appear in the December 15th, 2005 issue of the New England Journal of Medicine.

"Re-examining the guiding principles of decisions to use ANH right now is essential." asserts David Casarett, MA, MD, Assistant Professor of Geriatrics, University of Pennsylvania School of Medicine, and an investigator with the VA Center for Health Equity Research and Promotion. "It is not possible to prevent all disagreements about difficult decisions at the end of life. I guarantee that there will be another Schiavo case, or something very similar. But it is possible, and indeed it is essential, to clearly articulate the principles that should underlie decisions about ANH and to ensure that these principles guide decisions in clinical practice. Our paper was inspired by the Schiavo case," says Casarett. "That case was the ethical equivalent of an airplane crash--a highly visible tragedy that spurs investigation, analysis, and hopefully improvements and safeguards to prevent a recurrence."

Casarett and colleagues Jennifer Kapo, MD, Assistant Professor of Geriatric Medicine, and Arthur Caplan, PhD, Director of Penn's Center for Bioethics, argue that because ANH is associated with uncertain benefits and significant risks, it is essential to ensure that decisions are consistent with the patient's medical condition, prognosis, and goals for care. According to Casarett, "Artificial nutrition is generally not the life-saving treatment that people believe it to be. Unlike food and water, ANH is a medical therapy with substantial risks and burdens, which must be administered using technical medical procedures. In addition, it has no role in palliative care, since it does not promote patient comfort or ease suffering."

The article recommends five fundamental principles for clinicians to follow and a thorough discussion of the ethical and legal justification of the decision to use ANH. The authors also review the potential obstacles to ethical decision-making in the use of ANH, including cultural beliefs, patient education, and institutional financial and regulatory pressure that might affect the care that patients receive.

"The real tragedy of the Terri Schiavo's death" Casarett says, "was not that her family disagreed about her treatment, but rather that our politicians inserted themselves into that disagreement, like unwelcome neighbors at a private family gathering. A patient's and family's right to make independent decisions about ANH and other medical treatment should be defended against legal, financial, and administrative challenges at the bedside," says Casarett.

"Compassionate, ethically sound, and clinically reasonable efforts to facilitate decisions about ANH need to be part of a larger agenda to improve care for all patients with serious illness."
-end-
PENN Medicine is a $2.7 billion enterprise dedicated to the related missions of medical education, biomedical research, and high-quality patient care. PENN Medicine consists of the University of Pennsylvania School of Medicine (founded in 1765 as the nation's first medical school) and the University of Pennsylvania Health System.

Penn's School of Medicine is ranked #2 in the nation for receipt of NIH research funds; and ranked #4 in the nation in U.S. News & World Report's most recent ranking of top research-oriented medical schools. Supporting 1,400 fulltime faculty and 700 students, the School of Medicine is recognized worldwide for its superior education and training of the next generation of physician-scientists and leaders of academic medicine.

The University of Pennsylvania Health System includes three hospitals [Hospital of the University of Pennsylvania, which is consistently ranked one of the nation's few "Honor Roll" hospitals by U.S. News & World Report; Pennsylvania Hospital, the nation's first hospital; and Penn Presbyterian Medical Center]; a faculty practice plan; a primary-care provider network; two multispecialty satellite facilities; and home care and hospice.

University of Pennsylvania School of Medicine

Related Palliative Care Articles from Brightsurf:

Palliative care needed across China for everyone who needs it -- study
Palliative care should extend across China and pay more attention to managing non-malignant disease -- integrated within the country's healthcare system and available to everyone who needs it, according to a new study.

New palliative care model shown to reduce costs without compromising on quality of care
Findings from a large-scale clinical trial testing a new palliative care model have shown to be lower cost, viewed positively by patients and their carers while showing no difference in patient-reported outcomes when compared with standard care.

Palliative Care in emergency departments during COVID-19 pandemic
The clinical characteristics and outcomes of patients who received intervention by a COVID-19 palliative care response team are examined in this case series.

Palliative care for patients with cancer in COVID-19 era
The considerations and challenges affecting the palliative care specialty and delivery of palliative care in the COVID-19 era, as well as potential solutions, are discussed in this Viewpoint.

To face coronavirus disease 2019, surgeons must embrace palliative care
This Viewpoint describes the relevance of a palliative care approach to surgery during the coronavirus disease 2019 pandemic.

Call for palliative care to be adapted for severely ill Covid-19 patients
Emergency-style palliative care needs to implemented to meet the needs of Covid-19 patients who wouldn't benefit from a ventilator say researchers.

A COVID-19 palliative care pandemic plan: An essential tool
Palliative care physicians have created a coronavirus disease 2019 (COVID-19) palliative care plan as an essential tool to provide care and help manage scare resources during the pandemic.

MAiD is not driven by socioeconomic vulnerability or poor access to palliative care
A new study of people who received medical assistance in dying (MAiD) in Ontario found that about three-quarters were cared for by palliative care practitioners at the time of their request for MAiD, and MAiD recipients were younger, wealthier and more likely to be married than the general population at time of death.

Palliative vs. standard care for Parkinson's disease
This randomized clinical trial that included 210 patients with Parkinson's disease and related disorders and 175 caregivers examined whether outpatient palliative care was associated with better patient or caregiver outcomes compared with standard care.

Palliative care in hospitals linked to decrease in use of ICU; treatment intensity
A new study shows that implementing hospital-based palliative care services in New York State reduces treatment intensity at the end of life for hospitalized patients.

Read More: Palliative Care News and Palliative Care Current Events
Brightsurf.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com.