Position of the Academy of Nutrition and Dietetics: Ethical and Legal Issues in Feeding and Hydration

It is the position of the Academy of Nutrition and Dietetics that individuals have the right to request or refuse nutrition and hydration as medical treatment. Registered dietitians (RDs) should work collaboratively as part of the interprofessional team to make recommendations on providing, withdrawing, or withholding nutrition and hydration in individual cases and serve as active members of institutional ethics committees. RDs have an active role in determining the nutrition and hydration requirements for individuals throughout the life span. When individuals choose to forgo any type of nutrition and hydration (natural or artificial), or when individuals lack decision-making capacity and others must decide whether or not to provide artificial nutrition and hydration, RDs have a professional role in the ethical deliberation around those decisions. Across the life span, there are multiple instances when nutrition and hydration issues create ethical dilemmas. There is strong clinical, ethical, and legal support both for and against the administration of food and water when issues arise regarding what is or is not wanted by the individual and what is or is not warranted by empirical clinical evidence. When a conflict arises, the decision requires ethical deliberation. RDs' understanding of nutrition and hydration within the context of nutritional requirements and cultural, social, psychological, and spiritual needs provide an essential basis for ethical deliberation. RDs, as health care team members, have the responsibility to promote use of advanced directives. RDs promote the rights of the individual and help the health care team implement appropriate therapy. This paper supports the “Practice Paper of the Academy of Nutrition and Dietetics: Ethical and Legal Issues of Feeding and Hydration” published on the Academy website at: www.eatright.org/positions.     

Position of the American Dietetic Association: ethical and legal issues in nutrition,hydration, and feeding

It is the position of the American Dietetic Association that the development of clinical and ethical criteria for the nutrition and hydration of persons through the life span should be established by members of the health care team. Registered dietitians should work collaboratively to make nutrition, hydration, and feeding recommendations in individual cases. Registered dietitians have an active role in determining the nutrition and hydration requirements for individuals throughout the life span. When patients choose to forgo artificial nutrition and hydration, or when patients lack decision-making capacity, and others must decide whether or not to provide artificial nutrition and hydration, the registered dietitian has an active and responsible professional role in the ethical deliberation around that decision. There is strong clinical, ethical, and legal support both for and against the administration of food and water when issues arise regarding what is or is not wanted by the patient and what is or is not warranted by empirical clinical evidence. When a conflict arises, the decision to administer or withhold nutrition and hydration requires ethical deliberation. The registered dietitian's understanding of nutrition and hydration within the context of nutritional requirements and cultural, social, psychological, and spiritual needs provides an essential basis for ethical deliberation on issues of nutrition and hydration.     

Ethical Issues in Artificial Nutrition and Hydration: A Review

Healthcare professionals often face clinical and ethical challenges when charged with making decisions related to provision or lack of provision of artificial nutrition and hydration. The intent of this review is to supply a framework of clinical practices, ethical principles, legal precedents, and professional guidelines that will impart information and can assist decision making regarding artificial nutrition and hydration. Comprehensive understanding of the theory and practice of informed consent for competent adults, decisionally incompetent adults, and minors is necessary for making valid clinical judgments and for guiding patients and their families or surrogates in choosing options related to initiating, withholding, or withdrawing artificial nutrition and hydration. The framework offered in this review can serve as a basis for evaluation of appropriateness of artificial nutrition and hydration in 3 common conditions in which decision making is particularly challenging: terminal illness, advanced dementia, and a persistent vegetative state. The framework facilitates guidance for institutional policy makers and individual nutrition support professionals dealing with situations in which personal values often create ethical dilemmas related to artificial nutrition and hydration and its utility.     

Practice Paper of the Academy of Nutrition and Dietetics Abstract: Ethical and Legal Issues of Feeding and Hydration

It is the position of the Academy of Nutrition and Dietetics that individuals have the right to request or refuse nutrition and hydration as medical treatment. Registered dietitians should work collaboratively as part of an interprofessional team to make recommendations on providing, withdrawing, or withholding nutrition and hydration in individual cases and serve as active members of institutional ethics committees. This practice paper provides a proactive, integrated, systematic process to implement the Academy's position. The position and practice papers should be used together to address the history and supporting information of ethical and legal issues of feeding and hydration identified by the Academy. Elements of collaborative ethical deliberation are provided for pediatrics and adults and in different conditions. The process of ethical deliberation is presented with the roles and responsibilities of the registered dietitian and the dietetic technician, registered. Understanding the importance and applying concepts dealing with cultural values and religious diversity is necessary to integrate clinical ethics into nutrition care. Incorporating screening for quality-of-life goals is essential before implementing the Nutrition Care Process and improving health literacy with individual interactions. Developing institution-specific policies and procedures is necessary to accelerate the practice change with artificial nutrition, clinical ethics, and quality improvement projects to determine best practice. This paper supports the “Position of the Academy of Nutrition and Dietetics: Ethical and Legal Issues of Feeding and Hydration” published in the June 2013 issue of the Journal of the Academy of Nutrition and Dietetics.     

Autonomy: to live one's own life and to die one's own death

The present study describes the changes that have occurred in most Western countries, Brazil included, since medicine has shifted progressively from a paternalistic model to one that promotes patients autonomy and self-determination. Respect for patient autonomy and self-determination is the primary basis for withholding and withdrawing life support. An adult patient who has decision-making capacity and is appropriately informed has the right to forgo all forms of medical therapy, including life support measures. The right to refuse treatment applies equally to withholding therapy that might be offered, such as cardiopulmonary resuscitation, and to withdrawing therapy that is already underway, such as artificial hydration, nutrition, and ventilation. This right is based on the ethical principle of autonomy or self-determination. Helping an informed and capable patient to forgo life support under these circumstances is regarded as distinct from participating in requested homicide, assisted suicide, or passive/active euthanasia. The patient has the right to choose, including where the deathbed will be placed, and to be left alone with family at that time.     

Position of the American Dietetic Association: Integration of Medical Nutrition Therapy and Pharmacotherapy

It is the position of the American Dietetic Association that medical nutrition therapy (MNT), as a part of the Nutrition Care Process, should be the initial step and an integral component of medical treatment for management of specific disease states and conditions. If optimal control cannot be achieved with MNT alone and concurrent pharmacotherapy is required, the Association promotes a team approach and encourages active collaboration among registered dietitians (RDs) and other health care team members. RDs use MNT as a cost-effective means to achieve significant health benefits by preventing or altering the course of diabetes, obesity, hypertension, disorders of lipid metabolism, heart failure, osteoporosis, celiac disease, and chronic kidney disease, among other diseases. Should pharmacotherapy be needed to control these diseases, a team approach in which an RD brings expertise in food and nutrition and a pharmacist brings expertise in medications is essential. RDs and pharmacists share the goals of maintaining food and nutrient intake, nutritional status, and medication effectiveness while avoiding adverse food-medication interactions. RDs manipulate food and nutrient intake in medication regimens based on clinical significance of the interaction, medication dosage and duration, and recognition of potential adverse effects related to pharmacotherapy. RDs who provide MNT using enhanced patient education skills and pharmacotherapy knowledge are critical for successful outcomes and patient safety.     

Ethics and nutritional support therapy: a clinician's view

Whilst much has been written on the implications of withholding or withdrawing nutritional support therapyfrom the terminally ill, the comatose or vegetative patients, relatively little has been published on the ethical implications of nutritional therapy in other groups. This article briefly describes the history of ethics and the evolution of contemporary bio-ethics. The latter has been stimulated by rapid technological advances that now allow severely ill or injured patients to be kept alive for considerable periods of time. Central to recent changes in attitude is the shift away from ‘paternalism’ in medical care towards increasing patient autonomy in decision-making. Self-determination, together with the principles of non-maleficence, beneficence and justice represent the four principles that underpin present approaches to medical ethics. Clinical guidelines for provision or withdrawal of artificial nutrition are described. Application of these principles to a number of clinical scenarios, including the unconscious patient, the intensive care patient, the malnourished patient and the terminally ill patient are explored. This surgeon's view of ethical issues as they apply to nutritional support concludes that failure to provide nutritional support in one form or another for patients who have, or who are expected to have, seven days or more of inadequate oral intake should now be considered unethical.     

From ethical dilemma to hospital policy. The withholding or withdrawing of artificially provided nutrition and hydration

In 1990 St. Joseph's Hospital and Medical Center, Paterson, NJ, established a committee to create an institutional policy to facilitate the decision-making process when patients or their legally authorized surrogates request the withholding or withdrawing of artificially provided nutrition and hydration. Before drafting a policy, the committee agreed on the philosophical, ethical, and medical assumptions that would be the foundation for the policy. The group adopted nine policy assumptions and provided guidelines that address concerns common to all healthcare facilities. No policy that addresses the issue of when to withhold or withdraw life-sustaining treatment will be perfect, nor will it resolve all the complexities of such a decision. However, an imperfect policy is preferable to the absence of a policy, which can lead to an abuse of patients' rights and contribute to arbitrariness in medical decision making.     

Position of the American Dietetic Association: Nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and other eating disorders

It is the position of the American Dietetic Association that nutrition intervention, including nutritional counseling, by a registered dietitian (RD) is an essential component of the team treatment of patients with anorexia nervosa, bulimia nervosa, and other eating disorders during assessment and treatment across the continuum of care. Diagnostic criteria for eating disorders provide important guidelines for identification and treatment. However, it is thought that a continuum of disordered eating may exist that ranges from persistent dieting to subthreshold conditions and then to defined eating disorders, which include anorexia nervosa, bulimia nervosa, and binge eating disorder. Understanding the complexities of eating disorders, such as influencing factors, comorbid illness, medical and psychological complications, and boundary issues, is critical in the effective treatment of eating disorders. The nature of eating disorders requires a collaborative approach by an interdisciplinary team of psychological, nutritional, and medical specialists. The RD is an integral member of the treatment team and is uniquely qualified to provide medical nutrition therapy for the normalization of eating patterns and nutritional status. RDs provide nutritional counseling, recognize clinical signs related to eating disorders, and assist with medical monitoring while cognizant of psychotherapy and pharmacotherapy that are cornerstones of eating disorder treatment. Specialized resources are available for RDs to advance their level of expertise in the field of eating disorders. Further efforts with evidenced-based research must continue for improved treatment outcomes related to eating disorders along with identification of effective primary and secondary interventions.     

Removing life support: motivations, obligations. An opinion on NCCB Committee for Pro-Life Activities' statement on artificial hydration and nutrition

In April 1992 the Committee for Pro-Life Activities of the National Conference of Catholic Bishops issued a resource paper titled "Nutrition and Hydration: Moral and Pastoral Reflections." At best, this document and its conclusions may be viewed as a pastoral statement, offering some tentative reasoning and conclusions to be considered in cases that concern the use of medically assisted nutrition and hydration. When discussing the question, is the withholding or withdrawing of medically assisted hydration and nutrition always direct killing? the document applies two principles--"no reasonable hope of benefit" and "involving excessive burdens." The document's crucial part is its admission that artificial hydration and nutrition may be removed without the intention of causing death, and that "this kind of decision should not be equated with a decision to kill or with suicide." The committee assigns decision-making responsibility to patients, families, and healthcare professionals, but continues its discussion for 20 pages and offers cautions conclusions concerning removal of such therapy. Two assumptions seem to underlie the document's overly cautious conclusions, the first being that mere vegetative function mandates continued life support. The first assumption overemphasizes the value of physiological functioning insofar as the purpose of human life is concerned. It also is contrary to the goal of medicine, which envisions restoration of cognitive-affective function as an element of successful therapy. The second assumption is that withdrawal of artificial hydration and nutrition from persons in PVS may lead to euthanasia. But mandating the continuation of nonbeneficial therapy simply because it prolongs physiological function seems to lead people to favor euthanasia rather than reject it.(ABSTRACT TRUNCATED AT 250 WORDS)     

Preferences of registered dietitians and nurses recommending artificial nutrition and hydration for elderly patients

OBJECTIVE: The study was designed to identify how the beliefs and perceptions of registered dietitians (RDs) affect their decisions to propose artificial nutrition and hydration (ANH) for elderly patients as compared with nurses. DESIGN: A questionnaire consisting of demographic information, 13 belief statements, and eight patient scenarios requiring ANH was mailed to RDs (n=1,500) and nurses (n=1,500) throughout Florida. Thirteen statements, rated on a 5-point Likert scale, addressed beliefs that influence ANH decisions. Eight scenarios of patients, without an advance directive or surrogate decision maker, were created with variations in age, cognition, and emotion. For each scenario, participants selected a treatment, ANH or hydration, and responded: recommend; not recommend; undecided; or recommend a trial period; if no improvement, stop treatment. STATISTICAL ANALYSES PERFORMED: To establish reliability and validity, the instruments were pilot-tested with a group of RDs and nurses. Cross tabulations with chi2 tests compared the distribution of responses to the belief statements and scenarios. Statistical significance was P<0.05. RESULTS: Responses to the belief statement, "when in doubt, feed" differed significantly (P<0.001) between RDs and nurses, all other belief statements were not significantly different. In all eight scenarios, significantly more (P<0.001) RDs recommended ANH than did nurses. CONCLUSIONS: RDs clearly endorsed feeding when in doubt; therefore, they recommended ANH more than nurses. Nurses, who hesitated to feed when in doubt, were more diverse with their recommendations, either recommending a trial or not recommending ANH. A philosophical difference related to feeding was apparent between RDs and nurses and may affect consistent and quality care in patients without an advance directive or surrogate decision maker.     

Nutrition artificielle : initier,poursuivre, arrêter. Repères éthiques

Medical staffs that are competent in the techniques of enteral or parenteral nutrition are frequently called upon for clinical situations in which the indication of artificial nutrition is questionable. The decision may relate to the implementation, limitation or discontinuation of this therapeutics in substitution of vital functions. In such situations of uncertainty on the determination of the goodness, the non-desirability, or even the harmfulness of nutritional support, it seems important to offer general guidelines for making the decision. Our intention is not to give decisional criteria corresponding to various clinical situations encountered. These criteria, often technical, can be found in other publications. They have their own relevance. Our goal is rather to suggest lines of thought to construct a resolution adapted to the situation. The decision method we expose highlights the deliberation as a possibility to co-construct a decision in interacting with the patient, his/her relatives and nursing staffs. In this context, six processes are presented: (1) the creation of a deliberative; (2) a comprehensive approach of the patient, integrating all the contextual elements; (3) work on the representations and meanings related to food and nutrition; (4) attention to the temporality of each actor; (5) the promotion, if they wish and can, of patient self-determination and (6) an assessment of the consequences of the decision and a replay of the decisional approach. In not only providing technical expertise and in helping to create a joint deliberative space, health care teams, expert in nutritional support, would maintain an ethical vigilance in institutions.     

Dietitian involvement in the neonatal intensive care unit: more is better

OBJECTIVE: Describe the level of registered dietitian (RD) involvement in neonatal intensive care units (NICUs) and associations with NICU nutrition practices. DESIGN: Questionnaires were mailed to 820 NICUs in the United States with two follow-up mailings to nonresponders. Abbreviated phone surveys were conducted with a random sample of 10% of nonresponders. A nutrition care score was devised based on a sum of 10 survey questions (range 0 to 10) to summarize the intensity of reported practices. SUBJECTS/SETTING: Directors of NICUs in the United States and RDs associated with them. STATISTICAL ANALYSES: Chi2, analysis of variance, Bonferroni and Duncan multiple range tests, regression. RESULTS: Respondents from 417 (54%) of the 772 NICUs eligible for the study provided completed questionnaires. Among NICUs responding, 76% involved RDs in care (41% employed full- or part-time RDs, 35% employed consult RDs), and 24% had no RD. NICUs with full- or part-time RDs provided fewer kilocalories and more protein parenterally, and more kilocalories and protein enterally. NICUs with less RD involvement were more likely to provide full-term infant feedings (eg, unfortified breast milk, full-term formula) to very-low-birth-weight infants. Mean nutrition care score varied with RD involvement from 4.6+/-1.7 (mean+/-standard deviation) for NICUs with a consult RD and 4.7+/-1.4 for NICUs employing no RD to 5.6+/-1.7 for NICUs with a full- or part-time RD (overall P<.001). CONCLUSIONS: More involvement of RDs in NICUs increased the intensity of important aspects of nutrition care that may improve outcomes of very-low-birth-weight infants in NICUs. These findings highlight the importance of RDs as NICU team members.     

Nutrition support at the end of life: opinions of Louisiana dietitians

The purpose of this study was to determine the opinions of registered dietitians in Louisiana concerning nutrition support at the end of life. A questionnaire was mailed to the 777 active members of the Louisiana Dietetic Association. Questions addressed 3 issues: removal of nutrition support, the role of patients and family in decision making, and the role of the dietitian in decisions to use nutrition support for the terminally ill. A mean composite score was determined for each category. Kruskal-Wallis 1-way ANOVA was conducted on the composite scores to determine differences in responses by age, years of practice, and area of current practice. At least 60% of the respondents agreed with foregoing, withholding, or withdrawing nutrition support at the end of life. Most of the dietitians agreed that the patient or family is more qualified than the health care professional to make decisions about nutrition support at the end of life. More than 95% of the dietitians agreed that the dietitian should be involved in the decision-making process. However, only 50% of the dietitians felt fully qualified to provide the information needed to help a patient or family make the decision about nutrition support at the end of life. Differences of opinions about the removal of nutrition support were found by age, number of years of practice, and current area of practice. Results from this study may encourage dietitians to explore their own attitudes and seek continuing education on ethical dilemmas to enable them to make better decisions, provide better care, and become better patient advocates.     

Living will legislation, nursing home care, and the rejection of artificial nutrition and hydration: an analysis of bedside decision-making in three states

Although state living will legislation establishing the boundaries of unwanted medical intervention has become almost universal, many states define artificial nutrition and hydration as a basic comfort measure rather than extraordinary intervention. In addition, several states have legislation prohibiting its withholding or withdrawal under any circumstances. Despite the recent growth in public awareness and controversy concerning artificial nutrition and hydration, there is little known about the actual influence of prohibitive legislation on bedside decisions involving its withdrawal. An analysis is undertaken of nursing home decision-making concerning the withdrawal of artificial nutrition and hydration in three states with typical variation in living will legislation specific to its legality. Data from interviews with 140 nursing home directors of nursing service responding to hypothetical case vignettes suggest that living will laws prohibiting the withdrawal of artificial nutrition and hydration have little influence over bedside decision-making in nursing homes. Factors found to be determinate of the likelihood of the withdrawal of artificial nutrition and hydration include the competency of the nursing home resident and form of nursing home ownership. State context exerts a significant influence over the likelihood of artificial nutrition and hydration withdrawal, but not in a direction consistent with language of living will legislation.     

Position of the American Dietetic Association: nutrition intervention in the treatment of eating disorders

It is the position of the American Dietetic Association that nutrition intervention, including nutritional counseling by a registered dietitian (RD), is an essential component of team treatment of patients with anorexia nervosa, bulimia nervosa, and other eating disorders (EDs) during assessment and treatment across the continuum of care. Diagnostic criteria for EDs provide important guidelines for identification and treatment. In addition, individuals may experience disordered eating that extends along a range from food restriction to partial conditions to diagnosed EDs. Understanding the roles and responsibilities of RDs is critical to the effective care of individuals with EDs. The complexities of EDs, such as epidemiologic factors, treatment guidelines, special populations, and emerging trends highlight the nature of EDs, which require a collaborative approach by an interdisciplinary team of mental health, nutrition, and medical specialists. RDs are integral members of treatment teams and are uniquely qualified to provide medical nutrition therapy for the normalization of eating patterns and nutritional status. However, this role requires understanding of the psychologic and neurobiologic aspects of EDs. Advanced training is needed to work effectively with this population. Further efforts with evidenced-based research must continue for improved treatment outcomes related to EDs, along with identification of effective primary and secondary interventions.This paper supports the “Practice Paper of the American Dietetic Association: Nutrition Intervention in the Treatment of Eating Disorders” published online at www.eatright.org/positions.     

Ethical issues in artificial nutrition and hydration.

From the time of Hippocrates, approximately 2500 years ago, medical ethics has been seen as an essential complement to medical science in pursuit of the healing art of medicine. This is no less true today, not only for physicians but also for other essential professionals involved in patient care, including clinical nutrition support practitioners. One aspect of medical ethics that the clinical nutritionist must face involves decisions to provide, withhold, or withdraw artificial nutrition and hydration. Such a decision is not only technical but often has a strong moral component as well. Although it is the physician who writes any such order, the clinical nutritionist as fellow professional should be a part not only of the scientific aspects of the order but of the moral discourse leading to such an order and may certainly be involved in counseling physicians, other healthcare providers, patients, and families alike. This paper is intended to give the clinical nutritionist a familiarity with the discipline of medical ethics and its proper relationship to medical science, politics, and law. This review will then offer a more specific analysis of the ethical aspects of decisions to initiate, withhold, or withdraw artificial nutrition and hydration (ANH) and offer particular commentary on the ethically significant pronouncements of Pope John Paul II in March of 2004 related to vegetative patients and artificial or "assisted" nutrition and hydration.     

Implementation of dietitian recommendations for enteral nutrition results in improved outcomes

A primary role of the registered dietitian (RD) is to assess nutritional needs of patients in states of physiological stress and illness and to recommend changes to diet and tube feedings when warranted. However, implementation of changes is dependent upon the physician accepting the recommendations of the RD. This study evaluated outcomes of two groups of enterally fed patients in a long-term acute-care facility in northwest Louisiana: (a) those for whom the physician accepted RD recommendations; and (b) those for whom the physician did not accept RD recommendations. Data showed that physician-prescribed enteral formulas provided 10.0% less kilocalories and 7.8% less protein than the RD-assessed needs. t tests showed that when RD recommendations were implemented, patients had a significantly shorter length of stay (28.5+/-1.8 vs 30.5+/-4.8 days, P<0.05), as well as significantly improved albumin (0.13+/-0.17 vs -0.44+/-0.21 g/dL [1.3+/-1.7 vs -4.4+/-2.1 g/L], P<0.05) and weight gains (0.51+/-0.1 vs -0.42+/-0.2%, P<0.05) when compared to those who continued with physician's orders. These data suggest that if RDs had the authority to write nutrition orders and provide early nutrition intervention, patient care would improve.     

Practice paper of the American Dietetic Association: individualized nutrition approaches for older adults in health care communities

It is the position of the American Dietetic Association that the quality of life and nutritional status of older adults residing in health care communities can be enhanced by individualization to less-restrictive diets. The Association advocates the use of qualified registered dietitians (RDs) to assess and evaluate the need for nutrition care according to each person's individual medical condition, needs, desires, and rights. Dietetic technicians, registered, provide support to RDs in the assessment and implementation of individualized nutrition care. Individual rights and freedom of choice are important components of the assessment process. An RD must assess each older adult's risks vs benefits for therapeutic diets. Older adults select housing options that provide a range of services from minimal assistance to 24-hour skilled nursing care. Food is an important part of any living arrangement and an essential component for quality of life. A therapeutic diet that limits seasoning options and food choices can lead to poor food and fluid intake, resulting in undernutrition and negative health effects. Including older individuals in decisions about food can increase the desire to eat and improve quality of life. The expansion of health care communities creates a multitude of options for RDs and dietetic technicians, registered, to promote the role of good food and nutrition in the overall quality of life for the older adults they serve.     

Ethical and legal aspects of enteral nutrition

European ethical and legal positions with regard to EN vary slightly from country to country but are based on a common tradition derived from Graeco Roman ideas, religious thought and events of the 20th century. The Hippocratic tradition is based on 'beneficience' (do good) and 'non-maleficience' (do no harm). Religious thinking is based upon the presumption of providing food and drink by whatever means unless burden outweighs benefit. The concept of 'autonomy' (the patients right to decide) arose following in the decades after the Second World War and is enshrined in Human Rights law. The competent patient has the right to participate in decision making and to refuse treatment although the doctor is not obliged to give treatment which he or she considers futile or against the patient's interests. The incompetent patient is protected by law. The fourth principle is that of 'justice' i.e. equal access to healthcare for all. The law regards withholding and withdrawing treatment as the same. It also defines the provision of food and drink by mouth as basic care and feeding by artificial means as a medical treatment. It requires doctors to act in the best interests of the patient.