Alimentação e hidratação no fim de vida

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Moral dilemmas associated with thwithdrawal of artificial hydratioGillian Blakely, Jennifer Millw

AbstractWithholding artificial hydration from unconscious terminally ill patients is acom plex p hen om eno n identified as terminal dehydration. Towards the end o fa terminal illness it is acknowledged that a patient's desire for fluid and fooddiminishes, followed by a period of unconsciousness (McAulay, 2001). Inconsistentcare philosophies produce divergent opinions and often diametrically conflictingtreatmen ts (Cra ig, 1994). Add itionally, literature disputes the detrim ental effectsof dehydration, therefore, decisions pivot on legal and ethical considerations.Consequently, the vie^vpoints of the medical and nursing staff can vary;furthermore, recognition must be made to the psychological impact of therelatives. As term inal illness is bound less, all areas of healthcare ca n be affected.Further investigation into this dilemma is required to identify the most appropriatecare management plan.Key w ords: Artificial hiydrationTerminai d ehydration Care path wa ys Ethical and legal issues

7his article discusses the imp ortanc e o ftheethical and legal debate associated withthe decision of withholding artificialhydration (AH) from unconsciousterminally ill patients, a complex phenomenonidentified as terminal dehydration.Towards the terminal stages of illness apatient's desire for fluid and food diminishes,followed by a period of unconsciousness(McAulay, 2001). The decision to give fluidsinvolves the physician, the nurse, the familyand, when possible, the patient (Musgrave etal, 1996). Th e care m anagement plan for sucha circumstance, has lead to much controversy(SutclifFe and Ho lm es, 1 994; Vaz, 1999 ;McAulay, 2001), and Craig (1994) recognized

that these inconsistent care plans had lead towidely divergent opinio ns and often conflictingtreatments, such as administering AH therapyunder the belief that it alleviates uncomfortablesymptoms caused by dehydration (Hamdy

Gillian Blakely is Adult Nursing Research Assistantand Jennifer Millward is Senior L ecturer, Faculty ofHealth and Social Work, University of PlymouthAccepted for publication: July 2007

and Braverman, 1980), or in contrast, thewithdrawal of fluids is conducted to promotecomfo rt (Printz, 1988). This could result inerroneous implementation of policies foreither hydrating or not hydrating terminallyiU patients, thus potentially creating patientharm and stress to the family (Maxwell, 2005).Further investigation into this multifaceteddilemma is imperative to ensure the mostappropriate patient care pathway is identifiedand implemented.The managerial intricacies of terminaldehydration are recognized to include legal,ethical, physiological and psychologicalcomp onents (Craig, 1994; Fox, 1996). Th evariability of physiological appreciation,

and issues of legal and ethical implicationsund erpinn ing decisions, will also bereviewed, with reference to medical andnursing staff. Clearly, there is an overlapbetween these healthcare professionals' legaland ethical decision-making skills. However,they will be considered as separate entitiesso that the definitive roles can be estabhshed.Additionally, the psychological implicationsfor the family will be discussed.Overall, inconclusive evidence and thevarying knowledge of terminal dehydrationamong healthcare professionals, combined

with personal ethical principles, has proan exceptionally convoluted area of healtpractice.Literature reviewAn electronic search of specialist dataincluding MEDLINE, PubMed andBritish Nursing Index was undertaken. Sterms included: 'terminally iU', 'dehydr'legal issues' and 'ethics '. Th e searchfurther supplemented through hand searoft he chosen articles' reference lists and internet search using generic search eng

From the search, 286 potential arwere found be tween 1974 and 2006. Aexamining dehydration or the non-provof hydration in terminal iUness were cThe majority of articles identified over 10 years old; however, they w erdiscarded due to the specific nature ofcontent. Additionally, contemporary litemake reference to some of these soimplying their credibility. Eventuallyto accessibility restrictions, 30 articles chosen for reference.

Despite acquiring dated literature, gthemes arose alongside the contemparticles, wit h particula r reference tocomplexities of decision-making regawithdrawing AH from terminally ill paThis alone highlighted the stasis withitopic and the continuing unresolved surrounding such circumstances.Baci(grounciTerminal dehydration is a comphenomenon affecting patients in all arhealthcare. Clearly, legal factors and eprinciples will underpin medical and nudecision-making and subsequent pmanagem ent. However, Sutcliffe and H(1994) argued that the p erception otherapy differs between healthcare win hospitals arid hospices. Th e m ajoriterminally ill patients with an insufforal intake in secondary care receive pafiuids (Dalai and Bruera, 2004; Muset al, 1996), yet Ho use (1992) remthat hospice staff tend to accept a pa


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end, i.e. 'the end justifies the means' (Fox,1996). However, arguably, clinical decisionsmust not solely be based on the principleof one theory. Curtin and Flaherty (1982)constructed an ethical decision-makingframework in order to provide a systematicapproach to ethical problem s. Thisincorporates an analysis of the backgroundinformation to determine the nature of theproblem and to identify its ethical elements.Those involved in the decision are alsoacknowledged and together this allows thepotential choices available and possibleoutcomes to be considered. AltogetherCurtin and Flaherty's (1982) steps concludewith reviewing the ethical theories andultimately arriving at a resolution. However,a report by Lynn and Childress (1983)detailed that physicians often feel they areobliged to continue treatment in terminallyill patients.Oberele and Hughes (2001) comment thatend-of-life decision-making leads to muchdeliberation and reflection regarding whatis considered to be the correct approach.A research study by Micetich et al (1983)supports this. The authors con ducted asurvey of 93 doctors to determine attitudestowards hydration of terminally ill patients.Findings showed that 73% would suppo rtadministration of therapeutic intravenous(IV) fluids, 27% were prepared to subscribefluids at a sub-therapeutic rate and 50%regarded IV fluids as standard care forterm inal illness. Stone (1993) believesthis action to be an expression of 'doingsomething' rather than standing by. Lynn andChildress (1983) identified this provisionof symbolic treatment as an obligationphysicians felt com pelled to sub mit. Th eethical viability of such a decision has tobe questioned. Such a ritualized act wouldpromote a false sense of security amongthe healthcare team and the family (Fox,1996), and possibly could be considered asa procedure undertaken by the doctor toavoid unambiguous cause of death (Lynnand Childress, 1983).In addition to ethical considerationssurrou nding the withdrawal of AH , foodand drink has immense social connections(Slomka, 2003). Therefore, due to thesymbolic nature and psychological hopesthat are pinned on the provision of fluids,ceasing fluids once they are already started isconsidered to be more poignant, particularlyfor the family (Fox, 1996). Prin tz (1989)concurs, believing the withdrawal ofunbeneficial treatment has the same ethical

significance as not starting it. Nevertheless,the British Medical Association (1993) statewhere medical treatment fails to providefor a patient's welfare there is no ethicalobligation to provide it.The nursing staflf's perspectiveNurses also are faced with ethical dilemmassurrounding terminal dehydration.Tingle andCribb (1996) believe a nurse must assessthe potential harm and benefit of particularactions for that individual patient at thatspecific tim e. This applies the ethical co des ofbeneficence and non-maleficence, defined byMartin (2003) as the duty of doing good andthe duty of avoiding harm, respectively. Clearlythese two principles are interconnected andFox (1996) believes they may be violated insome approaches to hydration/dehydration ofterminally ill patients.

One of the greatest challenges for thenursing profession is considered by Blasszaurand Palfi (2005) to be caring for dying peopleand representing their interests. Davidsonet al (1990) researched such a dilemmaof ethical decision-making of registerednurses via an in ternation al study. Theyconcluded that decisions were influencedby cultural differences, which implies anurse's background and personal experiencescould affect care given (Fox, 1996; Jenk inand Millward, 2006). Fawcett (1993) agrees,com men ting prejudices gained from previousexperiences may cause some nurses to take amoral stance. Therefore, depending on theattitude of the staff member in question, thiscould produce conflicting views regardingindividual application of ethical principles.Furthermore, in this instance, considerationmust also be given to the ethical code ofautonomy, which is reflected in respectingthe patient's wishes (Davidson et al, 1990).

The N M C (2004) infer that a nurse mustvalue a patient's autonomy, acknowledgingtheir right to decide; therefore, when possible,terminally ill patients should have the rightto choose their treatment (Stone, 1993).Nevertheless, staff must respect any decisionsmade and the patient must receive the bestquality of care from health professionals whoare committed to professional clinical andethical obligations (Fox, 1996).The relatives' perspectiveDavidson et al (1990) described the ethicalprinciple of justice as the distribution ofcare in a reasonable way. Ting le and Cr ibb(1996) believe it to be the fair considerationof all those affected. Therefore, this includes

relatives and the psychological impadeciding to \vithdraw AH. Bruera and L(1998) recommend early discussions regatreatment choices should be held witpatient and family. Th us, by providingbest evidence for the benefits and busurroun ding th e withdrawal of AH ,allow an informed choice. Unfortunatesome instances, when this decision hasmade, the family have felt instrumentheir relative's death (Vaz, 1999). This occur if they were not fully informed oprinciples of dehydration. Thus, the nown knowledge of evidence-based pr(NMC, 2004 plO) is a pivotal point ipsychological care of the family, allmisconceptions to be dispelled (McA2001). Hence, the nurse's competencybe proportional to their understandindehydration management (Vaz, 1999).

The equipment used in AH can also relatives undue stress due to its domappearance (Fawcett, 1993). Baerg (1remarked the removal of such a bwould allow relatives the opportunity tocherished contact. Lamerton (1991) abelieving that this equipment made a calmost impossible.For both the nursing staff and relathe decision to withdraw fluids can pra mixture of emotions. Often a sassociation is formed between the provof fluids and care giving (Sutchffe,

Psychologically, fluids therefore symsecurity and life, hence their removacause distress due to the recognition that is imminent (Chadfield-Mohr and 1997). Brown and C hekry n (1989) beliis felt that the offering of compassionateis replaced with the sensation of helplesPotentially, some nursing staff may aluncomfortable with this decision, andneed to examine their own feelings (Jand Millward, 2006). However, abidith e Code of Professional Conduct ( N M C ,section 2), nurses have a duty to respeindividual beliefs and to overlook persubjectivity.DiscussionMcAulay (2001) remarks that pocontributions to the palliative managof a patient can occur via collaborativewo rk. Sutcliffe (1994) agrees, identifyingany decisions made will not only impapatient care but, w ill have specific consequfor the family.The interlinking principles of benefiand non-maleficence, therefore, will

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END-OF-LIFE CARE

dration, (Stone, 1993; Sutcliffe andes, 1994). Therefore, to provide the

hirst and dry mouth are reported to

ract th is, literature identifies simple

(Stone, 1993; M alone,A further criticism of dehy dration

Sutcliffe and H olm es, 1994).

reasingly being ackno wledged but againHealthcare professionals face an ethical and

of all factors. Th us, as each

The possession of sufficient knowledge,

ptima l quality of care, but that th e staff

of the health professionalsbeliefs. O f

part icu la r in te res t would b e a c o mp a ra b leanalysis o f t h o s e w o rk in g in a hosp i ta le n v i r o n m e n t w i t h t h o s e in a h o s p ic e .Addi t iona l ly , th e re l ig ious an d faith positionsofthe pa t ien ts ' re la t ives cou ld a lso impac t o ndec is ions mad e . Th is is an additional area ofc o n s id e ra t io n to an a l re a d y c o n v o lu te dsubject, but i s one of g re a t imp o r t a n c e th a tdeserves i ts own deba te . ISHil

Alexander MF, Fawcett JN , Runcim an PJ (2003) NursingPractice: Hospital and Home TlieAdult. 2nd edn. ChurchillLivingstone, E dinburghBaerg KL (1991) Effects of dehydration on the dyingpatient. Rehabil Nnrs 16(3): 155 -6Blasszaur B, Palfi I (2005) Moral dilemmas of nursing inend-of-life care in Hungary; a personal perspective. NursEthics 12(1): 92-10 5British Medical Association (1993) Medical EthicsToday.BM],LondonBrown P, Chek ryn J (1989) Th e dying patient anddehydration. Cancer Nurs 85(5): 1416Bruera E, Lawlor P (1998) Defining palliative careinterventions.J Palliat Care 14(2) : 23 ^Bruera E, MacDonald N (2000) To hydrate or to nothydrate. How should it he? J Clin Omol 18(5): 1156-8Chadfield-Mohr SM, Byatt CM (1997) Dehydration inthe terminally ill iatrogenic insult or natural process?Postgrad MedJ 73(862): 476-80Craig GM (1994) On withholding nutrition and hydrationin the terminally ill: has palliative medicine gone too far?J Med Ethics 20(3): 139-43Craig GM (1996) On withholding artificial hydration andnutrition from terminally ill sedated patients. The debatecontinues.J Med Ethics 22(3): 147-53Curtin L, Flaherty MJ (1982) Nursing Ethics: Tlteories an dPragmatics. Prentice H all, USADalai S, Bruera E (2004) Dehydration in cancer patients: totreat or not to treat. J Support Oncol 2(6): 46787Davidson B.Vander Laan R, Davis A et al (1990) Ethicalreasoning associated with the feeding of terminally illelderly cancer patients: an international perspective.Cmifcr Nurs 13(5): 286-92Fawcett H (1993) Interpreting a moral right, ethicaldilemmas in nutritional support for terminally ill patients.Prof Nurse 8(6): 380-3Fox E (1996) IV hydration in the termina lly ill: ritual ortherapy? Br J Nurs 5(1): 41-5General Medical Council (2002) Withholding and WithdrawingLife-Prolonging Treatmettts: Cood Practice in Decision-Makitig.GMC, London. Available at: http://www.gnic-uk.org/guidance/current/library/witholding_lifeprolonging_guidance.asp (last accessed 26 July 2007)

Hamdy RC, Braverman AM (1980) Ethical conflicts in thlong-term care ofthe aged. Br MedJ 280(6215): 717Human Rights Act (1998) The Human Rights Act 1998HMSO, London. Available at: http://\vww.opsi.gov.ukacts/actsl998 /80042 d.htm#s chl (last accessed 26 Jul2007)House N (1992) The hydration question: Hydration odehydration of terminally ill patients. Prof Nurse 8(144-8Jenkin A, Millward J (2006) A moral dilemma in theemergency room: confidentiality and domestic violenceAccid Emerg Nurs 14 : 38^2Lamerton R (1991) Dehydration in the dying patient. Lanc337(8747): 981-2Lynn J, Childress J (1983) Must patients always be givenfood and water? Tlie Hastings Centre Report 13(5): 1Malone N (1994) Hydration in the terminally ill patienNurs Stand 8(43): 29-32Martin EA (ed) (2003) A Dictionary of Nursing. 4th Oxford University Press, OxfordMaxwell L-A (2005) Purposeful dehydration in a terminallill cancer patient. Br J Nurs 14(21): 1117-19McAulay D (2001) Dehydration in the terminally iU patienNi/r.'jStonrf 10(16): 33-7Meisel A, Snyder L, Quill T (2000) Seven legal barriers toend-of-life care: myths, realities, and grains of truth._//4MedAssoc 284(19): 2495-501Micetich K C, Steinecker PH, Thomasma DC (1983) Arintravenous fluids morally required for a dying patientArch Intern Me d 143(55): 975-8Montgomery J (2003) Health Care Law. 2nd edn. OxUniversity Press, New YorkMusgrave CF (1990) Terminal dehydration. To give or noto give intravenous fluids? Cancer Nurs 13(1): 62-6Musgrave CF, Bartal N, Opstad J (1996) Intravenouhydration for terminal patients: what wre the attitudeof israeli terminal patients, their families, and their healtprofessionals? J Paiti Symptom Manage 12(1): 4751Nursing and Midwifery Council (2004) Code of ProfessConduct: Standards for Conduct, Performance atid EthicNM C, LondonOberele K, Hughes D (2001) Doctors' and nurseperceptions of ethical problems in end-of-life decision_//)(ifNiiri 33(6): 707-15Printz LA (1988) Is witholding hydration a valid comfomeasure in the terminally ill? Ceriatrics 43(11): 848Slomka J (2003) Withholding nutrition at the end olife: Clinical and ethical issues. Cleve Clin J Med 70548-52

Stone C (1993) Prescribed hydration in palliative care. BrNurs 2(7): 53-7Sutcliffe J (1994) Terminal dehydration. Nnrs Times 90(60-3Sutcliffe J, Holmes S (1994) Dehydration: burden or benefto the dying patient?_//4rfi' Nurs 19(1): 71-6Tingle J, Cribb C (1996) Nursitig Law and Ethics. BlacScience, OxfordVaz H (1999) The management if dehydration in terminalill patients. CIAP,Australia.Available http://www.clininfhealth.nsw.gov.au/hospolic/stvincents/stvin99/Helenhtm. (last accessed 26 July 2007)

KEY POINTSIThe potential withdrawal of artificial hydration has iead to continuing debates in the nursing

and medical communities.I Despite many stud ies investigating th e benefits and d etrimentai effects of terminal

dehydration, no conclusive arguments have been established.I Each case requires the balancing of legal and ethicai issues in conjunction with latest

evidence-based practice.IThe psychological impact of any decision made needs to be recognized.


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Alimentação e hidratação no fim de vida