Ethics Case Conference

Mr H; refusing treatment, tube feeding, and physician obligation

Amos BaileyAnd

Tom Huddle

4 December 2007

Mr HAutonomy, Patient Welfare and Tube Feeding What we know about tube feeding Patient welfare and patient autonomy; what

about when they conflict? Legal constraints: what we must do Morality: what we ought to do

Tube Feeding EfficacyKoretz Metaanalysis Am J Gastro Feb 07

Enteral nutrition (EN) and volitional nutritional support (VNS)

Conditions for which RCTs available:Perioperative

Cancer

Liver disease

Acute pancreatitis

IBD

COPD

Stroke

Strong evidence EN doesn’t help in dysphagic stroke pts in 1st

week VNS doesn’t help non-dysphagic stroke pts in

long term

Tube Feeding EfficacyKoretz Metaanalysis Am J Gastro Feb 07

“reasonable evidence” Malnourished geriatric pts

EN no benefit re mortality/pressure ulcers in a hip fx elderly population

VNS benefit in pts who could consume supplements

Tube Feeding EfficacyKoretz Metaanalysis Am J Gastro Feb 07

“some” evidence (low quality rcts) favors EN or VNS for: Perioperative Critically ill Liver disease

Tube Feeding EfficacyKoretz Metaanalysis Am J Gastro Feb 07

Tube Feeding Efficacy

Dementia: No rcts Trials we do have suggest no benefit (see

Finucane JAMA 282(1999): 1365-70)

Decisions re tube feeding

In most cases, the clinician “will have to rely on an understanding of the patient’s clinical condition and anticipated outcome, a judgment as to the patient’s ability to tolerate undernutrition, and an appreciation of the desires and needs of the patient and his or her family.”

Koretz, Am J Gastroenterology 2007;102:429.

Tube Feedingplausible scenarios

Clinical situations such as those in which there is a mechanical problem with eating but the patient would eat if they could physically seem to have the most benefit Tumor blocking swallowing Short Bowel Syndromes (TPN) Accident, Surgery with possible recovery of eating

Tube FeedingUsual Approach

Consider tube feeding as a medical intervention

Consider benefits and burdens of tube feeding in the individual case

Trial of tube feeding may clarify burdens and benefits

Mr HAutonomy, Patient Welfare and Tube Feeding What we know about tube feeding Patient welfare and patient autonomy; what

about when they conflict? Legal constraints: what we must do Morality: what we ought to do

Patient autonomy vs patient welfare: legal setting Courts have held:

Suicide is forbidden Patients have a right to refuse treatment;

exceptions: Preserve ethical integrity of docs—no. Preservation of life—no. Patient has kids, there’s noone else to take care of them

—yes.

(when tx is food/h2o, courts have agonized, but pts can still refuse)

Kay, “Causing Death for Compassionate Reasons in American Law” Am J Comp Law Fall 06

Patient autonomy vs patient welfare: legal setting Refusing treatment is not suicide: rationales

in legal opinions: Wanting to end therapy isnt the same as wanting

to end life Suicide is an affirmative act vs discontinuing

treatment is allowing disease to take its course Both of these seem questionable when the

treatment is food/h2o by tube feeding

Patient autonomy vs patient welfare: what ought docs to do? Patient autonomy tells us to let the patient

make the decision Our responsibility as doctors to further the

patient’s interest (construed as biological/psychological wellbeing) tells us to resist any decision that appears, in effect, to be suicide.

Human flourishing is best understood in terms of autonomous decision making; human dignity is reflected in unconstrained autonomous choices. The fact of choice is more important than what is

chosen Physician: purveyor of drugs/technology in

the service of patient wishes

Patient autonomy above all

Patient autonomy above all

If patient choice trumps other considerations, its hard to draw a line with suicide on the other side of it

Doc’s responsibility is to further patient wishes (even if these include acts tantamount to suicide)

Docs anyway kill patients (effectively) when they do things that hasten death e.g. opiates in the endstage COPD patient Withdrawal of support in the terminal icu patient

So what’s so awful about doing something similar when it goes with what the patient wants???

Patient autonomy above all

What to do with Mr H: Treat depression if present; but if Mr H has capacity and

his wishes continue to be for removal of his feeding tube as a means of ending his life, his physician should not protest or resist and should simply pull the tube.

Patient autonomy above all

Traditional Hippocratic view: Patient welfare comes first Patient well-being is construed along lines of

biological/psychological flourishing Exercise of autonomy is part of human

flourishing but not if exercised in opposition to one’s well-being.

Patient wishes are partly constitutive of patient welfare, but not necessarily determinative in all cases (such as when patients wish to commit suicide)

Traditional Hippocratic view and sucide If killing oneself is wrong, doctors killing

patients is doubly wrong (contrary to our aim of furthering patient well-being)

Physician imperative is to preserve life (although not at any cost) This is where the hippocratic view has evolved

somewhat in the past 50 years

Welfare trumps autonomy; then how far may autonomy be interfered with; fifty years ago many docs would have said

coercion toward the end of patient welfare was justifed force Mr H to keep his feeding tube.

Modified Hippocratic view of today would draw the line at coercion. We’re more aware of the burdens of treatment;

But; other things being equal, life is good!

Traditional Hippocratic view: Patient welfare comes first

intention behind an act trumps effect of the act in determining its character

Physician action that seems be killing is not so Opiates in COPD; principle of double effect

Death (if occurs) is a side effect of an act intended to relieve discomfort

Withdrawal of support; is indeed ceasing a burdensome treatment and allowing disease to take its course (unlike w/drawal of food and h2o when these are not burdensome)

Traditional Hippocratic view: Patient welfare comes first

Traditional Hippocratic view:Mr H Tube feedings are here not a burdensome treatment

Mr H’s desire for w/drawal of tube feedings amounts to intended suicide

Our task as physician is to further Mr H’s welfare and is thus to discourage such an intention, (without coercing Mr H); not coercing is right, as: This is the law This is also what’s right (with which many physicians would

have disagreed fifty years ago)

What to do with Mr H: Treat depression, sensitively ascertain Mr H’s

wishes; presuming he has capacity, be willing to go along with his wish to discontinue the feeding tube, even if this is his means of shortening his life; but be an advocate with Mr H for his welfare—urge him to reconsider such a determination.

Traditional Hippocratic view: Patient welfare comes first