Introduction
As life spans have lengthened and medical technology has grown more advanced, physicians and nurses inevitably become involved in end-of-life issues where the absence of do-not-resuscitate (DNR) orders and Advanced Directives force decisions about life-sustaining care. These extend to continuing or withdrawing feeding for seniors already far into frank dementia, for both children and adults already terminally ill, those in a persistent vegetative state, and when brain stem death has occurred.
Bioethics and the Moral Case
The law aside, decisions about nutrition and patient care for the terminally ill rests partly on moral principles and, for good or ill, on expert opinion. The moral imperative is an extension of four principles, the foremost perhaps being that of individual autonomy, the heritage of modern liberal democracy. That is, individual self-determination is a given on the assumption of competent judgment and within the bounds of the greater good of the community (embodied in the aforementioned legal mandates). By extension, patients are given free choice of therapies and interventions that may prolong their lives. If the means of persuasion is based on open, complete and rational information, then there is respect for individual autonomy (The Open University, n.d.).
Ethics and the Law
Two landmark cases in the United States brought bioethics to the forefront, led to the development of advanced health directives, and compelled the medical profession to examine its stand on sustaining life. In 1976, Karen Ann Quinlan collapsed into a persistent vegetative state (PVS) after consuming two opioids and alcohol. Even after her parents convinced the courts to have the hospital remove the ventilators that same year, Ms. Quinlan breathed on her own before expiring pneumonia nine years later. When the Terri Schiavo case erupted in 1990-93 – an alleged eating disorder causing hypokalemia that led to cardiac arrest and precipitated alternating coma and PVS – a great, sustained controversy erupted involving the hospital where the patient was first bought, the patient’s obstetrician, the husband who eventually wanted her removed from nutritional life support, all levels of the judicial system, even Congress and President Bush. Eventually, a court ruled in favor of the husband based on statements that she had reportedly made, e.g. “I don’t want to be kept alive on a machine” (Quill, 2005, p. 1632). In a related case, the U.S. Supreme Court had ruled that when a patient is incapacitated, the family can decide on her behalf but the individual states could set their standards of what is acceptable evidence about the patient’s expressed wishes.
In the UK context, physicians retain the critical role in decisions about nutrition and hydration for patients who are severely handicapped, in a persistent or permanent vegetative state, or who are terminally ill, notwithstanding the right of parents or Welfare Attorneys in Scotland. Due care is perhaps enhanced by standards defining brain stem death. As well, there is the landmark case of Airedale NHS Trust v Bland (1993), in which the five sitting Lords offered the opinion that among others: a) going by the end-result, the distinction between drug-assisted euthanasia and withholding parenteral nutrition is so fine as to be indistinguishable, but, b) the latter lacks the “guilty intent” that is one of two defining conditions for homicide. Even with the consent of patients, neither British law nor European Conventions protect suicide as a civil right (Howard & Bogle, 2004).
When Enteral Nutrition is Not Possible: Effect on Nursing Practice
Returning to the first principles, no one can dispute the validity of the principles of beneficence and non-maleficence. These are central to all medical disciplines and apply particularly to nurse practitioners who must carry out care directives for the terminally ill. The problem arises when ethicists and all those concerned with an end-of-life situation argue that withholding parenteral nutrition saves the patient from further distress and the agony of a prolonged process of dying. Is it not possible to argue that supporting life and delaying death as long as possible are absolute goods that cannot be obviated by any other consideration?
References
Howard, P. & Bogle, J. (2004). Lecture notes: Medical law and ethics. Oxford: Wiley-Blackwell.
Macfie, J. (2001). Ethics and nutritional support therapy: A clinician’s view. Clinical Nutrition, 20 (1) 87-99.
Open University, The (n.d.). Moral and ethical principles in end of life care. Web.
Quill, T. E. M.D. (2005).Terri Schiavo — A tragedy compounded. New England Journal of Medicine, 352 (16):1630-1633.