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by Adrian Treloar & Philip Howard
Adrian Treloar is Consultant and Senior Lecturer In
Old Age Psychiatry at the United Medical and Dental Schools of Guy's and St. Thomas'
Hospitals and Bexley Hospital Kent DAS 2BW
Philip Howard is Consultant Gastroenterologist and Senior Lecturer In Medicine at St.
George's Hospital Medical School, Blackshaw Road, Tooting, London SW19 ORE.
ABSTRACT
Tube feeding is now legally regarded as medical treatment. The provision of
nutrition through nasogastric or gastrostomy feeding tubes is not part of basic care
according to several recent court decisions. Despite this, doctors have misgivings about
the removal of feeding tubes and feel that cessation of tube feeding can be a direct cause
of death. We argue that feeding tube placement is a medical procedure and as such requires
consideration of the benefits and risks as for any other medical treatment. However, the
day-to-day use of feeding tubes, to provide hydration and nutrition, constitutes ordinary
care that does not require medical supervision. Withdrawal of tube feeding raises major
ethical and legal questions, as it removes a simple channel for the provision of
nutrition. With rare exceptions, cessation of tube feeding is done with the intention of
causing death through dehydration or starvation.
We conclude that the placement of feeding tubes constitutes medical treatment from an
ethical standpoint. However following tube placement, a different moral situation
pertains: the provision of feeding through such means constitutes ordinary care. This
analysis of the moral and legal distinction between tube placement and usage challenges
the validity of some court judgements.
KEY WORDS. Tube feeding, PEG feeding, Bland judgement.
Acknowledgements: None
Disclaimers: None
Sources of support: None
INTRODUCTION
There has been considerable debate about the ethical nature of tube feedings: landmark
judgements in both Britain and the United States (Bland, Conroy and Cruzan) have concluded
that tube feeding is medical treatment.(1,2,3) Since the Bland case, several patients have
had their feeding tubes removed after judicial review. Recently the court has agreed that
a feeding tube should not be replaced after it had fallen out in a patient who was not in
the persistent vegetative state.(4) Nevertheless, Craig(5) has argued that death through
dehydration can be onerous for both the patient and relatives and that there is a need to
satisfy thirst.
Despite these legal judgements, there is persistent concern amongst doctors about the
withdrawal of nutrition as a means of deliberately ending life.(6,7) The Law Commission8
stipulated that 'basic care' could not be refused to mentally incompetent patients.
However, 'basic care' was defined as the preservation of bodily cleanliness, alleviation
of severe pain and provision of direct oral hydration and nutrition. We doubt that such
limited standards of basic care would be acceptable in Nursing Homes or Hospitals. Some
ethicists hold that the provision of tube feeding is basic care.(9,10) A review of the
Jewish ethical position(11) shows a consensus that tube feeding, once instituted, may not
be withdrawn. Ethical analyses do not however appear to distinguish the insertion and
removal of feeding tubes as distinct from their daily use to administer nutrition.
We provide two brief case
histories that illustrate some of the difficulties in providing tube feeding before
considering the ethical implications in more depth.
CASE STUDIES
Case 1. A thirteen year old boy with severe cerebral palsy due to an inborn error of
amino-acid metabolism was poorly nourished. Assisted feeding by his parents took several
hours per day with the ever present risk of aspiration. Percutaneous gastrostomy (PEG)
tube placement was discussed with the parents. In particular, the risks of sedation for
such a severely disabled person, who was also underweight and had a severe kyphosis, were
carefully explained. It was felt that there was a small though definite risk of death from
the procedure, estimated at between 1 % and 5 %.
The procedure was uncomplicated.
Nutrient can now be administered either via a pump or by bolus injection with a syringe.
Tube feeding has proved easy, and the patient is now able to go out for the day. His
nutritional status has improved substantially. The mother describes the tube feeding as
"bliss" and sees no difference between the administration of nutrition through
the tube and any other aspect of his basic care. Over the 18 months since tube insertion,
his respiratory difficulties and muscular spasms have worsened. As a result it would now
be even harder to feed him without a PEG tube. Removal of the tube or cessation of feeding
would lead to death from dehydration or starvation. If the tube were to fall out, the
mother would be able to insert it within the first few hours (before the stoma starts to
close). If the tube became dislodged or blocked and required replacement, the same
principles that pertained to the original decision to insert the tube would apply, though
the risks would then be greater.
Case 2.
A twenty year old woman with cerebral palsy, severe kyphoscoliosis and asthma was
considered for PEG feeding because of chronic under-nutrition and repeated chest
infections related to aspiration. A general anaesthetic was deemed neccessay for tube
placement because of her marked skeletal deformity and to control her airway during the
procedure. It was also felt that the patient would not tolerate the procedure under
sedation. There was an estimated.30% - 40% risk of dying from the anaesthetic. The parents
considered the risks were unacceptably high, and the Consultant anaesthetist was not
prepared to offer elective post-procedural ventilation if the patient could not be weaned
from the anaesthetic. It was therefore agreed by all not to proceed with tube insertion.
At the time of writing, the patient continues to struggle with oral feeding, remains
underweight and is at risk from further aspiration pneumonia.
ETHICAL ANALYSIS
The decision to insert a PEG feeding tube should follow a clear discussion with the
patient and/or carers. The procedure itself carries risks that ought to be balanced
against the benefits that may accrue for the well-being of the patient. Good medical
practice requires the consent of the patient, or a near relative or carer in the case of
mental incapacity. Whilst the consent of a relative of a mentally incapacitated adult is
not recognised in law(12), it is regarded as sound medical practice to seek the views of
relatives and/or carers in such instances. (It seems likely that the procedure would be
covered by the common law plea of necessity in the event of a legal dispute).
Hydration and nutrition are
essential to all human existence. Therefore, access to food and water is a basic human
right. Doctors, relatives and carers have a corresponding duty to provide patients with
such sustenance. This basic form of care is not considered ethically obligatory where:
(a) the patient is actually dying, when the provision of tube feeding might be considered
unduly intrusive and unnecessary. (Death from dehydration may take a few weeks, which is
immaterial to the patient facing imminent death).
(b) where the means of providing adequate nutrition might be unduly hazardous, as in the
second case report. Nevertheless, neither of these exceptions removes the duty to care for
the dying or severely handicapped and to relieve mental and physical distress.
Once the feeding tube is in place and the provision of nutrition has been thereby
facilitated, a new ethical situation applies. There now exists a simple means of providing
life-sustaining nutrition without due risk or burden to the patient. There is usually no
reason to withdraw feeding other than to cause the death of the patient. Consent to
feeding via the tube is implicit in the initial agreement to tube placement. Where the
tube is deliberately removed or feeding stopped in the knowledge that the patient is
unable to swallow, the action amounts to causing death through starvation and could
constitute criminal negligence.
CONCLUSION
We agree with the Jewish position that, once initiated, tube feeding is ethically
difficult to stop. Cessation of feeding would normally constitute a deliberate intention
to end life, unless the patient is already in the process of dying and further provision
of hydration and nutrition is materially irrelevant to the outcome. Patients with feeding
tubes in situ have a right to basic nutrition and hydration: given their ease of use, we
propose that tube feeding constitutes basic care. This conflicts with legal judgements
about the use of feeding tubes. It appears that the Bland judgement and other similar
cases have confused the nature of tube feeding. The Bland judgement is based upon the
assumption that the use of the tube, once placed, constitutes medical treatment and that
its use is no different from either tube insertion or removal. Patients have died as a
result of deliberate removal of this basic form of care. We hold that removing the feeding
tube is the proximate cause of death from dehydration or starvation. If insertion of the
tube is regarded as medical treatment and tube feeding as ordinary care, the ethical
issues surrounding tube withdrawal and the cessation of feeding become clearer.
References
1. Airedale NHS Trust v Bland [1993] AC 789
2. Cruzan v Director, Missouri Dept of Health, 110 Sct 2841 (1990)
3. Strasser W: The Conroy Case: An overview. In Lynn J (ed): By No Extraordinary
Means: The Choice to Forgo Life-Sustaining Food and Water. Bloomington, IN, Indiana
University Press, 1989, p 245.
4. Doctors ask to cut life support. Re: Miss D. The Guardian newspaper 21st March
1997.
5. Craig G M. On withholding nutrition in the terminally ill: has palliative
medicine gone too far? Journal of Medical Ethics 1994; 20:139- 43.
6. Soloman M Z, O'Donnell L, Jennings B, et al. Decisions near the end of life:
Professional views on life sustaining treatments. American Journal of Public Health 1993;
14: 83.
7. Personal communication
8. Mental Incapacity. Law Commission No 231. para 5.34. Pub HMSO 1998.
9. Mellander G. On removing food and water; Against the Stream. Hastings Centre
Report 14:11,1984.
10. Callahan D. On feeding the dying. Hastings Centre Report 13: 22, 1983.
11. Schostak R Z. Jewish ethical guidelines for resuscitation, artificial nutrition
and hydration of the dying elderly. Journal of Medical Ethics 1994; 20: 93-100.
12. Mental Incapacity. Law Commission No 231. para 2.18. Pub HMSO 1995.
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