Artificial Nutrition Support: Introduction
What supports nutritional support?
There is no doubt that a patient on complete starvation will die eventually. Similarly it is obvious that the alternative to tube feeding in complete dysphagia or to parenteral nutrition in intestinal failure is death within a finite time.
It is almost impossible to perform blinded studies of nutritional support versus no nutritional support due to obvious reasons.
It is therefore not a scientific question if nutritional support is necessary in starvation but rather to which degree may a patient be starved without increasing his risk or what is an adequate balance between the risks of artificial nutrition and the risks of starvation.
Although nutritional support therapy is exactly what it says—supportive rather than specific treatment of the underlying disease. It prevents the harmful effects of starvation while the underlying condition resolves. It is thus, only one facet of overall management and needs to be integrated properly into it. Shortcomings in other aspects of care may negate any benefits of nutritional support.
There is excellent evidence that undernutrition is an independent risk factor for higher morbidity, increased length of hospital stay, higher readmission rates, delayed recovery, lower quality of life as well as higher hospital costs and higher mortality.
How does the law regard enteral nutrition? Is it basic care or a medical treatment?
The law differentiates between oral intake and enteral tube feeding. While tube feeding is clearly considered therapy, oral nutritional supplements can be basic care as well as therapy.
What should be done in case of doubt whether enteral tube feeding will be beneficial
or when the prognosis of the underlying condition is uncertain?
If in doubt give a trial of treatment. This should be for a defined period agreed among all
members of the team and with the patient’s family and/or representative. Goals and criteria for continuing or discontinuing the feed should be agreed in advance.
Persistent vegetative state
In cases of severe brain damage where the prospect of recovery is extremely unlikely, how does the law regard withdrawal of food and fluid administration by tube?
The law was clarified by the Cuzan case in the US and by the Tony Bland case in the UK. The courts will not entertain an application to withdraw treatment within 12 months of the onset of the condition, by which time it becomes possible to determine whether the patient has lost all features of personhood although brain stem function persists
i.e. a persistent vegetative state. The court may then give permission for doctors to stop treatment, ‘if it is in the best interests of the patient’.
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