Those in favour of the preservation of life at all costs vie with those who espouse euthanasia and assisted suicide. Why is there a dilemma in modern clinical practice? The problem with medical ethics is that their interpretation and implementation are influenced by the core beliefs of the individual concerned, whether a doctor, patient, family member or politician. This article will deal with the ethical issues relating to patients with oral feeding difficulties (OFD), particularly towards the end of life, drawing extensively on the recent Royal College of Physicians (RCP) working party report on these issues. Many documents have dealt with these issues but the recently introduced Mental Capacity Act 2005 in England and Wales, together with pressures to place PEG tubes in nursing homes, has focused attention on the continuing unease about the lack of consensus, including among doctors, about when ANH is appropriate. A futile treatment is unethical and not in the patient's best interests.Įthics underpin UK law which is constantly being challenged and changed. 2– 5 In other words, this treatment frequently ignores autonomy, provides no benefit (benificence), causes harm (malificence) and consumes resources which might benefit others (justice). It is now clear that the use of PEG feeding in dementia achieves no discernible benefit in most patients but often causes mortality and morbidity. 2 This inevitably led to considerable ethical debate. However, the introduction of the fine-bore nasogastric feeding tube (NGT) and percutaneous endoscopic gastrostomy (PEG) in the early 1980s meant that many demented patients could be fed artificially – frequently without proper consent. Until only 30 years ago, such patients were treated permissively without artificial nutrition and hydration (ANH). 1 For example, the natural history in advanced dementia is commonly for cognitive decline with deterioration in swallowing, leading to malnutrition and finally death from pneumonia. This challenge is especially evident in the nutritional support and hydration of patients towards the end of life. Furthermore, the evolution of medical knowledge and technology has posed a serious challenge to our interpretation and implementation of ethics. Ethics should know no international boundaries but the law in some countries is often supportive of practices illegal elsewhere. Autonomy, benificence, malificence and justice have formed the basis of medical ethics, but the passage of years has seen these principles ignored, altered, distorted and misinterpreted. It is now 2,500 years since Hippocrates stated his four pillars of medical ethics. It is not possible to practise safely without a working knowledge of the implications of recent legislation such as the Mental Capacity Act 2005. Physicians are constantly confronted by ethical problems in their everyday practice. Nil by mouth should not be the initial default option for oral feeding difficulties, but nutritional interventions are not risk free Multi-disciplinary teams must be at the core of decision making for patients lacking capacity with emphasis on full consultation with family, carers and advocatesĪdvanced decisions should be encouraged before capacity is lost Informed consent involving those with intact mental capacity is ethically essential before commencing nasogastric or gastrostomy feeding The ethics of caring for those with oral feeding difficulties towards the end of life have been challenged by the recent introduction of artificial nutritional interventions
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