Artificial Nutrition and Hydration: The Evolution of Ethics, Evidence, and Policy

Ethical Analysis of Withdrawing Total Artificial Heart Support

“…As a rule, physicians ought to comply with these requests if the therapy has become ineffective or if the patient or surrogate judges that continuing therapy (such as mechanical ventilation, artificial nutrition and hydration, dialysis, or pacemaker support) constitutes an unacceptable burden that is no longer consistent with his or her health care–related values, goals, or preferences. 16,17 Under appropriate circumstances, carrying out requests to withdraw LST is legally permissible. 18 The right to withdraw LST is codified in nearly every US state’s legislation and also by the judicial system, including the US Supreme Court, 19 even if death of the patient follows.…”

“…23 However, it does not follow that any of these properties makes TAHs ethically distinguishable from other long-term, continuous, and constitutive therapies (such as mechanical ventilation) for which permissibility of withdrawing support is well established. 16,24 To the extent that VAD support comes closest in its clinical characteristics to TAH, it is noteworthy that ethicists have already argued that it is ethically permissible to withdraw VAD support. 25,26 …”

Ethical Analysis of Withdrawing Total Artificial Heart Support

“…As a rule, physicians ought to comply with these requests if the therapy has become ineffective or if the patient or surrogate judges that continuing therapy (such as mechanical ventilation, artificial nutrition and hydration, dialysis, or pacemaker support) constitutes an unacceptable burden that is no longer consistent with his or her health carerelated values, goals, or preferences. 16,17 Under appropriate circumstances, carrying out requests to withdraw LST is legally permissible. 18 The right to withdraw LST is codified in nearly every US state's legislation and also by the judicial system, including the US Supreme Court, 19 even if death of the patient follows.…”

“…23 However, it does not follow that any of these properties makes TAHs ethically distinguishable from other long-term, continuous, and constitutive therapies (such as mechanical ventilation) for which permissibility of withdrawing support is well established. 16,24 To the extent that VAD support comes closest in its clinical characteristics to TAH, it is noteworthy that ethicists have already argued that it is ethically permissible to withdraw VAD support. 25,26 The location of the artificial heart within the thorax, flanked by the lungs, in a pocket previously occupied by the patient's native heart, does not distinguish it from other forms of LST.…”

Caring for the Actively Dying

“…36 However, providing food and drink to a loved one is a form of nurturing; emotional overlay may make family members reluctant to give AHN up, even when the patient does not want it. 37 As with cardiopulmonary resuscitation, a frank discussion should be initiated about the potential benefits of AHN, which tend to diminish at EOL, and the potential risks, which remain considerable in a person who no longer has the physiologic wherewithal to make use of nutrients. Affirmation of the family's desire to help the patient and the health care team's commitment to provide the best possible care, coupled with an explanation of the patient's condition and a recommendation congruent with the patient and family's goals, can help ease anxiety.…”