Ethical Aspects of Artificially Administered Nutrition and Hydration: An ASPEN Position Paper

Abstract

The American Society for Parenteral and Enteral Nutrition (ASPEN) Position Paper focus is on applying the 4 ethical principles for clinician's decision-making in the use of artificially administered nutrition and hydration (AANH) for adult and pediatric patients. These basic principles are (1) autonomy, respect the patient's healthcare preferences; (2) beneficence, provide healthcare in the best interest of the patient; (3) nonmaleficence, do no harm; and (4) justice, provide all individuals a fair and appropriate distribution of healthcare resources. Preventing and resolving ethical dilemmas is addressed, with an emphasis on a collaborative, interdisciplinary approach. Optimizing early communication and promoting advance care planning, involving completion of an advance directive, including designation of a surrogate decision-maker, are encouraged. Clinicians achieve respect for autonomy when they incorporate the patient, family, community, country, geographical, and presumed cultural values and religious belief considerations into ethical decision-making for adults and children with a shared decision-making process. These discussions should be guided by the 4 ethical principles. Hospital committees and teams, limited-time trials, clinician obligation with conflicts, and forgoing of AANH are addressed. Specific patient conditions are addressed because of the concern for potential ethical issues: coma, decreased consciousness, and dementia; advanced dementia; cancer; eating disorders; and end-stage disease/terminal illness. Incorporated in the Position Paper are ethical decisions during a pandemic and a legal summary involving ethical issues. International authors presented the similarities and differences within their own country or region and compared them with the US perspective.

The Difficult Decision Not to Prescribe Artificial Nutrition by Health Professionals and Family: Bioethical Aspects

“…For this reason, it has been an essential source of ethical concern and controversy AAN (30). However, in 2021, the American Society for Parenteral and Enteral Nutrition (ASPEN) affirmed that AAN and hydration are medical treatments (9). Therefore, ethical principles could guide healthcare professionals' decisions in collaboration with patients and their surrogates (33)(34)(35).…”

Clinical Nutrition and Human Rights. An International Position Paper

“…Recommendations for preventing and resolving ethical dilemmas are addressed with an emphasis on a collaborative interdisciplinary approach following the twenty proposed ethics position statements. The laws of individual states and national governments have to be considered, but overall the international perspective on the ethics of AANH are essentially similar 56 …”

“…The laws of individual states and national governments have to be considered, but overall the international perspective on the ethics of AANH are essentially similar. 56…”

Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Revised 2021 standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in nutrition support

“…Since patients/clients requiring nutrition support therapy present with varied and complex treatment issues, the RDN must consider the ethical implications 36–38 of nutrition and hydration, 39,40 particularly in certain populations, such as those with dementia 41 or receiving palliative 42 or end‐of‐life care. Care decisions need to reflect the wishes of the patient/client and/or family/surrogate decision‐maker, consistent with an advanced directive that may be in place.…”