Perception of artificial nutrition withdrawal improves with experience

By Anne Harding

NEW YORK (Reuters Health) - Nurses and other caregivers who have dealt with withdrawal of artificial nutrition (AN) for palliative care patients have a better perception of the process than those who have not previously encountered it, according to a new study from France.

However, most of the caregivers - whether or not they had personal experience with AN withdrawal - said there was not enough information available on AN in palliative care.

A 2005 French law says AN and artificial hydration are medical treatments that can be refused by patients and withdrawn by practitioners, Dr. Benoit Leheup of the Metz-Thionville Regional Hospital in Metz and his colleagues note in their report.

Clinical guidelines commissioned by the country's National Federation of Comprehensive Cancer Centers state that AN is not justified for patients with a life expectancy of less than three months, or a World Health Organization Performance Score of two or higher.

"Despite these guidelines, the withdrawal of AN remains a sensitive issue within medical and paramedical teams," the researchers wrote in the American Journal of Hospice and Palliative Medicine, online February 13.

To better understand how caregivers perceive AN, Dr. Leheup and his team surveyed nurses and nurses' aides in the medicine, surgery and palliative care departments of their hospital. They had responses from 274, 60% of whom said they had personal clinical experience with AN withdrawal.

Overall, most survey participants did not consider withdrawal of AN to be contrary to ethics, law, or spiritual or religious beliefs, and individuals with personal experience of AN withdrawal were more likely to say the practice wasn't contrary to law, ethics or their beliefs.

Those with experience with AN were also more likely to say that the patient's life expectancy and nutritional status should be taken into account on making the decision to withdraw AN, and less likely to say that AN withdrawal could be considered assisted suicide.

However, only 23% of the individuals with personal clinical experience of AN withdrawal said information regarding AN in palliative care was sufficient, and just 9.3% of study participants agreed information on AN was sufficient.

"The coherence of the withdrawal of AN with the personal beliefs of the caregivers, already high in the absence of being confronted with this practice, improves further after such confrontation," Dr. Leheup and colleagues write. "The lack of information perceived by the caregivers must prompt us to develop additional training on the withdrawal of AN, its goals, and its clinical consequences."

Dr. Howard Brody, the John P. McGovern Centennial Chair in Family Medicine at the University of Texas Medical Branch in Galveston, studies medical ethics and reviewed the study for Reuters Health. He pointed out that the study says nothing about the religion of the respondents, which would be useful information given that the Catholic church "has been vocal lately" in calling withdrawal of artificial nutrition and hydration into question.

"It certainly seems true to me that those who have strong anti reactions to the idea of withdrawing ANH are reacting much less to the medical/nursing realities than to the symbolism. So it would not be surprising that an 'anti' feeling would be less prevalent among those with actual clinical experience of withdrawal," Dr. Brody said via e-mail.

The issue of the ethics of AN withdrawal in palliative care has largely been resolved in the United States, Dr. Keith Swetz, an associate professor of medicine at the Mayo Clinic College of Medicine in Rochester, Minnesota, said in an interview. Dr. Swetz studies issues in end-of-life care, and reviewed the new findings for Reuters Health.

"This is one area where the American legal system at a national level has already made a decision on this. That is that the withholding and withdrawal of life-sustaining treatment is permitted and the provision of artificial nutrition and hydration is a medical procedure," Dr. Swetz said. "The Supreme Court in 1990, in the case of Nancy Cruzan, has said that it is legal and ethical to allow a treatment to be stopped if it no longer meets the patient's goals of care." The Cruzan case specifically addressed the issue of AN.

If a similar survey were done among U.S. clinicians, he added, "I suspect the result would be different at this time versus if it were done 25 years ago."

SOURCE: http://bit.ly/1qDSPei

Am J Hospice Palliative Med 2014.

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