Forgoing artificial nutrition or hydration at the end of life: a large cross-sectional survey in Belgium

Kenneth Chambaere, Ilse Loodts, Luc Deliens, Joachim Cohen

Journal of Medical Ethics
Journal of Medical Ethics

OBJECTIVES: To examine the frequency and characteristics of decisions to forgo artificial nutrition and/or hydration (ANH) at the end of life. DESIGN: Postal questionnaire survey regarding end-of-life decisions (including ANH) to physicians certifying a large representative sample (n=6927) of Belgian death certificates in 2007.

SETTING: Flanders, Belgium, 2007.

PARTICIPANTS: Treating physicians of deceased patients.

RESULTS: Response rate was 58.4%. A decision to forgo ANH occurred in 6.6% of all deaths (4.2% withheld,3.0% withdrawn). Being female, dying in a care home or hospital and suffering from nervous system diseases(including dementia) or malignancies were the most important patient-related factors positively associated with a decision to forgo ANH. Physicians indicated that the decision to forgo ANH had had some life-shortening effects in 77% of cases. There had been no consultation with the patient in 81%, mostly due to incapacity (coma or dementia). The family, colleague physicians and nurses were involved in decision making in 76%,41% and 62%, respectively.

CONCLUSIONS: A substantial number of deaths are preceded by a decision to forgo ANH in Belgium. These decisions, ethically laden and involving a considerable chance of life shortening, are mostly not preceded by discussion with the patient despite existing patient rights legislation. It is recommended that physicians and patients and their families alike dedicate ample time to the discussion of treatment options and communication about the possibility of forgoing ANH and that this discussion takes place earlier as part of overall end-of life care planning rather than at the very end of life..

Chambaere K, Loodts I, Deliens L, Cohen J. Forgoing artificial nutrition or hydration at the end of life: a large cross-sectional survey in Belgium. J Med Ethics. 2014 Jul;40(7):501-4.

Best evidence in critical care medicine. Early versus late parenteral nutrition in the adult ICU: feeding the patient or our conscience?

Jeff P Kerrie, Sean M Bagshaw, Peter G Brindley

Canadian Journal of Anesthesia
Canadian Journal of Anesthesia

Critical illness increases the risk of malnutrition, which can increase infections, prolong mechanical ventilation, delay recovery, and increase mortality. While enteral nutrition (EN) is considered optimal, this is not always an option. Furthermore, algorithms for parenteral nutrition (PN) vary significantly, and it is unclear whether early initiation or delay of parenteral feeding is preferable.

Objective: This study compares intensive care unit (ICU) duration of stay in adults randomized to early initiation of PN (within 48 hr of ICU admission) vs delayed (at eight days or later after ICU admission), as consistent with European and North American guidelines, respectively. . . .

Conclusions: While ICU and 90-day survival were not significantly different, patients in the late PN group were discharged earlier from both the ICU and the hospital. Late PN initiation was also associated with fewer infections, shorter mechanical ventilation time, shorter RRT time, and lower overall healthcare costs. While there were more episodes of hypoglycemia and more inflammation in the late PN group, there was no apparent clinical consequence. No primary or secondary end points showed that early PN was superior.

Kerrie JP, Bagshaw SM, Brindley PG. Best evidence in critical care medicine. Early versus late parenteral nutrition in the adult ICU: feeding the patient or our conscience? Can J Anesthesia. 2012 Feb 03;59(5):494-498.

(Thesis) Hospital Ethics Committees in the USA and in Germany Bioethics qua Practice, Nurses’ Participation and the Issues of Care

Helen Kohlen


In this work the institutionalisation of Hospital Ethics Committees in the USA and in Germany will be analysed by focussing on nurses’ participation and the representation of caring issues. Therefore, questions about the design of Hospital Ethics Committees and how their practices really look like, will be raised. The central question is, how the traditional care ethos of the helping professions in medicine and nursing can find its place in discussions of these committees while hospitals have increasingly been organised along economic criteria.

. . . .My observations and interviews in the field work show that care practices in the tradition of Hippocratic Medicine are no longer self-evident for the helping professions. Physicians and nurses do rather struggle for a care ethos especially with regard to end-of- life questions and regulations of tube-feeding. The “cases” for ethics consultation brought into the committees by physicians and nurses did not rarely emerge as social problems and as a lack of professional competence. The problems appeared to be solvable by translating them into a language of principles and making the process manageable. These principle-based discussions in the practical arena of the hospital resemble discourse practices embedded within the larger bioethical debates in the political arena. Technical procedures given by management and administration do fit into the use of abstract principles and contribute to a language that limits the possibilities to think – what is at stake for patients – in terms of caring relations rather than thinking in terms of rules, regulations and control.

Kohlen H. (Thesis) Hospital Ethics Committees in the USA and in Germany Bioethics qua Practice, Nurses’ Participation and the Issues of Care. Gotfried Wilhelm Leibniz University, Hanover, Germany. 2008 Apr 02.

Advance Directives and Dementia

Gregory E Kaebnick

The Hastings Center Report
The Hastings Center Report

A competent person can avoid the onset of dementia by refusing life-sustaining medical care and by voluntarily stopping eating and drinking, bringing life to an end well before any health crisis. A competent person can also try to limit the duration of dementia by drafting an advance directive that sets bounds on the life-sustaining care, including artificial nutrition and hydration, that medical caregivers can provide when the person no longer has the capacity to make her own medical decisions. But between these two strategies there can lie a significant gap. A person could live with moderate to severe dementia for a considerable time, no longer able to voluntarily stop eating and drinking yet also not yet requiring the life-sustaining care forbidden by advance directive. This gap has been much discussed in recent years in the Hastings Center Report. Several years ago (in the May-June 2014 issue), Paul Menzel and M. Colette Chandler-Cramer argued for what they described as a moderate correction to the dominant view that food and water should always be offered to a patient with dementia if the patient expresses a desire to eat and drink. The problem is taken up again by the legal scholar Norman L. Cantor in this issue (July-August 2018), and Cantor, too, tries to find a moderate alternative.

Kaebnick GE. Advance Directives and Dementia. Hastings Cent Rep. 2018 Aug 16;48(4):2.