Appropriate Use of Artificial Nutrition and Hydration
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Casarett et al. (Dec. 15 issue)1 claim that artificial nutrition and hydration (ANH) do not constitute "a basic intervention that can be administered by anyone. . . . ANH is a medical therapy administered for a medical indication."
There are two problems with this defense of the right to refuse ANH in this way. First, there is no consensus about the definitions of "artificial" and "natural." Once gastrostomy is performed, calling tube feeding artificial seems somewhat arbitrary. It is certainly not much more "artificial" than is artificial baby formula in artificial bottles.
Second, if ANH must be a medical therapy in order for it to be refused, we may have an unrecognized problem: What about patients with severe cognitive impairment who could be fed by hand but are not because hand feeding is too time-intensive and labor-intensive?2,3
We recently argued4 that a right to self-determination and bodily integrity confers the right to refuse any therapies, medical or otherwise. Our formulation does not require a debate about whether ANH is "natural" or "artificial," and it more solidly bases a right to refuse ANH on uncontroversial principles.
Thomas I. Cochrane, M.D., M.B.A.
Brigham and Women's Hospital
Boston, MA 02115
tcochrane@partners.org
Robert D. Truog, M.D.
Children's Hospital Boston
Boston, MA 02115
References
Casarett D, Kapo J, Caplan A. Appropriate use of artificial nutrition and hydration -- fundamental principles and recommendations. N Engl J Med 2005;353:2607-2612.
Mitchell SL, Buchanan JL, Littlehale S, Hamel MB. Tube-feeding versus hand-feeding nursing home residents with advanced dementia: a cost comparison. J Am Med Dir Assoc 2003;4:27-33.
Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA 1999;282:1365-1370.
Truog RD, Cochrane TI. Refusal of hydration and nutrition: irrelevance of the "artificial" vs "natural" distinction. Arch Intern Med 2005;165:2574-2576.
To the Editor: Casarett et al. discuss proxy decision making with respect to ANH for the patient who is not competent to make such decisions. In this article, the authors recommend that state laws not require "clear and convincing" evidence of a patient's wishes in such cases but, rather, a less burdensome standard of proof.
Although I agree that the current standard is difficult to prove, I must disagree with the feasibility of the authors' suggestion. The standard of clear and convincing evidence is a procedural safeguard used by the courts to ensure the avoidance of an erroneous decision with respect to weighty issues.1 In cases in which initiation or withdrawal of ANH would cause or prevent the death of the patient, such a high standard is required by due process under the U.S. Constitution.2,3
I agree that this evidentiary standard and the court process are burdensome, but changing them may not be possible. Alternatively, the best solution may simply be to avoid this legal issue by fostering good communication and decision making at the bedside and thus obviating the involvement of the courts.4
Darren P. Mareiniss, M.D., J.D.
North Texas Bioethics Network
Plano, TX 75025
dpmmd@sbcglobal.net
References
Addington v. Texas, 441 U.S. 418, 423 (1979).
Cruzan v. Director, Missouri Dept. of Health, 497 U.S. 261, 282-4 (1990).
Mareiniss DP. A comparison of Cruzan and Schiavo: the burden of proof, due process, and autonomy in the persistently vegetative patient. J Leg Med 2005;26:233-259.
Bloche MG. Managing conflict at the end of life. N Engl J Med 2005;352:2371-2373.
To the Editor: Casarett et al. state: "The bulk of the available evidence suggests that ANH does not improve the survival of patients with dementia" and give several references for this statement. Unfortunately, to the best of my knowledge, there has not been a single adequately controlled study to back up this often-repeated statement. What is needed is a prospective study in which a group of patients with dementia who are unable to swallow are divided into two groups, with one given ANH and the other no nutrition. It is inconceivable, physiologically, that the patients in the ANH group would not live longer than those who did not receive food. There may well be other valid reasons, as cited, for not imposing ANH on patients with dementia, but the data with regard to survival simply do not yet exist.
Shimon M. Glick, M.D.
Ben Gurion University
84105 Beer Sheva, Israel
gshimon@bgu.ac.il
The authors reply: Drs. Cochrane and Truog misunderstand our argument about ANH. We did not distinguish between "natural" and "artificial" interventions and agree that these terms have outlived their usefulness. Nor did we suggest that the right of patients to refuse ANH is grounded in the designation of ANH as a technical, medical intervention. Indeed, autonomous persons retain the right to refuse the impositions of others whether or not those impositions have a technical nature. Instead, we simply recommended that physicians describe ANH as a medical intervention to help patients and families better understand its risks and burdens. Finally, Drs. Cochrane and Truog suggest that ANH should not be considered a medical intervention because feeding is straightforward once a gastrostomy tube is placed. This argument is misleading and ignores the substantial risks and discomforts of the procedure itself.
Dr. Mareiniss's criticism, although technically correct, is also misleading. Although the courts can require clear and convincing evidence in order to protect a patient's best interests, Dr. Mareiniss errs in assuming that ANH is always in the patient's best interest. ANH does not always extend life, and it may be associated with substantial risks and burdens. If there were strong evidence that ANH improves the survival of patients with advanced dementia and weight loss, for instance, Dr. Mareiniss's argument might have merit. But we find his position puzzling, given the absence of evidence to support the efficacy of ANH for this indication.
Dr. Glick seems to make a similar error. He notes that no randomized, controlled trials have evaluated the survival benefit of ANH in patients with advanced dementia. He concludes that, therefore, we should assume that ANH is effective. This is an interesting approach to the practice of evidence-based medicine but one with which we are unfamiliar. In our experience, in the absence of convincing data with regard to effectiveness, and in the presence of data indicating substantial risks, one generally assumes that a treatment is not beneficial.
Dr. Glick finds it "inconceivable" that ANH is ineffective in patients with dementia. However, we need not look far to compile a list of treatments — such as trepanning, gastric freezing for ulcers, and even the use of sodium-channel blockers for the suppression of cardiac arrhythmias1 — that have been discredited. Presumably, the proponents of these treatments would have found it similarly "inconceivable" that they could ever be relegated to the wastebaskets of medical history. We should learn from our mistakes and temper our intuitions with both caution and the use of data.
David Casarett, M.D.
Veterans Affairs Center for Health Equity Research and Promotion
Philadelphia, PA 19104
casarett@mail.med.upenn.edu
Jennifer Kapo, M.D.
Arthur Caplan, Ph.D.
University of Pennsylvania
Philadelphia PA 19104
References
The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med 1989;321:406-412.
There are two problems with this defense of the right to refuse ANH in this way. First, there is no consensus about the definitions of "artificial" and "natural." Once gastrostomy is performed, calling tube feeding artificial seems somewhat arbitrary. It is certainly not much more "artificial" than is artificial baby formula in artificial bottles.
Second, if ANH must be a medical therapy in order for it to be refused, we may have an unrecognized problem: What about patients with severe cognitive impairment who could be fed by hand but are not because hand feeding is too time-intensive and labor-intensive?2,3
We recently argued4 that a right to self-determination and bodily integrity confers the right to refuse any therapies, medical or otherwise. Our formulation does not require a debate about whether ANH is "natural" or "artificial," and it more solidly bases a right to refuse ANH on uncontroversial principles.
Thomas I. Cochrane, M.D., M.B.A.
Brigham and Women's Hospital
Boston, MA 02115
tcochrane@partners.org
Robert D. Truog, M.D.
Children's Hospital Boston
Boston, MA 02115
References
Casarett D, Kapo J, Caplan A. Appropriate use of artificial nutrition and hydration -- fundamental principles and recommendations. N Engl J Med 2005;353:2607-2612.
Mitchell SL, Buchanan JL, Littlehale S, Hamel MB. Tube-feeding versus hand-feeding nursing home residents with advanced dementia: a cost comparison. J Am Med Dir Assoc 2003;4:27-33.
Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA 1999;282:1365-1370.
Truog RD, Cochrane TI. Refusal of hydration and nutrition: irrelevance of the "artificial" vs "natural" distinction. Arch Intern Med 2005;165:2574-2576.
To the Editor: Casarett et al. discuss proxy decision making with respect to ANH for the patient who is not competent to make such decisions. In this article, the authors recommend that state laws not require "clear and convincing" evidence of a patient's wishes in such cases but, rather, a less burdensome standard of proof.
Although I agree that the current standard is difficult to prove, I must disagree with the feasibility of the authors' suggestion. The standard of clear and convincing evidence is a procedural safeguard used by the courts to ensure the avoidance of an erroneous decision with respect to weighty issues.1 In cases in which initiation or withdrawal of ANH would cause or prevent the death of the patient, such a high standard is required by due process under the U.S. Constitution.2,3
I agree that this evidentiary standard and the court process are burdensome, but changing them may not be possible. Alternatively, the best solution may simply be to avoid this legal issue by fostering good communication and decision making at the bedside and thus obviating the involvement of the courts.4
Darren P. Mareiniss, M.D., J.D.
North Texas Bioethics Network
Plano, TX 75025
dpmmd@sbcglobal.net
References
Addington v. Texas, 441 U.S. 418, 423 (1979).
Cruzan v. Director, Missouri Dept. of Health, 497 U.S. 261, 282-4 (1990).
Mareiniss DP. A comparison of Cruzan and Schiavo: the burden of proof, due process, and autonomy in the persistently vegetative patient. J Leg Med 2005;26:233-259.
Bloche MG. Managing conflict at the end of life. N Engl J Med 2005;352:2371-2373.
To the Editor: Casarett et al. state: "The bulk of the available evidence suggests that ANH does not improve the survival of patients with dementia" and give several references for this statement. Unfortunately, to the best of my knowledge, there has not been a single adequately controlled study to back up this often-repeated statement. What is needed is a prospective study in which a group of patients with dementia who are unable to swallow are divided into two groups, with one given ANH and the other no nutrition. It is inconceivable, physiologically, that the patients in the ANH group would not live longer than those who did not receive food. There may well be other valid reasons, as cited, for not imposing ANH on patients with dementia, but the data with regard to survival simply do not yet exist.
Shimon M. Glick, M.D.
Ben Gurion University
84105 Beer Sheva, Israel
gshimon@bgu.ac.il
The authors reply: Drs. Cochrane and Truog misunderstand our argument about ANH. We did not distinguish between "natural" and "artificial" interventions and agree that these terms have outlived their usefulness. Nor did we suggest that the right of patients to refuse ANH is grounded in the designation of ANH as a technical, medical intervention. Indeed, autonomous persons retain the right to refuse the impositions of others whether or not those impositions have a technical nature. Instead, we simply recommended that physicians describe ANH as a medical intervention to help patients and families better understand its risks and burdens. Finally, Drs. Cochrane and Truog suggest that ANH should not be considered a medical intervention because feeding is straightforward once a gastrostomy tube is placed. This argument is misleading and ignores the substantial risks and discomforts of the procedure itself.
Dr. Mareiniss's criticism, although technically correct, is also misleading. Although the courts can require clear and convincing evidence in order to protect a patient's best interests, Dr. Mareiniss errs in assuming that ANH is always in the patient's best interest. ANH does not always extend life, and it may be associated with substantial risks and burdens. If there were strong evidence that ANH improves the survival of patients with advanced dementia and weight loss, for instance, Dr. Mareiniss's argument might have merit. But we find his position puzzling, given the absence of evidence to support the efficacy of ANH for this indication.
Dr. Glick seems to make a similar error. He notes that no randomized, controlled trials have evaluated the survival benefit of ANH in patients with advanced dementia. He concludes that, therefore, we should assume that ANH is effective. This is an interesting approach to the practice of evidence-based medicine but one with which we are unfamiliar. In our experience, in the absence of convincing data with regard to effectiveness, and in the presence of data indicating substantial risks, one generally assumes that a treatment is not beneficial.
Dr. Glick finds it "inconceivable" that ANH is ineffective in patients with dementia. However, we need not look far to compile a list of treatments — such as trepanning, gastric freezing for ulcers, and even the use of sodium-channel blockers for the suppression of cardiac arrhythmias1 — that have been discredited. Presumably, the proponents of these treatments would have found it similarly "inconceivable" that they could ever be relegated to the wastebaskets of medical history. We should learn from our mistakes and temper our intuitions with both caution and the use of data.
David Casarett, M.D.
Veterans Affairs Center for Health Equity Research and Promotion
Philadelphia, PA 19104
casarett@mail.med.upenn.edu
Jennifer Kapo, M.D.
Arthur Caplan, Ph.D.
University of Pennsylvania
Philadelphia PA 19104
References
The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med 1989;321:406-412.