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Topic: Patient refusal of nutrition and hydration

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	Responding to Intractable Terminal Suffering..., Annals 7 Mar 00
		In contrast, for a patient with severe, unrelieved suffering and advanced, incurable illness, cessation of eating and drinking might be considered part of the right to refuse treatment (31, 48, 53).
		All severely ill patients who experience substantial suffering and have a poor prognosis should be informed about the potential of palliative care to address their symptoms (58, 59).
		Although the patient's refusal of food and fluids technically does not require the physician's participation, a physician should be part of the team who assesses the patient's request and provides palliative care as the process unfolds.
	www.acponline.org /ethics/quill.htm (4653 words)

	Policy on Patient Refusal of Life-Sustaing Treatment
		When a patient, or surrogate(s) acting on behalf of a patient, refuses recommended treatment, a dilemma can be created for health care professionals: respect for a patient's wishes can conflict with the obligation to help and not to harm the patient.
		Patients with decisional capacity (i.e., the ability to understand the consequences of their decisions) have the right to refuse to seek or accept treatment or care for a condition or illness.
		Refusal of a specific treatment does not of itself indicate that the patient lacks decision-making capacity; however, a refusal may initiate an inquiry about this capacity.
	www.clevelandclinic.org /bioethics/policies/patientrefusal.html (994 words)

	Nutrition Encyclopedia (Site not responding. Last check: 2007-10-24)
		With advances in molecular biology, biochemistry, and genetics, nutrition science is additionally developing into the study of integrative metabolism, which seeks to connect diet and health through the lens of biochemical processes.
		There is no apparent consistency in science-based nutritional recommendations between countries, indicating the role of politics as well as cultural bias in research emphasis and interpretation.
		Nutrition is taught in schools in many countries.
	www.hallencyclopedia.com /topic/Nutrition.html (6635 words)

	NUTRITION AND HYDRATION
		At other times, although the shortening of the patient's life is one foreseeable result of an omission, the real purpose of the omission was to relieve the patient of a particular procedure that was of limited usefulness to the patient or unreasonably burdensome for the patient and the patient's family or caregivers.
		For example, a confused or demented patient may find medically assisted nutrition and hydration more frightening and burdensome than other patients do because he or she cannot understand what it is. The patient may even repeatedly pull out feeding tubes, requiring burdensome physical restraints if this form of feeding is to be continued.
		When a patient is not competent to make his or her own decisions, a proxy decision maker who shares the patient's moral convictions, such as a family member or guardian, may be designated to represent the patient's interests and interpret his or her wishes.
	jmahoney.com /nutrition_and_hydration.htm (7966 words)

	Patient refusal of nutrition and hydration - Wikipedia, the free encyclopedia
		People who feel they are near the end of their life often consciously refuse food and/or water.
		Published studies [1] indicate that "within the context of adequate palliative care, the refusal of food and fluids does not contribute to suffering among the terminally ill", and might actually contribute to a comfortable passage from life: "At least for some persons, starvation does correlate with reported euphoria."
		Patient Refusal of Nutrition and Hydration: Walking the Ever-Finer Line American Journal Hospice and Palliative Care, pp.
	en.wikipedia.org /wiki/Patient_refusal_of_nutrition_and_hydration (119 words)

	Patient Refusal of Nutrition and Hydration
		Patient refusal of nutrition and hydration (PRNH) is hardly new, indeed, virtually all hospice clinicians remember people who came to a point in their illness when they could be described as having "lost their will to live" and who recognized that continued eating and drinking was having an undesired, life-prolonging effect.
		Patient refusal of nutrition and hydration meets this criteria and, thus, can be considered among the commonly accepted practices of patient-initiated refusal (or withdrawal) of mechanical ventilation, renal dialysis, or antibiotic use.
		In the process of informing and obtaining consent from patients -- and, perhaps especially, in discussions with the legal surrogate(s) of an incapacitated patient -- it must be remembered that the decision to prevent malnutrition or dehydration is a de facto decision to have the person die of something else.
	www.amsa.org /dd/prnh.cfm (3693 words)

	Today's Dietitian
		Nutrition support would be mandated for all patients in a persistant vegetative state even if against their wishes—whether stated or not.
		Voluntary refusal of food and fluids is regarded as voluntary, passive euthanasia since the medical team honors a competent patient’s refusal of intake with the full knowledge that death will result sooner than the natural course of illness.
		Patient refusal of hydration and nutrition an alternative to physician-assisted suicide or voluntary active euthanasia.
	www.todaysdietitian.com /newarchives/jan2006pg35.shtml (2212 words)

	EatRight.org Home Page (Site not responding. Last check: 2007-10-24)
		On the other hand, one may be reluctant to withdraw feeding because it is morally obligatory, the patient is neither terminally ill nor permanently unconscious, the family wishes to continue feeding, or withdrawal of nutrition and hydration is considered by the agent to be the intentional killing of the patient.
		Finn, with the conclusion that “withholding and/or withdrawal of artificial nutrition and hydration froma person in a persistent vegetative state merely permits the natural process of dying and is not mercy killing or euthanasia” (18).
		Their statement concludes that “we are concerned that withdrawal of all life support, including nutrition and hydration, not be viewed as appropriate or automatically indicated for the entire class of persistently unconscious patients simply because of a judgment that they are beyond the reach of medical treatment that would restore consciousness.
	www.eatright.org /index_adar0502.cfm (9674 words)

	Euthanasia - Wikipedia, the free encyclopedia
		Living wills and Do Not Resuscitate orders are legal instruments that make a patient's treatment decisions known ahead of time; allowing a patient to die based on such decisions is not considered to be euthanasia.
		Such declarations can be used when a patient is in coma or otherwise unable to state whether they want euthanasia or not.
		Usually the sedative sodium thiopental is intravenously administered to induce a coma, and after making sure the patient is in a deep coma, typically after some minutes, a muscle relaxant is administered to stop the breathing and cause death.
	www.wikipedia.org /wiki/Euthanasia (2693 words)

	Michael Schiavo ADMITTED on Larry King Live that he didn
		If we want to determine if subjects who are deprived of nutrition and hydration die any more comfortably than those who are nourished and hydrated, the subjects would have to be unaware of whether they are receiving food and fluids or not.
		Ira Byock, another proponent of helping patients to die by withholding food and fluids, admits that the clinical reports of patients dying peacefully or in a euphoric state are just anecdotal and have not been matched by research studies.
		Given the glaring flaws in the research about the sensations of starving patients and the ethical impossibility of designing research studies on this question that are any better, it is clearly an expression of bias to publicize to patients the "comfort" of self-starvation.
	www.propertyrightsresearch.org /2005/articles03/michael_schiavo_admitted_on_larr.htm (5651 words)

	ANA Position Statement: Foregoing Nutrition and Hydration
		In cases where a patient is unable to make his wishes known, or is unable to evaluate the benefits and harms of refusing artificial nutrition and hydration, the decision of a surrogate should be relied upon.
		In circumstances in which the patient never has been competent (including infants, children, many mentally disabled persons, and the never competent mentally ill), the patient's surrogate in collaboration with the health care team decides whether the provision of artificial nutrition and hydration is in the patient's best interest.
		A process for transferring care of a patient to another qualified nurse, when a decision to forego artificial nutrition and hydration conflicts with the nurse's own personal beliefs and values, should be in place in each institution.
	www.nursingworld.org /readroom/position/ethics/etnutr.htm (1341 words)

	Physician-Assisted Suicide and Active Euthanasia: An Annotated Bibliography, Courtney Garroutte,student essays,PAS, ...
		This article surveys the possibility that a rational and competent patient can refuse hydration and nutrition as a way to end their suffering and/or life without the ethical problems associated with PAS and euthanasia.
		Patients are required to request the medication that will end their lives on two separate occasions and must put in writing that they request to die.
		The intention most patients and physician have when choosing to implement PAS are not intentions of death, moreover, they are intentions of relieving pain or ending suffering.
	www.englishdiscourse.org /edr.1.3garroutte.html (1791 words)

	NUTRITION AND HYDRATION
		At other times, although the shortening of the patient's life is one foreseeable result of an omission, the real purpose of the omission was to relieve the patient of a particular procedure that was of limited usefulness to the patient or unreasonably burdensome for the patient and the patient's family or caregivers.
		For example, a confused or demented patient may find medically assisted nutrition and hydration more frightening and burdensome than other patients do because he or she cannot understand what it is. The patient may even repeatedly pull out feeding tubes, requiring burdensome physical restraints if this form of feeding is to be continued.
		When a patient is not competent to make his or her own decisions, a proxy decision maker who shares the patient's moral convictions, such as a family member or guardian, may be designated to represent the patient's interests and interpret his or her wishes.
	www.jmahoney.com /nutrition_and_hydration.htm (7967 words)

	Advance Directives: Frequently Asked Questions
		A Living Will is a legal document in which patients are able to state in advance their desire to receive or their desire to withhold life support procedures when they are permanently unconscious or terminally ill and unable to make informed decisions.
		Patients' expressed preferences about health care treatments should be documented as they evolve in the course of treatment.
		Quality medical care also includes providing patients with the supportive atmosphere in which to reflect on end of life choices and to allow their wishes to be communicated to their health care providers and to their families.
	www.clevelandclinic.org /bioethics/patients/adfaq.html (1330 words)

	Treatment of Pain and Suffering in the Terminally Ill - Chapter 13
		Although physicians are obliged to honor a patient’s directives to forsake life-support therapies, they also have the right to try to influence the patient in a direction different from the one chosen, as long as it is done with respect for the patient’s autonomy and not by coercive or manipulative means.
		Second, because the patient has a prolonged period in which to change his or her mind, one avoids the possibility the decision was made in a moment of irrational thinking, for it gives ample opportunity for reflection and retraction.
		Third, a pact should be made by the patient with his or her physician to use appropriate therapy to minimize suffering during the dying process and to remain available to comfort the patient by physical presence as well as treatment of symptoms, including pain, dyspnea, and dryness of the mouth.
	www.preciouslegacy.com /chap13.html (5306 words)

	"Dying Comfortably" of Starvation and Dehydration: What Is the Evidence? (Site not responding. Last check: 2007-10-24)
		Typically, the patients and the medical staff were aware that the patients were not being nourished and hydrated.
		Ira Byock, another proponent of helping patients to die by withholding food and fluids, admits that the clinical reports of patients dying peacefully or in a euphoric state are just anecdotal and have not been matched by research studies.
		Given the glaring flaws in the research about the sensations of starving patients and the ethical impossibility of designing research studies on this question that are any better, it is clearly an expression of bias to publicize to patients the "comfort" of self-starvation.
	www.stbernardch.net /vm/index.asp?vm_id=2&art_id=27477 (1357 words)

	Decubitus Ulcers - Explanation
		Patient's rights, as it is currently practiced, allows for patient refusal of medications, food, fluids and treatments such as turning.
		Patient refusal of nutrition and positioning may lead to the development of decubitus ulcers as well.
		It is possible to greatly reduce pressure ulcer development by frequent turning and appropriate padding even in terminal situations were a patient is not receiving nutrition and hydration.
	www.ldhpmed.com /DU_explanation.htm (1569 words)

	Nutrition and Hydration: Moral and Pastoral Reflections
		Ideally the patient will act with the advice of loved ones, of health care personnei who have expert knowledge of medicai aspects of the case, and of pastorai counselors who can help explore the moral issues and spiritual values involved.
		[40] Morally even the patient making decisions for himself or herself is bound by norms that prohibit the directly intended causing of death through action or omission and by the distinction between ordinary and extraordinary means.
		Here, too, moral limits remain relevant - that is, morally the proxy may not deliberately cause a patient's death or refuse what is clearly ordinary means, even if he or she believes the patient would have made such a decision.
	www.embracingourdying.com /church/nutrition9.html (380 words)

	Dehydration Summary
		Patients who are dehydrated due to diabetes, kidney disease, or adrenal gland disorders must receive treatment for these conditions as well as for the resulting dehydration.
		For severe cases of dehydration where fainting, unconsciousness, or any other severely inhibiting symptom is present (the patient is incapable of standing or thinking clearly), emergency attention is required.
		In extreme cases, the losses may be great enough to exceed the body's ability to absorb water from the gastrointestinal tract; in these cases, it is not possible to drink enough water to stay hydrated, and the only way to avoid dehydration is to reduce perspiration (through rest, a move to a cooler environment, etc.).
	www.bookrags.com /Dehydration (2909 words)

	Artificial nutrition and hydration:It is time to take a stand - George P. Graham - Homiletic & Pastoral Review - ...
		The directives (58) indicate that there should be a presumption in favor of providing nutrition and hydration to all patients as long as this is of sufficient benefit to outweigh the burdens involved to the patient.
		The most fundamental principle governing the morality of nutrition and hydration is that taught by Pope John Paul II in The Gospel of Life—the absolute inviolability of innocent human life.
		A second major case involving refusal of nutrition and hydration involved Nancy Beth Cruzan, a young accident victim who was being fed with a gastrostomy.37 This is the only case involving the withdrawal of ANH that went to the United States Supreme Court.
	www.catholic.net /RCC/Periodicals/Homiletic/May1999/nutrition.html (5210 words)

	Withdrawing Medical Nutrition and Hydration (Site not responding. Last check: 2007-10-24)
		Competent patient, of course, may refuse MN and H, though of course morality of such a refusal can be questioned.
		They further assert that if the 'burden' one is trying to relieve by discontinuing medically assisted nutrition and hydration is the burden of remaining alive in the allegedly undignified condition of PVS, such a decision is unacceptable, because one's intent is only achieved by deliberately ensuring the patient's death from malnutrition or dehydration.
		Such patients might include those with fairly severe dementia for whom the restrains required could be a constant source of fear, discomfort, and struggle.
	www.su.edu /faculty/bpennhol/Phil130.MNH.htm (1727 words)

	Hospice and Palliative Care - Ira Byock
		Ira R. Byock, M.D. In the midst of an increasingly heated debate over physician-assisted suicide (PAS) another option available to patients who are determined to end their lives is receiving serious attention -- the conscious refusal of nutrition and hydration.
		While the currently available research is not exhaustive, hospice clinicians now possess respectable scientific data to supplement anecdotal experience in forming their own opinions, and informing patients about nutrition and hydration.
		The practice of a physician or nurse responding to a patient's request for assistance in suicide by discussing the option of refusing to eat or drink appears to stretch the "fine line" of ethical practice to the point of disappearing.
	www.dyingwell.com /prnh.htm (3658 words)

	Statement of Principles for Healthcare Decisions Concerning Assisted Nutrition and Hydration and Related Issues' (Site not responding. Last check: 2007-10-24)
		The responsibility to provide or to continue to provide Assisted Nutrition and Hydration (ANH) — referred to by some as artificial nutrition and hydration — to individuals who are diagnosed to be in a so-called Persistent Vegetative State (PVS) is one of the most challenging medical-moral issues confronting individuals and families.
		For instance, there is a clear consensus that assisted nutrition and hydration are "not morally obligatory either when they bring no comfort to a person who is imminently dying or when they cannot be assimilated by a person’s body" (ERD, Part 5).
		We hold for a presumption in favor of providing medically assisted nutrition and hydration to patients who need it, which presumption would yield in cases where such procedures have no medically reasonable hope of sustaining life or pose excessive risks or burdens.
	www.archstl.org /commoffice/2000/columns/000714.htm (819 words)

	Dehydration: Why It Is So Dangerous - Diarrhoea, Diarrhea, Rehydration
		Dehydration caused by diarrhoea is one of the biggest single killers of children in the modern world and diarrhoea itself is one of the major causes of nutritional loss and poor growth.
		In severe dehydration, these effects become more pronounced and the patient may develop evidence of hypovolaemic shock, including: diminished consciousness, lack of urine output, cool moist extremities, a rapid and feeble pulse (the radial pulse may be undetectable), low or undetectable blood pressure, and peripheral cyanosis.
		For severe cases of dehydration where fainting, unconsciousness, or any other severely inhibiting symptom is present (the patient is incapable of standing or thinking clearly), emergency attention is required.
	www.diarrhoea.org /dehydration (1538 words)

	Fasting - information and nutrition related article
		Because the presence of food in a person's system can cause complications when they are anesthetized, medical personnel strongly suggest that their patients fast for several hours before the procedure.
		People who feel they are near the end of their life sometimes consciously refuse food and/or water.
		The term in the medical literature is Patient refusal of nutrition and hydration.
	www.nutrition-information.net /Fasting.html (2904 words)

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