Suaaort Line April 2006 Volume 28 No. 2

On February 2 5, 1990, Terri Schiavo, then 27 years of age, suffered cardiac arrest believed to be due to hypokalemia caused by an eating disorder, resulting in severe hypoxic-ischemic encephalopa- thy Because Mrs. Schiavo left no advance directive, in accordance with principles of standard ethical and legal practice, health-care decisions on her behalf became the right of her husband, Michael Schiavo. Mr. Schiavo was also made the legal guardian under Florida law, which delegates the spouse as the decision-maker in the absence of a named health-care proxy. After 3 years of traditional and experimental treat- ment, Michael Schiavo accepted the neurologic diagnosis of PVS. Believing that his wife would not want to be kept alive in this irreversibly incapacitated condition, and recalling her past state- ments to this effect, Mr. Schiavo made his first decision to withhold treatment for urinary sepsis. The Schindlers, Terri's parents, did not agree with this decision aiid attempted to have Michael

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ersistent (Permanent) Vegetative State and Nutrition Support ria R. Andrews, MS, RD, FADA, CNSD, CHE Ws*-++$iJ$

forum; picketing by special &erest groups outside the hospice where Terri spent her final days; death threats on the part of some extremists; and a media spectacle.

This story prompted many dietitians and other nutrition support professionals to ponder their moral, ethical, and legal obligations related to the provision of amficial nutrition and hydration for PVS patients. Before exploring these issues, it is important to understand the condition of PVS and associated diagnostic criteria.

What is PVS?

The 1994 Multi-Society Task Force on PVS of the American Academy of Neurology defined persistent vegetative state as a vegetative state 1 month after acute brain injury or from degenerative or metabolic disorders. Vegetative state was defined by the Task Force as a "complete unawareness of the self and the environment, accompanied by sleep- wake cycles, with either complete or

partial preservation of hypothalamic and brain-stem autonomic functions" (3). Function of the cerebral cortex and thdamus are lost, but the brainstem is relatively intact. Because patients in a PVS retain autonomic brain function and are capable of involuntary responses, including the ability to breathe indepen- dently, most do not require mechanical ventilation. Although it may seem counterintuitive, patients in a PVS have sleep-wake cycles, yet are considered to be unconscious. They are not aware of themselves or the environment (3). Because patients in a PVS lack self- awareness, they do not have capacity to suffer (4). The gag, cough, and swallowing reflexes usually remain intact. Hand-feeding, therefore, is possible if food is placed at the back of the throat, but most patients are tube- fed for reasons of safety and practicality (5). Most have reflex eye movement but cannot purposefully track moving objects or move eyes voluntarily. Patients in a PVS cannot move their

T~~~~~ ~~~i~ schiavo ( a ~ ~ ~ ~ i , , ) died on March 3 1,2005, after 15 years in a persistent vegetative sbte ~ V S ) and a lengthy family, legal, and political battle that was played out in aided by seemingly unending media coverage. The Terri Schiavo case renewed interest and raised concern among health professionals as to the appropriate treatment of patients in a PVS. The case has special meaning to nutrition support dietitians because thv decide the appropriateness of tube feeding for

population and Other members of he health-care team and the family in the decision-makng process regarding the feeding. This article provides an overview of nutritional, medical, ethical, legal, and moral issues relevant to the provision and withdrawal of artificial nutrition and hydration in this population.

Introduction trunks or extremities. Some may utter vocalizations such as grunts; many show a variety of facial expressions and may smile or shed tears. However, these actions are neither voluntary nor purposeful. Other diagnostic criteria are included in the Table (6).

The Multi-Society Task Force intro- duced the term permanent vegetative state with temporal cut-offs to qualify as permanent, depending on the cause of injury. The Task Force concluded that recovery from a PVS in adults and children due to posttraumatic injury is unlikely after 12 months, and recovery after 3 months is very rare if a PVS was caused by nontraumatic brain injury. The picture is bleaker for patients in a PVS due to degenerative or metabolic disorders in whom there is no possibility of recovery (4). This ~ulti-Society+.@ Task Force report was approved by' the American Academy of Neurology, Child Neurology Society, American I Neurological Association, American

removed as Tem's legal guardian. While the court case was playing out, an interim pardim was named. U1timatelJ', the S~hhldler's efforts fded, and Michael resmed guardianship. This set the

for the long personal and legal battle between the Schindlers and

'chiavo (I). It wasn't until 8 years after the initial

event that led to the PVS diagnosis thit Michael requested removal of feeding. The Schindlers refused to accept Tem's condition as irreversible and expressed some fundamental religious convictions that compounded schism (1). The case was embroiled in conmnersy from court decisions that were handed down, then later overturned by the Florida legisla- ture, prompted by a plea from Florida's governor; the unprecedented action by the United States Congress, which met in a special emergency session on March 20,2005, to pass legislation aimed at intervening on Terri's behalf (2); a United States President pro- claiming his moral stand in a public

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Association of Neurological Surgeons, and the American Academy of Pediatrics (3,7).

Following the Multi-Society Task Force report, the American Congress of Rehabilitation Medicine issued a position statement that asserted that

- the PVS diagnosis should not be made until 12 months after injury. Because this view conflicted with that of the American Academy of Neurology, the Aspen (not to be confused with the American Society for Parenteral and Enteral Nutrition) Neurobehavioral Conference, composed of delegates from neurology, neurosurgery, and neurorehabilitation, developed a consensus statement on prognostic and diagnostic criteria for vegetative state. Participants at the Aspen Conference developed various prognostic parameters, depending on the underlying cause of the brain injury. They recommended that the term persistent vegetative state be abandoned in favor of permanent vegetative state when the time limits were passed, as outlined in their state-

Neurology as a teaching tool (7). PVS is distinguished from coma,

a condition in which the patient is unconscious, lacking both awareness and wakefulness, and from brain death in which patients lose all brain functions, including brainstem flnctions. In addition to assisted feeding, patients who are in a PVS require daily skin care and personal hygiene, along with range of motion exercises to slow the development of contractures. With good nutritional, nursing, and medical care, those who are in a PVS can survive for long periods of time (6);

Although there now seems to be consensus among experts, the lack of unanimous consensus during this past decade among health professionals on the nomenclature, definition, and criteria for diagnosing unconscious states has, in part, contributed to the confusion wimessed in the Schiavo case. The addition of public, congressional, and media misinformation about the PVS ignited the powder keg of controversy that was wimessed in this case.

ment, he^ also operationally defined a new condition entitled minimally 1 Nutrition Support in PVS

conscious state, a term reserved for patients who retain some capacity for cognitive function, which is distinguish- able &om patients in a vegetative state. The &pen statement was ultimately endorsed by several professional organizations that also endorsed the Multi-Society Task Force position and is used by the American Academy of

Feeding should begin as soon as the patient is medically stable and should continue until PVS is diagnosed defin- itively and the decision to withdraw feeding is made by those with legal and ethical authority to do so. Patients should be provided feeding, generally by tube, in appropriate composition and volume based on accepted standards

rable. Diagnostic Criteria for PVS

No evidence of awareness of self or environment

No evidence of ability to interact with others

No evidence of sustained; reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile, or noxious stimuli

No evidence of language comprehension or expression

Sufficiently preserved hypothalamic and brainstem autonomic functions to pennit survival with medical and nursing care

Bowel and bladder incontinence

Variably preserved cranial nerve reflexes (pupillary, oculocephalic, corneal, vestibulo-ocular, and gag) and spinal reflexes

Reproduced with permission from the National Center for Ethics in Health Care of the Department of Veterans Affairs (6).

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of practice (i.e., adequate quantities to preserve life and skin integrity) (5). Fiber-containing formulas may be helpful in maintaining normal bowel function (5,8). Initially, tube feeding may be given by nasogasmc tube, but if the feeding is required beyond 30 days, a gastrostomy tube should be placed (9).

Ethical and Legal Issues and Withdrawal of Nutrition Support

When the decision is made to with- draw medically assisted nutrition and hydration in accordance with the patient's wishes, as expressed in the form of an advance directive, or by a surrogate decision maker, the nutrition support professional should follow the principles of medical ethics and consider standards of ethical practice, as defined by their professional organization.

It has become an accepted standard of practice to view artificially provided nutrition and hydration as a treatment that may be withheld or withdrawn. While decisions to withdraw treatment are more emotionally laden, there is no ethical, moral, or legal distinction between withdrawing and withholding treatment (i.e., no difference between discontinuing life support and not start- ing it). These standards were affirmed by the United States Supreme Court in the 1990 Cmmn decision, ironically another case involving withdrawal of tube feeding in a young woman in a PVS (10). In the case of PVS, the issue usually centers on withdrawing numtion support because the diagnosis does and should take some time to confirm.

The principles of medical ethics that are relevant to decisions about the withdrawal of numtion support are autonomy, beneficence, nonrnaleficence, and justice.

Autonomy In American society, autonomy is

the cornerstone of medical ethics (5). Autonomy is defined as the right of a person with decisional capacity to self- determination (i.e., the patient's right to make the final decision) after the individual is afforded appropriate and complete information on which to base the decision. This process is known as informed consent. The right of

autonomy may seem to be compromised by being in the PVS because affected patients cannot directly communicate wishes. However, the right to self- determination is extended to patients who have lost decisional capacity through advance directives and verbal testimony of those who knew them. Sound ethical practice dictates that the patient's prior expressed wishes be honored in the event of incapacity. Although written evidence of the patient's wishes is always helpful, it is not required. Verbal testimony of those who knew the patient may be used to guide treatment decisions.

In the case of a patient who is incapable of making a decision, nutrition support and other health- care professionals should turn to the surrogate for treatment decisions. If the patient named a durable power of attorney for health care (DPAHC) in a written directive, it is this person who has the ethical and legal authority to make health-care decisions. This may or may not be a blood relative of the patient. If no DPAHC has been desig- nated, the next of kin is empowered to make substituted judgment or best interest decisions on behalf of the patient. Substituted judgment implies that the person making the decision has knowledge of the patient's wishes and, therefore, makes a decision that the patient would have made if able. If the person's wishes are not readily known, best interest is the guiding principle. To employ this principle, the risks and benefits of the procedure or treatment are weighed as they relate to the patient's values, meaning, source of fulfillment, and priorities. Although the order of priority of next of kin may vary among states, the patient's spouse universally is viewed and accepted as the one who has primary authority.

Beneence Beneficence means to do good or

achieve benefit (i.e., the action taken should be one that will bring about the most good for the patient). "Good" may be defined differently by different people. In the case of PVS, some may view "good" as maintaining life at all costs. Others consider death to be

preferable. According to a Harris poll conducted the month after Terri Schiavo's death, United States adults favor not using life support technology to prolong the life of someone in a PVS by a nearly 4-to-1 margin (1 1).

Nm-cence Nonmaleficence is defined as "to do

no harm," (i.e., beneficence defined from a different approach). Primurn a m nocere (above all, first do no harm) is a basic premise of medicine (12). . Judging whether a treatment such as tube feeding may have more harm thah benefit in the case of PVS is more dif- ficult than in other terminal conditions unless it is c o n w to the patient's right of autonomy or the patient clearly shows signs of feeding intolerance. Failing to discontinue treatment when the desire to discontinue is in keeping with the patient's or surrogate's wishes or when the treatment becomes more burdensome than beneficial is a viola- tion of the principle of autonomy and nonmaleficence, respectively (13).

referred to as distributke justice, is the fair allocation of resources. An ethical conflict occurs when individual needs that consume funding are advanced to the detriment of available resources for others (13). The moral equivalent to this ethical principle is "fairness," that is, each person is treated as equal to all others in the same or similar circumstance (14). Although this concept has not been explicitly considered in the context of resources consumed by patients in a PVS, who are often cared for in nursing homes with federal funding sources, this discussion is beginning to surface. Questions on the equitability of allo- cating scarce health-care resources to someone who is unaware of his or her surroundings and will not recover from his or her condition are being raised in private discussions and in the medical literature (1 5). As this debate intensifies,

. it has been suggested that, employing the principle of justice, people who choose to continue life-sustaining treatment despite a diagmsis of PVS should be required to purchase special insurance to pay for such care (14).

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Professimal statements Professional organizations have

weighed in on this issue, producing position statements, some of which are specific to PVS. The American Dietetic Association (ADA) issued two relevant position papers, one addressing terminal illness in general (14) and the other specific to feeding permanently uncon- scious patients (5). The ADA affirms the patient's right to refuse treatment, including artificial nutrition and hydration, stating that "the principle of autonomy is one of the fundamental principles underlying medical care choices" and "affirms the patient's right to self-determination as the overriding principle" (14). The ADA charges dietitians with the responsibility to work collaboratively with other members of the health-care team and take an active role in deliberations of ethics and numtion support decisions. The ADA asserts that the dietitian's under- standing of this issue in the context of cultural, social, psychological, spiritual, and nutritional requirements provides an excellent basis for participation in deliberations. The ADA recognizes conditions in which feeding may be discontinued, including PVS (5,14).

Similar sentiments are expressed by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) (8), American Nurses Association (ANA) (1 6), American Medical Association (AMA) (1 7, 18), Society of Critical Care Medicine (SCCM) (19), American College of Physicians in cooperation with' the American Society of Internal Medicine (20), Hastings Center (2 l), and the American Academy of Neurology (AAN) (4,22,23). Each of these orga- nizations views medically assisted nutrition and hydration as medical treatments that may be withheld or withdrawn at the patient's or surrogate's request or when the burdens exceed the benefits. In their position paper, the AAN asserts that artificial numtion and hydration may be discontinued in accord with the same principles and practices that govern other forms of medical treatment. It further states that the patient's right to self-determination is central to the ethical, legal, and

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medical principles that encompass decisions about treatment. It is AAN's position that treatment that provides no benefit may be discontinued and "medical treatment, including the provision of artificial nutrition and hydration, provides no benefit to patients in a persistent vegetative state, once the diagnosis has been established to a high degree of medical certainty" (2 3).

I Symptoms Associated with Withdrawing Nutrition Support

When tube feeding is discontinued in a patient in a PVS, the typical length of survival is 10 to 14 days. Death occurs as a result of dehydration (not malnu- trition) and electrolyte imbalance (4). There may be reluctance on the part

I of health professionals, including 1 nutrition support specialists, to with-

draw nutrition support based on the belief that this action causes suffering (24). The media fostered this belief through inaccurate news reports during

// the withdrawal of tube feeding of Terri Schiavo. This sentiment is contrary to

I factual data. First and foremost, by definition,

patients in a PVS do not have the capacity to suffer because of their lack of self-awareness. Extensive clinical

I experience, positron emission tomogra- phy scans, and neurologic examinations formed the basis of the conclusion that patients in a PVS are insensate and unaware and lack the cerebral cortical capacity to be conscious of pain (4).

Second, reports from those who have witnessed the death of patients in a

I PVS following withdrawal of feeding document the peaceful nature of this process (10). Such patients do not experience hunger or thirst. Facial swelling from prolonged artificial feeding and hydration begins to

I decrease as the patient becomes I progressively dehydrated, and the face 1

i may assume a more normal appearance. Except for obvious dryness of skin and mucous membranes, impending death from acute dehydration may not be apparent to the family or health-care workers (4).

These findings are in keeping with the experiences by hospice professionals, whn rennt-t thgt rleh~rrlrotinn in the

terminal patient is neither distressful nor painful. On the contrary, they report relief from distressing symptoms of dying when artificially provided nutrition and hydration are withdrawn from this population (25-35). Joyce Zenvehk, a hospice nurse, was the first to report this phenomenon in her pioneering article, "The Dehydration Question" (25), in which she reported that dehydration is palliative for termi- nal patients. She reported relief from choking and drowning sensations, with less coughing and congestion, as . pulmonary secretions are lessened; decreased urine output, with less need for catheterization and fewer bedwetting episodes; decreased gastrointestinal fluid, with fewer bouts of vomiting, bloating, and diarrhea; decreased peripheral edema; and no need for restraints to prevent patients from dislodging their tubes or intravenous lines. The only untoward symptom is dry mouth, which is easily ameliorated with good mouth care. This translates to a comfortable and peaceful death, with less pain and distress. Many others have aflirmed this position (26-35) such that it has now become an accepted standard of practice in palliative care to avoid the use of medically assisted nutrition and hydration. Therefore, concern about withdrawing nutrition support in the patient who is in a PVS because it will involve suffering is unfounded.

It is important to note that once the decision is made to discontinue feed- ing, intravenous hydration should not be provided lest the patient's death is unnecessarily prolonged, with death occurring from malnutrition, not dehydra tion.

Religious and Moral Considerations

The consideration of withdrawing medically assisted nutrition and hydra- tion in a PVS, as with other terminal conditions, involves religious beliefs for patients, families, and clinicians. The subsequent discussion is not meant to be an exhaustive review of this very complex topic. It is only meant to highlight some of the discussion among religious experts that has appeared in the rerent I i t ~ r q h ~ t - P

The major religious organizations in the United States respect the sanctity of life, but it is dangerous to generalize specific positions of the various faith traditions because there is often lack of agreement within traditions. In general, and with a few exceptions vocalized by more conservative factions, the major religious organizations in this country accept the position that artificial num- tion and hydration is a medical treatment that may be withheld or withdrawn in the case of terminal illness, when bur- dens of treatment outweigh benefits, or if no benefits can be derived from the treatment. Members of most faith traditions are not compelled to accept technology to prolong life ( 3 6 4 9 , but there is no universal or unanimous acceptance of this position. Therefore, the health professional must be sensitive to individual variation and take an individualized approach. When religious and moral dilemmas arise, it behooves clinicians to encourage patients and/ or surrogates to seek guidance from religious authorities of their own tradition (1 3).

The Jewish and Roman Catholic traditions have been vocal, as of late, on the specific topic of withdrawing artificial nutrition and hydration in the case of PVS, so the remainder of the discussion focuses on these religious traditions.

Jewish Tradition Elliot Dorff, rabbi, rector, and

philosopher at the University of Judaism and vice-chair of the Conservative Movement's Committee on Jewish Law and Standards, offers a summary of applying Jewish law to PVS and out- lines the varying positions of the three major approaches to the Jewish trad- tion (37). The three primary approaches to Judaism are Orthodox, Conservative, and Reform. The basic religious differ- ences involve the extent to which ancient Jewish law is interpreted. Orthodox Judaism maintains that the interpreta- tion of Jewish law cannot be applied to new circumstances. It is binding because it is the will of God. Conservatives believe that, although God's law is binding, it has been the product of human interpretation over time and ~ n n t ; n n ~ c tn A e T r e l n n P I T ~ ; P C + +n inter-

pretation of rabbinic scholars. Reform Judaism is the most liberal in that it asserts that individual Jews may make decisions based on their own interpre- tation of the law. In addition to the differing religious approaches, there are cultural differences. Jewish faithful from different countries, generations, or families differ in their approach to Jewish tradition and medical issues.

With regard to artificial nutition and hydration, most Orthodox and some Conservative rabbis consider this as food and fluid that is necessary and, therefore, must continue. On the other hand, the Conservative Movement's

on J e w ' Law and Standards views medically assisted nutrition as a "medicine" that may be withheld or withdrawn when there is no reasonable hope for recovery. In this case, such treatment is considered as merely prolonging the dying process. Specific to the issue of PVS, there are two arguments that may, in the eyes of Conservative Judaism, justify discontin- uation of nutrition support. If nutrition and hydration fall within the category of "medicinen rather than "food," a view that is held by some but not all of this tradition, then it may be argued that because the artificial form of nutrition is unable to cure, it may be discontinied. The second factor that may justify withdrawing feeding in the case of PVS involves the definition of "brain death." If brain death is defined as the irreversible function of the neocortex rather than the whole brain, the person in a PVS is considered dead, thereby justifjmg withdrawal of nuuition. Most Jewish scholars of the Orthodox and Conservative movements do not accept the latter definition. More liberal Conservative Jews and the Conservative Movement's Committee on Jewish Law and Standards relate more to the first point of artificially provided nutrition and hydration as medical treatments that may be withheld or withdrawn under circumstances previously outlined. Reform Jews generally decide on the matters based on their own conscience. Rabbi Dorff cautions physicians that while Jewish tradition is hesitant to remove life support from a patient in a PVS, not allJews follow the guidelines

of their particular tradition, and the guidance of rabbis also varies (37).

Catbolic Traditim Pope John Paul 11 issued a papal

allocution as he addressed the International Congress on Life- Sustaining Treatments and the Vegetative State on March 20,2004 (45). This statement created a wave of controversy both outside and within the ranks of the Roman Catholic Church. It has been suggested that the allocution was prompted by the Terri Schiavo case. Her parents were Romah Catholic, were vehemently opposed to the discontinuation of Teni's feeding, and sought spiritual guidance from Rome (46).

An allocution is a formal speech that, in the eyes of the Roman Catholic Church, is a form of teaching. It is not meant to be a statement of "infallible truth," but it is meant to clarify how the Church applies principles to a particular In this statemenS the Pope decreed that in case of PVS, the administration of food and fluid, even when provided by artificial means, always represents basic care that must be provided (i.e., ordinary and, therefore,

o b l i ~ t o ~ ) . The allocution is based on several premises, the accuracy of which will not be debated in this article, including high numbers of diagnostic errors with pvs, documented cases of at least partial recovery, and the right to basic health care that includes "nutrition, hydration, cleanliness, and warmth..." (45). It considers the with- drawal of fee- in these cAmmmnces as lldn to euthanasia and the that removal of feeding results in death by starvation and dehydration, which, according to this document and in contrast to what has been presented in this article, causes suffering. It is important to underscore that the allocution refers only to the case of PVS and should not be interpreted as guidance for other conditions, such as terminal illness (45).

Some view this statement as a major reversal in Catholic Church moral tra- dition (47). In the previously published Ethical and ReZig"YI Directives (ERDs) fi Catholic Health Care Services, parts 5

and 58 allow for the discontinuation of artificially provided nutrition in the case of terminal illness and when burdens outweigh benefits (46). This directive asserts that Catholics are not obligated to preserve life if, in the judgment of the patient, there is excessive burden. The Catechrjrn ofthe Catholic Church affirms this right by stating that to discontinue burdensome, dangerous, extraordinary, or disproportionate treatments is legitimate. The ERDs empbix bt +rOportiomte burden is dehed by the patient sendment is consistent with the Vatican's 1980

on Euthae and Pope John Paul's encyclical letter Evangelium lhze (48).

Others argue that the allocution is consistent with traditional Catholic moral teaching, with a distinction drawn between food being useful prr md ineffective per accidens. In other words, according to the allocution, the provi- sion of food and fluid is, in principle, ordinary and pmportionate yet does not Preclude the possibility of a moral judgment on the appropriate use of artificially provided food and fluid in particular patient circumstances (49).

Two divergent responses to the d o - have emerged from catholic

theologians. One position maintains that artificial feeding is a benefit to the patient in a PVS by preserving life, irrespective of qudry. proponents argue that unconsciousness is not a fPcal pathology; the live for a long time with good norsing and nutritional care. From their point of view, withdrawing nutrition in this population, who they claim are not d+g, is lkin to passive euthanvia.

The opposing view holds that artifi- cial feeding in a PVS is of no benefit to the patient because it preserves only biologic life and cannot restore the patient to a state in which he or she can pursue higher goals. In this viewpoint, artificial feeding is not only futile but is excessively burdensome because the patient never will be able to pursue the higher goals of life. Proponents favor the presumption artificial nutrition md hydration in this population (36).

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The nutrition support dietitian and other health-care providers should be aware that the jury is still out on how this will affect their practice in terms of caring for patients in a PVS from different faith traditions and in terms of the policies that govern their place of work Sensitivity to and acceptance of differing opinions and approaches is key to ensuring patient autonomy.

An Ethical Framework for Conflict Resolution

The Schiavo case is not unique. With literally thousands of patients in the United States having diagnoses of PVS, it is inevitable that the nutrition support dietitian will encounter con- flict that involves feeding decisions. Some basic competencies are essential to be prepared to respond effectively to such situations.

Knowledge and Continuing Eduuztion Extensive knowledge of nutrition

support treatments, including indica- tions, contraindications, potential benefit, and complicatiops in various conditions, is pivotal to the ability to guide patients, surrogates, and the health-care team effectively in making appropriate feeding decisions. One must also possess knowledge of medical ethics, professional ethics, legal issues, and moral issues surrounding such decisions. It is essential that nutrition professionals be well-versed in the emerging body of knowledge of nutri- tion support treatment. "Good ethics begins with good facts" (12).

Communicatratrm Knowledge must be shared, and good

communication is the key. Effective communication involves effective listening and speaking. Involved parties must have a safe venue for communi- cating concerns, facts, and ethical principles. Health-care professionals also must be skilled at presenting information in a form that the patient or surrogate can understand (12).

A United Fnmt Nothing is more confusing to patients

and families who are attempting to make very important, life-altering health-care decisions than conflicting information

from the health-care team. The team must reach a consensus on the appro- priate ethical and clinical approach and present this in a form that demonstrates a united front. It may be helpful to seek consultation with the facility's ethics committee. It is desirable for a numtion support dietitian to be part of the ethics committee (12).

I Conclusions

Based on the principles of medical ethics, the position of many healthlcare professional organizations (including ADA and U.P.E.N.), moral reasoning, and legal precedent, artificial nutrition and hydration are considered the same as any other medical treatment and may be withheld or withdrawn under certain circumstances.

Conflicting ethical principles and differing personal views may lead to conflict in health-care decision making that requires the attention of nutrition support dietitians and other health-care professionals. Decisions surrounding feeding are often the most difficult because the giving of food has emotional and symbolic meaning. Yet, feeding at any cost and by any method may not always represent the best choice from both a clinical and personal perspective. Some basic guidelines can assist the numtion support dietitian in playing an active role in facilitating sound clinical, ethical, legal, and moral decision making. The "12 Cs" proposed by Barrocas and associates (12) provide a template for dealing with conflicting forces: common sense, common decency, competence, commitment, communications, consultation, collab- oration, consent/consensus, concern, care, compassion, and comfort.

Maria R. Andrews, MS, RD, FADA, CNSD, CCHE, is Chief; Nummtion and Food Service, New Mexico VA Health Care System, Albuquerque, N.M.

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Presbyterian Church USA; 1983. I

Dietitians in Nutrition Support

Mark your calendar for the upcoming DNS-Nestle Advanced Skills Workshop When: June 16 & 17,2006

Where: USC Surgical Skills Center & Pasadena Hilton,

Workshop Curriculum: Hands-on and didactic sessions on physical assessment, feeding tube placement, and indirect calorimetry as well as a Round Table session on various nutrition support topics.

Registration Fee (includes all sessions and meals): Early Bird (by May 15): $275 for DNS members and $325 for non-DNS members; after May 15: $300 for DNS members and $375 for non-DNS members.

More information available at www.dnsdpg.org or contact Mary Marian at mmarianazQcomcast.net.