Last Days of Life (PDQ®): Supportive care - Health Professional Information [NCI] - Ethical Issues
Providing nutrition to patients at the end of life is a very complex and individualized decision. Ideally, the options for nutrition support for end-of-life care should be discussed in advance, and information on all nutritional choices and their consequences should be provided to the patient and family. Patients are best able to make decisions if they are well informed about the possible risks and benefits of artificial nutrition. Considerations of financial cost, burden to patient and family of additional hospitalizations and medical procedures, and all potential complications must be weighed against any potential benefit derived from artificial nutrition support. Supplemental nutrition may be beneficial in the treatment of advanced cancer, where quality of life would otherwise suffer and death would be caused by malnutrition rather than the underlying disease, such as in mechanical obstruction or malabsorption resulting in intolerance of oral intake.
Treatment Options for Stages I and II
Hepatoblastoma of pure fetal histology: For tumors of pure fetal histology, complete surgical resection followed by watchful waiting or single-agent doxorubicin.In the Children's Oncology Group (COG) study COG-P9645, stage I pure fetal histology hepatoblastomas with two or fewer mitoses per 10 high power fields were not treated with chemotherapy. Completely excised tumor of purely fetal and favorable histology may be carefully followed without...
The rationale for providing artificial nutrition at the very end of life is less clear. One study has concluded that artificial nutrition—specifically, parenteral nutrition—neither influenced the outcome nor improved the quality of life in terminally ill patients.
The controversial nature of providing artificial nutrition at the end of life has prompted the American Academy of Hospice and Palliative Medicine (AAHPM) to recommend that individual clinical situations be assessed using clinical judgment and skill to determine when artificial nutrition is appropriate. Recognizing that the primary intention of nutrition is to benefit the patient, AAHPM concludes that withholding artificial nutrition near the end of life may be appropriate medical care if the risks outweigh the possible benefit to the patient.
The goal of end-of-life care is to relieve suffering and alleviate distressing symptoms. The patient's needs and desires must be the focus, with their best interests being the guide for decision making, influenced by religious, ethical, and compassionate issues.[4,5,6]
Broadly defined, resuscitation includes all interventions that provide cardiovascular, respiratory, and metabolic support necessary to maintain and sustain the life of a dying patient. It is important for patients, families, and proxies to understand that choices may be made specifying what supportive measures, if any, should be given preceding death and at the time of death. People often believe that there is plenty of time to discuss resuscitation and the surrounding issues. However, many dying patients do not make choices in advance or have not communicated their decisions to their families, proxies, and the health care team. If these issues are unresolved at the time of end-of-life events, undesired support and resuscitation may result. Studies suggest that this aggressive care is associated with worse patient quality of life and worse adjustment to bereavement for loved ones.[7,8]
Narrowly defined, a Do Not Resuscitate (DNR) order instructs health care providers that, in the event of cardiopulmonary arrest, cardiopulmonary resuscitation (CPR, including chest compressions and/or ventilations) should not be performed and that natural death be allowed to proceed. DNR orders must be made before cardiac arrest and may be recommended by physicians when CPR is considered medically futile or would be ineffective in returning a patient to life. A DNR order may also be made at the instruction of the patient (or family or proxy) when CPR is not consistent with the goals of care. It is advisable for a patient who has clear thoughts about these issues to initiate conversations with the health care team (or appointed health care agents in the outpatient setting) and to have forms completed as early as possible (i.e., before hospital admission), before the capacity to make such decisions is lost. Although patients with end-stage disease and their families are often uncomfortable bringing up the issues surrounding DNR orders, physicians and nurses can tactfully and respectfully address these issues appropriately and in a timely fashion. Lack of standardization in many institutions may contribute to ineffective and unclear discussions around DNR orders. (Refer to the PDQ summary on Transitional Care Planning for more information.)