Appropriate use of artificial nutrition and hydration--fundamental principles and recommendations.

For two decades, clinicians have been guided by an agreement about the appropriate use of artificial nutrition and hydration (ANH). In general, ANH has been seen as a medical treatment that patients or their surrogates may accept or refuse on the basis of the same considerations that guide all other treatment decisions: the potential benefits, risks, and discomfort of the treatment and the religious and cultural beliefs of the patients or surrogates. Although this agreement has never been universal, it is well established among ethicists,1 clinicians,2-5 and the courts. For instance, the 1990 Supreme Court decision in the well-known case of Nancy Cruzan specifically stated that the administration of ANH without consent is an intrusion on personal liberty.6-11 However, this agreement has faced recent challenges to its legitimacy. For instance, even though the cases of Terri Schiavo12 and Robert Wendland13 were complicated by disagreements among family members, the cases also involved public questioning of the premise that decisions about ANH should be made in the same way in which decisions about other treatments are made. Similarly, a recent papal statement that strongly discourages the withdrawal of ANH from patients in a permanent vegetative state will have a profound effect on decisions about ANH if it is accepted into Catholic doctrine.14,15 Several states have made the withdrawal of ANH more difficult than the withdrawal of other forms of life-sustaining treatment.16 Clinicians also face substantial obstacles that prevent them from applying sound, ethical reasoning when discussing ANH with patients and families. For instance, patients and families are often not fully informed of the relevant risks and potential benefits of ANH.17 In addition, financial incentives and regulatory concerns promote the use of ANH in a manner that may be inconsistent with medical evidence and with the preferences of patients and their families.18,19 Finally, preferences about ANH may not be honored after a patient is moved from one care setting to another.20 It is not possible to prevent all disagreements about the use of ANH. But it is possible, and indeed it is essential, to clarify the principles that should underlie decisions about ANH and to ensure that these principles guide decisions in clinical practice. Therefore, in this article we examine the ethical principles that have guided the appropriate use of ANH during the past 20 years and recommend steps to promote clinical practices that are more consistent with these principles.