Through my clinical dietetics rotation today, I had the opportunity to attend two medical ethics meetings- a meeting of the Ethics Committee this morning before work, and an “Ethics in the Round” lunch and learn event.
“Medical Ethics” is a term used to refer to the values and guidelines that govern decisions in medical practice. All health care professionals need to be cognizant of the ethical issues that they make each and every day, and dietitians are no exception.
One of the areas that most relates to the work of a clinical dietitian is the use of enteral or parenteral nutrition. Enteral nutrition refers to feeding through the gastrointestinal (GI) tract using a tube, catheter, or stoma that delivers nutrients from a location further down the tract than the mouth (1). Parenteral nutrition refers to administering nutrition directly into the circulatory system (1). Most of the time, being able to use these methods to deliver nutrition to an individual is a wonderful thing that can sustain them while they are recovering from trauma or illness.
However, there are cases in which artificial nutrition will prolong life, but not necessarily promote a high quality of life.
Many of you have likely heard of the Terri Schiavo case. In this case, there was dispute between family members (which lasted from 1998 to 2005) over whether or not to continue feeding through her PEG (percutaneous endoscopic gastrostomy) tube, although doctors declared her to be in a “persistent vegetative state”. Eventually, after the case escalated to a point of federal involvement, the feeding tube was removed for the final time.
An excellent article from Today’s Dietitian addresses the issues related to PEG tube feeding at end of life. Associated risks and indications for placement should be considered prior to using a PEG tube. Although the dietitian is typically not involved in the decision of whether or not to place the PEG, they should be aware of the rationale behind the placement.
- Potential complications of the surgery to place the PEG
- Possible infection around the PEG placement site
- Tube malfunctions (such as a blocked or leaking tube)
- Intolerance of feeding
- Possible fluid overload and electrolyte imbalance
The most evidence-based and clinically useful indications for placing a PEG tube include:
- head and neck cancer
- acute stroke with dysphagia
- neuromuscular dystrophy syndromes
- gastric decompression
While some practitioners may believe that tube feedings are a level of basic humane care, the wishes of the patient and family must be considered.
One of the best things that can be done is to have advance directives or living wills that clearly spell out your desire to have or not have artificial nutrition placed in case of a medical event.
Other topics discussed today were the use of “bloodless surgery centers”, in order to eliminate the need for blood transfusions during surgery for some religious groups.
As I am diving more in depth into patient cases and medical histories, I am learning so much about the world of health care. I am realizing that I still have a LOT to learn, and I am so thankful for the many things that I am being exposed to over the course of this internship.
(1) Nelms, Sucher, and Long. Nutrition Therapy and Pathophysiology, 2007.