Withholding and withdrawing artificial nutrition and hydration

Question 1

What is artificial nutrition and hydration (ANH)?

Answer 1

Nutrition and hydration provided through artificial means such as feeding tubes (e.g. NG and gastric tubes) and IV routes (TPN or partial parental nutrition)

Question 2

What are indications for initiating ANH?

Answer 2

1. Neurological impairment leading to inability to feed orally and/or risk of aspiration
2. Malnutrition due to inadequate intake or increased caloric requirements
3. Malabsorption due to intestinal disease or short gut syndrome
4. Support of chronic diseases such as cancer or CHD

Question 3

How are treatment decisions and advance care planning decisions made for children?

Answer 3

1. Known wishes in the case of a child or youth with decision making capacity to consent
2. Best interests as determined by a substitute decision maker

Question 4

What are the general principles from the AAP report on forgoing medically provided nutrition and hydration in children?

Answer 4

1. Children capable of safely eating and drinking who show signs of wanting to eat or drink should be provided food and fluids.
2. Medically provided fluids and nutrition constitute a medical intervention that may be withheld or withdrawn for the same types of reasons that justify the medical withholding or withdrawing of other medical treatments.
3. Decisions about whether medical interventions should be provided to a child, including medically provided fluids and nutrition, should be based on whether the intervention provides net benefits to the child.
4. The primary focus in decision-making should be the interests of the child.
5. Although withholding or withdrawing medically provided fluids and nutrition may be morally permissible, it is not morally required.
6. Medically provided fluids and nutrition may be withdrawn from a child who permanently lacks awareness and the ability to interact with the environment. Examples of such children include children in a persistent vegetative state or children with anencephaly. The diagnosis and prognosis should be confirmed by a qualified neurologist or other specialist with expertise in the evaluation of children with these conditions.
7. Medically provided fluids and nutrition can be withdrawn from children when such measures only prolong and add morbidity to the process of dying. In these situations, continued fluids and nutrition often provide very limited, if any, benefit and may cause substantial discomfort. Some examples of children in this group include those with terminal illnesses in the final stages of dying, infants born with heart defects that are ultimately incompatible with survival beyond a few months and for which transplant is the only therapeutic option, infants with renal agenesis, or infants with a severe gastrointestinal malformation or a disease that is destructive to a large portion of the gastrointestinal tract, leading to total intestinal failure, and whose parents have opted for palliative care rather than intestinal transplant.
8. Parents or guardians should be fully involved in shared decision-making with the physician and health care team and should support the decision to withhold or withdraw medically provided fluids and nutrition. Parents should be reassured that their child will be kept comfortable and should be informed about the likely course of events, including broad estimates of when they child’s death is anticipated. Comprehensive palliative care measures for the child, including appropriate sedation and oral hygiene, should be provided in this situation.
9. Ethics consultation is strongly recommended when particularly difficult or controversial decisions are being considered.