The approach of sectors within the medical community to nutrition and hydration in the care of patients at the end of life has undergone a massive shift over the course of the past decade. One might reasonably argue that few areas in healthcare practice have undergone more extensive modification than nutrition and hydration care decisions. The omission of nutrition and hydration as a part of the healthcare regimen has extended from those “in extremis” (wholly unable to maintain homeostasis, facing imminent death) to include those more accurately defined as profoundly injured or disabled, or in certain cases, because there is a suspicion on the part of the healthcare team of irreversible infirmity (terminal illness or condition).
The underpinnings of this transition in healthcare find their basis in philosophical changes within the medical community rather than any rigorously controlled scientific studies. A review of the literature on the topic reveals that the majority of the research relates to provider attitudes toward nutrition and hydration decisions.
This transition in approach to nutrition and hydration at the end-of-life is closely interwoven with the rise of hospice, palliative care, and hospitalist specializations. While these specializations have brought beneficial aspects to modern healthcare, each specialist group retains a subculture which has operated to shift the standard of care, at times to extremes. It is one thing for the omission of nutrition and hydration to accompany the end of life, and quite another to be the causative factor. It is one thing to omit care at the request of the patient/surrogate, quite another for the decision to be imposed by the healthcare provider.
With these issues in mind, the Second Annual Fall Foliage Dinner Discussion in Bioethics focused on questions of “Nutrition and Hydration at the End of Life.” Held Friday, October 8, 2010 at the Radisson Hotel Ballroom in Manchester, New Hampshire, the conference is hosted annually by the Cabrini Institute.
Cabrini Institute, Inc. was founded in 2009 to promote ethical healthcare policy and practices, and to preserve faith-based healthcare. These goals are primarily met through ethics consultation and education. The Annual Fall Foliage Dinner Discussion forms an important aspect of the educational outreach objective.
This year the conference was, once again, co-sponsored by The Center for Bioethics & Human Dignity and the Tennessee Center for Bioethics and Culture. The cooperation and support of these two organizations has been essential to the success of this educational mission.
A powerhouse of Trinity Graduate School alumni converged to present various perspectives and field questions from an audience populated by a broad spectrum of individuals from across the country. Attendees included those personally facing or caring for others with chronic debilitating illnesses, an adjunct professor of philosophy and ethics from Franciscan University Steubenville, a leading local hospitalist and palliative care physician, and a variety of local medical practitioners, as well as a practitioner member of a New Hampshire state health committee, and a local television talk-show host.
Dr. Gregory Rutecki demonstrated, from a review of the medical literature, the impact of healthcare finances on decisions to feed and the means employed to deliver nutrition and hydration. Dr. D. Joy Riley offered a profound narrative, from a philosophical perspective, on what it means to eat and to be fed. Dr. Ryan Nash provided perspective from his experience as a palliative care physician. He made the case that “one size does not fit all” in decisions regarding nutrition and hydration, and stressed the importance of making decisions appropriate to the underlying diagnosis, not solely on philosophical grounds. Colleen McCormick presented a patient case study and used it as a starting point to define “end of life,” and how it can be identified in light of the concepts of homeostasis and extremis. Ms. McCormick also unfolded for the audience the latest Ethical and Religious Directive of the United States Conference of Catholic Bishops, which speaks specifically to the moral choices involved in the decision-making process concerning nutrition and hydration in patient care.
This conference could not have taken place without a profound collaborative effort on the part of all the parties involved, and it is with sincere gratitude that I thank each one for the sacrificial investment made. A journal publication of the papers presented at the conference, and DVD copies of the conference presentation may be ordered through the Cabrini Institute website: http://www.cabriniinstitute.com.
