American Society for Parenteral and Enteral Nutrition Statement on Ethics of Withholding and/or Withdrawing Nutrition Support Therapy
The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is dedicated to improving patient care by advancing the science and practice of nutrition support therapy. Nutrition support therapy (defined here as enteral or parenteral nutrition) is provided when patients are unable to take adequate hydration or nutrients independently by mouth. Nutrition support therapy is considered a medical therapy. Withholding or withdrawing nutrition support therapy often involves different considerations than other life-sustaining therapies, in part because of emotional, religious, and symbolic meanings. The use of nutrition support therapy involves understanding the medical indications, including benefits and burdens. Next, it involves applying these interventions in a moral, ethical, and legal construct that is satisfactory to patients, families, and caregivers.
Specific Legal and Ethical Recommendations from A.S.P.E.N. regarding Nutrition Support Therapy
- Legally and ethically, nutrition support therapy should be considered a medical therapy.
- The decision to receive or refuse nutrition support therapy should reflect the autonomy and wishes of the patient. The benefits and burdens of nutrition support therapy, and the interventions required to deliver it, should be considered before offering this therapy.
- Care providers should be familiar with current evidence of the benefits and burdens of nutrition support therapy.
- Patients should be encouraged to have living wills and/or advance directives and to discuss with their loved ones their wishes in the event of a serious or terminal accident or disease. These directives should include nutrition support therapy.
- Competent patients or the legal surrogate of incompetent patients shall be involved in decisions regarding withholding or withdrawing of treatment. Incompetent patients' wishes (as documented in advance directives) shall be considered in making decisions to withhold/withdraw nutrition support therapy.
- Nutrition support therapy should be modified or discontinued when there are disproportionate burdens or when benefit can no longer be demonstrated.
- Institutions should develop clear policies regarding the withdrawal or withholding of nutrition support therapy and communicate these policies to patients in accordance with the Patient Self-Determination Act.
American Society for Parenteral and Enteral Nutrition Board of Directors, Task Force on Standards for Specialized Nutrition Support for Hospitalized Adult Patients: Russell MD, Andrews MR, Brewer CK, Rogers JZ, Seidner DL. Standards for specialized nutrition support: adult hospitalized patients. Nutr Clin Pract 2002; 17:384-391
A.S.P.E.N. Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr2002; 26(Suppl): 1SA-138SA. Errata 2002;26:144