Doctor Diana Cardenas, Doctor of Medicine and Philosophy, reflects on the status of artificial nutrition which is a regular topic of debate, especially for the terminally ill or patients with an altered state of consciousness. Considered by the Claeys-Leonetti Law of 2 February 2016 to be a “treatment that can be stopped as soon as it is met unreasonable persistence”, is this classed as “supportive” or “therapeutic” care?
“Nutritional support” or “medical nutrition” or even “artificial nutrition” developed forty years ago, is deemed to be “a relative revolution in medicine”. It allows patients to be fed by the oral, parenteral (via a catheter introduced into a vein) or enteral (via a feeding tube inserted into the stomach or intestine) route. It has an “effect on the course of the disease”, prolonging “the life of patients who, in time gone by, would have died through malnutrition”, because it “meets individual nutritional requirements in an appropriate, adequate manner”. However, although the primary aim is to feed the patient, “the symbolic and emotional nature of the act of feeding, even using artificial means, should not be overlooked”.
Doctor Cardenas also points out that artificial feeding has “scientifically proven side effects” and that the “nutrients actually ‘treat’ as well as feed”, which makes it similar to “medication”. Bearing these points in mind, “is feeding a patient a therapeutic procedure or a form of supportive care? Is it a case of healing, supporting a vital function or making the patient more comfortable?”
As far as Doctor Cardenas is concerned, “there’s no room for this divide. The act of feeding a patient must be assessed from the care perspective and seen as helping a patient to recover”. This “dual care/treatment status” creates constant tension between both these concepts”, particularly if it isn’t recognised. This may apply to a patient and his/her family when “the emotional and symbolic link associated with feeding is initially viewed as a priority”. In this situation, nutrition should be deemed a form of care, “respect for others which goes beyond the purely biological realms of maintaining the symbolic and emotional aspect associated with the act of feeding”. “Comfortable oral feeding” is therefore not aimed at “quantitative nutritional objectives”, but at “comforting” and sometimes “accompanying a person until death”. In the case of a dying patient, “the total abstinence of nutrition may have to be considered as an ethical act which, under no circumstances whatsoever would be seen as a sign of abuse or euthanasia”. Conversely, in the case of patients whose conscience is chronically impaired, nutrition has a life-sustaining purpose, which can sometimes be synonymous with artificial life support. Nevertheless, it can also remain an ethical requirement if it impacts upon disease progression.