Thread by @WhistlingDixie4

One of the useful things about a conference in Europe is the opportunity to understand a breath of socio-cultural perspectives (it’s almost like we’re better together 💁🏻‍♀️🇪🇺)

Anyway, looking forward to this - let’s go
#LIVES2022

https://twitter.com/whistlingdixie4/status/1584806432536264704

This is a joint session from ethics and metabolism & nutrition section. They start with Arabi who highlights the variability - he’s trained in US, works in Saudia Arabia and has relationship with Australia

He starts by pointing to this paper

pubmed.ncbi.nlm.nih.gov/25581712/

He highlights that there is more agreement for withholding than withdrawing nutrition and that attitude are surprisingly consistent across this large part of the world

He then says that artificial nutrition in Saudia Arabia is more likely to be considered a basic part of care

..that they have clear guidelines they cannot stop it - unless it harms.

Similar practices exist we’re told in China

They ask Debue if feeding holds benefit in EOL care - she says it is complicated question answered in terms of individual goals.
She asks is feeding artificially it ‘care’ in itself?

(And yes there are things we do because they are care then because they have tangible benefit)

She says you need to understand the values of the individual being cared for

And then used my favourite phrase ‘goals of care’ @ICUdecisions

Latour then says, somewhat cryptically, the answer is ‘do or don’t feed’

He remembers a European survey of 160 ICU nurses and end of life care, it showed that that ~40% agreed artificial nutrition should continue in end of life care …the same thought it shouldn’t…and there was then ~20% who still sat in the middle

He then mentions this from July 2022

ccforum.biomedcentral.com/articles/10.11…

He said that thirst and hunger are big players when it comes to comfort - so we do really need to look and think about what we do

Then Hartog says …but palliative care physicians would tell us that patients at end of life rarely have hunger …it’s different than thirst (there isn’t a palliative care physician on the panel so I’ll tag
@drkathrynmannix )

Debue says if we focus on justice - we have to stop

But we also need to use other principles including benevolence and some of that is about framing the decision correctly

Arabi says it also depends on the patient
- there are patients who are imminently dying of sepsis or severe ARDS
- and then there are patients for whom ‘starvation’ will impact their dying (I presume he means tangible here, as a mode or contributor)

Latour then says it is important to frame the question clinically by first asking

Does my patient have thirst?
Does my patient have hunger?

(This seems an important framing point - rather than ‘is it ok to stop’. I do often find when I have difficult questions in intensive care, asking them a different way leads to clearer answers)

They ask the audience for their experience. A nurse from Israel says they have a law that they can’t withdraw feed but…

But they can withhold individual bags of feed if it causes discomfort

But usually it isn’t discomfort, it’s futile

Another (doctor) from Israel adds to this that removing an NG tube can add comfort (he says you wouldn’t put a NG in a person who was actively recognised as imminently dying) and indicates that with open dialogue with a family you can get there

Latour then asks why do we all seem to agree pain relief is important - do we neglect ad forget thirst and hunger??

Casaer says - but hunger at the end of life is rare, we know this

Next is an audience member from the Netherlands

She says most of our patients deteriorate fast when we withdraw treatment - and we give pain and or sedation - so do those things not treat any potential ‘discomfort’ from ‘knowing’ hunger or thirst

(I’ve paraphrased here)

Am not clear if this is answered but Arabi mentions another clear question

‘What is feeding anyway’

?full feeding ?tropic feeding

And then Hartog perhaps when the NG tube makes the answer is easier.

(I think she means because an NG tube itself has a particular burden)

Casaer says to also must consider the clinical team and some can get on board with individualised approaches and others find a lack of clear strict protocols uncomfortable (he refers to cockpit approach)

(Am adding this as it seems relevant pubmed.ncbi.nlm.nih.gov/22381995/)

Another audience member from Israel:

He said that when he asks about what people would want at end of life, he doesn’t ask about nutrition because for him it’s always been ‘a given’ that it would be

He says he understands removing NG feed…

But adds what about 5% dextrose and some fluid. Is that a way to make the family more comfortable and not see (the patient) *starved to death?

*their word

(personal opinion: 5% dextrose isn’t a source of nutrition & this stance doesn’t fit with what I understand as care)

Latour rounds up and says

- ask the family members what a patient likes…if they say chocolate and that was their favourite thing he would get some chocolate, melt it and rub it in their mouth and that is how he sees personalised care

Debue backs this up and uses the phrase ‘pleasure in the ITU’

Which is a laudable goal to be sure and a phrase I like, in part because it challenges us

(Food as nutrition or food as pleasure? The goals of the dying are not the same as the goals of the recovering patient)

And finally for anyone interested, in adding this UK document of relevance

The end
#LIVES2022
bma.org.uk/media/1161/bma…