Is AHN a form of medical treatment, as many in health care believe? Or, is it something much more basic and natural, more akin to eating and drinking? Those who believe the latter, think it is obvious that it is simple, ordinary food and water. The former group points out that air is ordinary as well, but when it must be provided medically (as with a ventilator), it is medical treatment. Although laws vary by jurisdiction, the most common legal view of AHN is that it constitutes medical treatment, but recognizes the fact that some in society view it otherwise. For example, the NYS Proxy Law does not automatically grant permission for an agent of an incapacitated patient to forgo AHN, but it does if the agent is reasonably familiar with the patient's view of AHN.

The answer to the first question stakes out the boundaries of the second. If one believes AHN is medical treatment, then any decision about its use is made in the manner of medical decisions. That means we weigh the burdens and benefits of the treatment, including the likelihood that it will accomplish what we think it will. That means it is a part of the overall medical treatment plan, which is in turn, aimed at achieving defined goals of medical care. Finally, those goals of care are determined from the patient's perspective. The patient's values and attitudes dictate legitimate goals of treatment, either as expressed by the patient, or by an appropriate surrogate if the patient is incapable of deciding.

On the other hand, if AHN is not medical treatment, then decisions about its use are much simpler. If the patient is not eating and drinking, AHN is mandatory in all cases, irrespective of patient wishes, goals of treatment, likelihood of improvement, or burden of its administration.

Although the two kinds of questions are related as noted above, it is important to consider them independently. Pointing out that some people would suffer "thirst" or "hunger" in some cases, does not make the point that AHN is not medical treatment; it simply means that those factors must be weighed heavily in the medical decision making for those particular patients.

If one sees AHN as medical treatment, the medical literature must be the source of information regarding the relevant factors in such a decision (research regarding likely outcomes, risks and benefits). This is best summarized in a 1999 article by Finucane et al. [1] This review article addresses the potential of AHN to prevent complications in demented patients who are unable to eat and drink normal amounts of food and water safely. The specific endpoints include:

• Does Tube Feeding Prevent Aspiration Pneumonia? This is pneumonia caused by sucking mouth bacteria into the windpipe and lungs. The authors found no published studies suggesting that tube feeding can reduce the risk of aspiration pneumonia.
• Does Tube Feeding Prevent Consequences of Malnutrition? People with inadequate nutrition often lose weight and muscle mass. The authors found some evidence of benefit is some studies but patients still deteriorated in those outcome measures. Furthermore, tube feeding had no effect in wasting diseases such as AIDS and cancer in which a metabolic derangement is believed to cause wasting, not calorie deficiency.
• Is Survival Improved by Tube Feeding? This is at the core of most arguments for tube feedings: without it, patients would "starve to death." The authors found no published studies suggesting that tube feeding can prolong survival in demented patients who were unable to swallow normally.
• Are Pressure Ulcers Prevented or Improved by Tube Feeding? Skin ulcers commonly occur in end stage dementia. The authors found no published studies suggesting that tube feeding can improve pressure sore outcomes.
• Can Tube Feeding Improve Functional Status or Patient Comfort? Again, no studies could be found to support such claims.

Of course, feeding tubes are used in patients other than those with dementia, but one can generalize from this data in many of those cases. What always must remain clear however, is that no medical rule or guideline is universal. The details of a particular case must be used to arrive at a decision about what is best for the specific patient being considered. Most importantly, one must be wary of slogans or other emotionally charged language.[2] Nobody knows exactly what it is like to die without hydration and nutrition, but it is certainly not like a healthy, alert person feels when unable to find food and water. [3] Indeed, dying patients become easily overhydrated when given what would otherwise be a "normal" amount of fluid. Finally, fluids alone, without full nutritional support is never medically coherent treatment for more than a couple of days since it is deficient in protein and other necessary nutrients. The patient will certainly die, but it will take weeks instead of days and will be associated with complications not seen when both are withheld.

References

[2]Ahronheim JC, Gasner RM. The sloganism of starvation. Lancet 1990; 1:278.

[3] Sullivan RJ. Accepting death without artificial nutrition and hydration. J Gen Intern Med 1993; 8:220-224

Jack P. Freer, MD, FACP 3/13/00