Legal Decisions Affecting the Limitation of Nutritional Support

SUMMARY

The withholding of nutritional support from patients is one of the most controversial issues in modern medical ethics and law. Withholding support from a consenting, terminally ill patient is the simplest case situation to defend, but patients in a persistent vegetative state or irreversible, chronic illness, require more careful deliberation. Regarding this issue, five primary principles have been utilized in legal decision making. These include: futility, autonomy, integrity of health professionals, states interests, balancing benefits versus harm and quality of life. The two landmark legal cases which have set the tone for most other court decisions are Paul Brophy and Nancy Beth Cruzan. Both cases clarified the right of competent adults to refuse nutritional support, even if life-saving. In the Cruzan case, however, states were given the authority to request clear and convincing evidence for the previous wishes of the incompetent patient. In summary, competent patients entering a hospice program should make informed decisions about their desires for feeding, as they do with other treatment decisions. Optimally, those wishes should be codified into an advance directive and a proxy decision maker named. If a patient is not competent, and without previously expressed wishes, immediate family members are usually consulted for what they believe are the patient’s best interests. Last, although limitations of care for terminally ill children fall under the same general guidelines as for adults, the “Baby Doe Rules” are a complicating factor.

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Notes on contributors

Eugene V. Boisaubin

Eugene V. Boisaubin, MD, is Associate Professor, Department of Internal Medicine, Medical Branch at Galveston, TX.