Artificial Nutrition and Hydration (ANH) Paper

Artificial Nutrition and Hydration
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Abstract
ANH refers to a clinical therapy designed to assist critically ill patients to acquire water and food in case they are unable to ingest through normal means. Its main purpose is to elongate the life of a patient at the end of life situation. Some of the most common techniques include the utilization of PEG tubes, NG, and intravenous administration. The application of ANH has created many controversies across the globe. Proponents of this medical intervention submit that it should be used since it delivers a chance for survival especially in circumstances where patients need nutritional support. It greatly helps patients suffering from diseases such as cerebral palsy, dementia, and stroke. ANH is quite beneficial for patients with transitory issues in the gastrointestinal tract, swallowing and some chronic conditions. It can also increase the time for precise evaluation of chances of recuperation if the diagnosis is undefined. However, persons against the use of ANH note that it causes many negative effects hence its harm and burdens outweigh its possible benefits. For instance, studies have established that NG tubes and PEG tubes lead to complications such as aspiration pneumonia, esophageal reflux, and bleeding. Therefore, it may not necessarily promote chances of survival. Based on my personal opinion, the use of ANH should be guided by the code of ethics such as justice, non-maleficence, beneficence, and autonomy.

Keywords: artificial nutrition and hydration, ethics, patients

Overview
Patients with life-threatening and advanced illnesses normally lose the capability to drink and eat or/and interest in fluids and foods. Artificial nutrition and hydration (ANH) were initially launched to offer support to critically ill patients for a short-term. ANH refers to a medical treatment that replaces or supplements ordinary drinking and eating (Esbensen, 2014). It enables an individual to acquire hydration (fluids) and nutrition (food) when they are incapable of ingesting them. In so doing, it offers an opportunity for patients at the end of life to sustain their life albeit in the short-term basis. However, the intervention is unlikely to extend life for patients suffering from acute conditions (Hui Dev & Bruera, 2015). Some adults may reject ANH even if it leads to death. More importantly, the use of ANH has generated debates across the globe due to its ethical or moral standards and its legality.
ANH can be achieved through intravenous administration, hypodermoclysis, nasogastric (NG) tubes, and percutaneous endoscopic gastrostomy (PEG). Precisely intravenous administration method uses blood veins to supply fluids into the body, which are intended to maintain the daily needs for nutrition and hydration (Bükki et al., 2014). However, this process cannot provide significant nutrition. Moreover, hypodemoclysis refers to a procedure whereby infusion of the fluid takes place through small-sized needles that are often implanted into the arms, back, abdomen, or thighs (Esbensen, 2014). They deliver small quantities of fluids per day, which is not exceeding one liter.
Nasogastric tubes are also used in ANH whereby they deliver sufficient fluids and nutrition into the stomach via the nose (Bükki et al., 2014). They canmeet the daily nutritional requirement of the patients and are often utilized during acute illness period. Percutaneous endoscopic gastrostomy (PEG) involves placement of a tube into the stomach via the abdomen. It is normally utilized when it is expected that patients will not be in a position to recommence normal feeding for a long period (Hui Dev & Bruera, 2015). The method is the most widely utilized technique for offering nutrition and hydration care for patients suffering from diseases such as stroke.
PEG tube insertion Procedure
The procedure of PEG tube placement comprises two main processes. Firstly, the Gauderer-ponsky process encompasses execution of a gastroscopy to assess the stomach’s anatomy. The anterior wall of the stomach is identified and techniques are utilized to ensure that no organ that exists between the skin and the wall (Kitzinger & Kitzinger, 2015). Furthermore, digital pressure is utilized to the abdominal wall, which indents the gastric wall. Trans-illumination is used where the endoscope in the stomach emit light that can be seen via the abdominal wall (Esbensen, 2014). After trans-illumination, a small needle is inserted into the stomach prior to insertion of the larger cannula.
An angiocath is utilized to puncture the wall of the abdomen via a small incision, and a soft guidewire is placed through this and dragged out of the mouth. Subsequently, the feeding tube is inserted into the guidewire and pulled via the stomach, esophagus, mouth, and out of the opening (Hui Dev & Bruera, 2015). The second process embroils Russell introducer method. In this regard, Seldinger technique is utilized to introduce a wire into the intestinal area or stomach. A wide range of dilators is applied to raise the gastrostomy size. The tube is then pressed in over the inserted wire (Esbensen, 2014).
Why ANH is necessary
Various studies have attempted to describe the benefits of ANH, especially among the terminally ill individuals. According to Hui Dev & Bruera, (2015), ANH is an important medical procedure, which can prolong the lives of patients in life-limiting conditions. In fact, the scholars argued that delivering fluids and food has a significant impact on many patients, as they are normally associated to the provision of fluids and foods to nourishment and comfort. Therefore, it usually acts as the technique of preserving or giving life to those who greatly need support.
Esbensen, (2014) maintained that supplying fluids and food so long as an individual needs them and can securely take them is essential. Some persons also particularly request to obtain artificial hydration or nutrition when suffering from a fatal condition. Therefore, it is not appropriate to deny them the right to use it (Esbensen, 2014). The ANH is easier to start although it may lead to a wide range of challenges when deciding to withdraw the therapy. Therefore, the researchers noted that it is imperative to initiate a discussion with families to ensure that they are conversant with its benefits and burdens of continuing this treatment (Bükki et al., 2014).
Proponents of ANH submit that such therapies are proposed to be applied temporarily. In so doing, they enable a patient with a reversible or treatable condition to regain his/her health. Additionally, based on Kitzinger & Kitzinger, (2015) perspectives, these procedures facilitate the patients to recuperate their capability to drink and eat normally. Furthermore, ANH can serve very effectively for patients with short-term challenges in their gastrointestinal tract. Therefore, they are quite beneficial when used among individuals with moderately severe conditions. ANH can assist these persons in timely or quick recovery. Additionally, they are used for patients with some types of chronic illnesses (Kitzinger & Kitzinger, 2015).
Hui Dev & Bruera, (2015) support the use of ANH therapies since they lengthen life and permit time for correct evaluation of a person’s chances of convalescence. Such medical interventions are necessary for situations where the diagnosis or prognosis of the patient is unclear. Most notably, in case a patient is reliant on artificial hydration or nutrition for sufficient nutrition, and that individual is satisfied with the life he/she leads, the therapy has qualitative and physiological importance (Hui Dev & Bruera, 2015).
Proponents of ANH highlight that there is a wide range of patients who take advantage of techniques such as PEG placements. For instance, patients suffering from benign and malignant underlying conditions can use this process to attain desired body weight (Hui Dev & Bruera, 2015). A study by Bükki et al., (2014) established that introduction of PEG tubes following the confirmation of medical necessity can stop further loss in body weight. Therefore, it increases the chances of survival. Nonetheless, the study suggested that the choice to use PEG tubes must be individualized based on the patient’s life expectancy, diagnosis, preferences, and needs. The key objective of the placement should be to enhance the quality of life, nutritional status, and the survival rates of patients (Bükki et al., 2014).
Based on the findings of Rahnemai-Azar et al., (2014) study, nasogastric (NG) tubes are beneficial for patients suffering from stroke or cerebrovascular disease. In most cases, caregivers recommend initiation of NG tubes among patients who are unable to meet their nutritional needs. The use of the NG tubes helps to support these patients for fourweeks as opposed to PEG tube, which requires more time. Fortunately, the tubes offer reliable and safe nutritional means in cerebrovascular patients. Moreover, PEG method is useful for persons experiencing amyotrophic lateral sclerosis (ALS) (Rahnemai-Azar et al., 2014). Studies have also indicated that PEG can be placed in patients experiencing restricted pulmonary function. The survival rate of these patients after PEG use is quite over 50 per cent (Hui Dev & Bruera, 2015). Likewise, PEG has been identified to play a major part in helping patients with dysfunctional and motor neurons diseases to cope with their nutritional needs. For instance, bulbar palsy and cerebral palsy patients normally agonize from episodes of swallowing and feeding challenges that may contribute to infections, chronic pulmonary aspiration, growth failure, and poor nutritional status (Esbensen, 2014). Similarly, PEG helps in ulcer healing, enhances survival rates and offer nutritional support among dementia patients.
Reasons why ANH is harmful and risky
Arguments against the utilization of ANH imply that the risks surpass the benefits of this therapy. For instance, it may increase suffering and pain especially among patients with digestive tract infarction (Esbensen, 2014). Similarly, persons in the persistent vegetative state (PVS) may not benefit from the therapy since they cannot make an informed decision. Bükki et al., (2014) argued that ANH is not acceptable especially if it becomes a burden to the patient. The researcher also noted that it leads to a wide range of complications to the patient. Therefore, they noted that if the burdens and risk of a medical intervention outweigh the impending benefits, then the doctor or nurse has a responsibility withholding it (Bükki et al., 2014).
Opponents of ANH noted that any medical therapy must be guided by the principle of non-maleficence and beneficence, which encourages them to optimize the possible benefits to the patients while at the same time, reduces impending harm (Hui Dev & Bruera, 2015). In such circumstance, they should pay attention to the overall/general benefits such as spiritual and psychological well-being, the quality of life, and potential outcome of the disease. Moreover, they contend that extending life may never be the ultimate goal and at all times must be placed based to the patient’s wellbeing. For this reason, ANH should not be applied because it is a disproportionate treatment based on the ethical perspective (Esbensen, 2014). Furthermore, they support that withholding or withdrawing a therapy that offers no value should be emphasized.
A series of studies have established that use of PEG tubes is associated with complications such as bleeding, aspirations pneumonia and injuries of an internal organ. Precisely, Kitzinger & Kitzinger, (2015) discovered that placement of PEG causes excessive bleeding from mesenteric vein, splenic vein, gastric arteries, and PEG tract. Similarly, bleeding can occur from rectus sheath hematoma. Caregivers must ensure that patients’ coagulation disorders are corrected before ANH (Kitzinger & Kitzinger, 2015).
Opponents of ANH highlights that use of AHN is ethically unacceptable because they do not promote the quality of life or weight gain among cancer patients. In fact, they raise the risk of problems and infections, which increase the chances of death. Moreover, the NG tubes expose patients to pneumonia, which can substantially reduce their chances of survival (Bükki et al., 2014). ANH must be avoided because it is contrary to the principle of justice. In this regard, they claimed that although all persons are entitled to acquire the best available care, resources must be shared fairly. However, they contend that therapies, which are useless, should be avoided since they elongate the dying phases and suffering of the patient. In respect to scarce resources, there must be an adequate utilization of ethically suitable criteria (Rahnemai-Azar et al., 2014).
Personal Opinion
Personally, I think the decision to withhold or withdraw ANH should be guided by the principles of justice, nonmaleficence, beneficence, and autonomy. In particular, autonomy demands that physician must respect the surrogate’s or patient’s right to self-determination (Kitzinger & Kitzinger, 2015). Therefore, they should be given the right to decide about withdrawing, withholding, or initiating ANH. Secondly, the principle of beneficence proposes that a caregiver’s actions should seek to help the patient signifying that is proper to offer ANH if it assists the patient to satisfy the quality of life and medical goals (Hui Dev & Bruera, 2015). Thirdly, tenets of nonmaleficence advise that the prevention of harm and the eradication of suffering and pain. Therefore, it necessitates that if the harm or burdens of ANH are greater than probable advantages or benefits, then the therapy must not be introduced or should be withheld or withdrawn. Fourthly, justice doctrine requires that healthcare givers must make resolutions in an unbiased manner (Esbensen, 2014). Therefore, the decisions concerning the application of ANH must not be based upon factors such as economic situation, or chronological age. However, I believe these values may lead to disagreements or clashes, hence breeding an ethical dilemma needing suitable resolutions.

References
Bükki, J., Unterpaul, T., Nübling, G., Jox, R. J., & Lorenzl, S. (2014). Decision making at the end of life—cancer patients’ and their caregivers’ views on ANH. Supportive Care in Cancer, 22(12), 3287-3299.
Esbensen, L. (2014). Health Care Ethics: Theological Foundations, Contemporary Issues, and Controversial Cases, revised edition by Michael R. Panicola, David M. Belde, John Paul Slosar, and Mark F. Repenshek, and: On Moral Medicine: Theological Perspectives in Medical Ethics, ed. by M. Therese Lysaught and Joseph J. Kotva Jr. with Stephen E. Lammers and Allen Verhey. Journal of the Society of Christian Ethics, 34(2), 211-214.
Hui, D., Dev, R., & Bruera, E. (2015). The last days of life: symptom burden and impact on nutrition and hydration in cancer patients. Current opinion in supportive and palliative care, 9(4), 346.Kitzinger, C., & Kitzinger, J. (2015). Withdrawing artificial nutrition and hydration from minimally conscious and vegetative patients: family perspectives. Journal of medical ethics, 41(2), 157-160.Rahnemai-Azar, A. A., Rahnemaiazar, A. A., Naghshizadian, R., Kurtz, A., & Farkas, D. T. (2014). Percutaneous endoscopic gastrostomy: indications, technique, complications and management. World Journal of Gastroenterology: WJG, 20(24), 7739.