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CME/CE

End-of-Life Care in the Setting of Cancer: Withdrawing Nutrition and Hydration

  • Authors: Linda Emanuel, MD, PhD; Frank D. Ferris, MD; Charles F. von Gunten, MD, PhD, FACP; Jaime H. Von Roenn, MD
  • CME/CE Released: 3/24/2010
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 3/24/2011
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Target Audience and Goal Statement

This activity is intended for physicians, physician assistants, nurse practitioners, nurses, pharmacists, students, and other clinicians who care for patients at the end of life.

The goal of this activity is to facilitate clinician decision making and implementation of decisions about life-sustaining treatments, particularly artificial nutrition and hydration, near the time of death.

Upon completion of this activity, participants will be able to:

  1. Discuss the principles for withholding or withdrawing therapy at the end of life
  2. Describe the evidence base for artificial nutrition and hydration
  3. Describe the use of a 7-step approach to discuss the withholding or withdrawing of artificial nutrition or hydration
  4. Examine methods for assisting families and professionals with their need to give care
  5. Examine methods for discussing hospice care with patients and caregivers


Disclosures

As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


Author(s)

  • Linda Emanuel, MD, PhD

    Author, researcher, educator, previously practicing clinician; Principal, The EPEC Project; Director, Buehler Center on Aging, Heath and Society (where the EPEC Project and its derivatives are housed), Northwestern University Feinberg School of Medicine, Chicago, Illinois

    Disclosures

    Disclosure: Linda Emanuel, MD, PhD, has disclosed no relevant financial relationships.
    Dr. Emanuel does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics not approved by the US Food and Drug Administration (FDA) for use in the United States.
    Dr. Emanuel does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

  • Frank D. Ferris, MD

    Director, International Programs, Center for Palliative Studies, San Diego Hospice & Palliative Care, San Diego, California; Professor, Department of Family and Preventative Medicine, University of California, San Diego, La Jolla, California; Co-principal, The EPEC Project

    Disclosures

    Disclosure: Frank D. Ferris, MD, has disclosed no relevant financial relationships.
    Dr. Ferris does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics not approved by the US Food and Drug Administration (FDA) for use in the United States.
    Dr. Ferris does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

  • Charles F. von Gunten, MD, PhD

    Medical Director, Center for Palliative Studies, San Diego Hospice & Palliative Care, San Diego, California; Associate Clinical Professor, University of California, San Diego, School of Medicine; Co-principal, The EPEC Project; Past Chairman, The American Board of Hospice and Palliative Medicine

    Disclosures

    Disclosure: Charles F. von Gunten, MD, PhD, FACP, has disclosed no relevant financial relationships.
    Dr. von Gunten does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics not approved by the US Food and Drug Administration (FDA) for use in the United States.
    Dr. von Gunten does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

  • Jaime H. Von Roenn, MD

    Medical Director, Palliative Care and Home Hospice Program, Northwestern Memorial Hospital, Chicago, Illinois; Professor of Medicine, Division of Hematology/Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Co-Principal, The EPEC Project; Editor, EPEC-O Curriculum; Member, Board of Directors, American Society of Clinical Oncology; Editor-in-Chief, The Journal of Supportive Oncology

    Disclosures

    Disclosure: Jamie H. Von Roenn, MD, has disclosed the following relevant financial relationships:
    Received grants for educational research from: Par Pharmaceuticals
    Serves as an advisor to: Par Pharmaceuticals (served as Principal Investigator of a national, phase 2 clinical trial funded by the company)
    Serves as a consultant for: Alder Biopharmaceuticals; Insys Therapeutics; and SuperGen
    Dr. Von Roenn does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics not approved by the US Food and Drug Administration (FDA) for use in the United States.
    Dr. Von Roenn does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Editor(s)

  • Susan Yox, RN, EdD

    Director, Editorial Content, Medscape from WebMD

    Disclosures

    Disclosure: Susan Yox, RN, EdD, has disclosed no relevant financial relationships.

  • Cheryl Arenella, MD, MPH

    Cancer Education Program Specialist, Contractor, National Cancer Institute, Office of Education and Special Initiatives, Rockville, Maryland

    Disclosures

    Disclosure: Cheryl Arenella, MD, MPH, has disclosed no relevant financial relationships.

Nurse Planner

  • Susan Yox, RN, EdD

    Director, Editorial Content, Medscape from WebMD

    Disclosures

    Disclosure: Susan Yox, RN, EdD, has disclosed no relevant financial relationships.

CME Reviewer(s)

  • Laurie E. Scudder, MS, NP

    Accreditation Coordinator, Continuing Professional Education Department, Medscape, LLC; Clinical Assistant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC; Nurse Practitioner, School-Based Health Centers, Baltimore City Public Schools, Baltimore, Maryland

    Disclosures

    Disclosure: Laurie E. Scudder, MS, NP, has disclosed no relevant financial relationships.


Accreditation Statements

    For Physicians

  • Medscape, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

    Medscape, LLC designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™ . Physicians should only claim credit commensurate with the extent of their participation in the activity.

    Medscape, LLC staff have disclosed that they have no relevant financial relationships.

    The EPEC™-O curriculum was initially produced by the EPEC Project™ at Northwestern University’s Feinberg School of Medicine, with major funding provided by the National Cancer Institute, with supplemental funding provided by the Lance Armstrong Foundation.

    Contact This Provider

    For Nurses

  • Medscape, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

    Awarded 1.5 contact hour(s) of continuing nursing education for RNs and APNs; none of these credits is in the area of pharmacology.

    Accreditation of this program does not imply endorsement by either Medscape, LLC or ANCC.

    Contact This Provider

    For Pharmacists

  • Medscape, LLC is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

    Medscape, LLC designates this continuing education activity for 1.5 contact hour(s) (0.15 CEUs) (Universal Activity Number 0461-9999-10-073-H01-P).

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. MedscapeCME encourages you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates by accessing "Edit Your Profile" at the top of your Medscape homepage.

*The credit that you receive is based on your user profile.

CME/CE

End-of-Life Care in the Setting of Cancer: Withdrawing Nutrition and Hydration

Authors: Linda Emanuel, MD, PhD; Frank D. Ferris, MD; Charles F. von Gunten, MD, PhD, FACP; Jaime H. Von Roenn, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME/CE Released: 3/24/2010

Valid for credit through: 3/24/2011

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Making Decisions About Life-Sustaining Treatment

Editor's Note:

This text has been excerpted and adapted from: Emanuel LL, Ferris FD, von Gunten CF, Von Roenn J, editors. EPEC™-O: Education in Palliative and End-of-life Care for Oncology (Module 11: Withdrawing Nutrition, Hydration Copyright The EPEC™ Project, Chicago, Ill, 2005). The EPEC™-O curriculum was produced by The EPEC™ Project, with major funding provided by the National Cancer Institute, and with supplemental funding provided by the Lance Armstrong Foundation.

Making Decisions About Life-Sustaining Treatment

Facilitating decision making and implementing decisions about life-sustaining treatments are essential skills for clinicians. Impediments to good care include misconceptions about legal and ethical issues, as well as unfamiliarity with the practical aspects of implementation.

This educational activity discusses approaches to determining and implementing treatment preferences in regard to the withholding or withdrawing of interventions. First, general principles and approaches are covered. Next, specific issues of artificial nutrition and hydration are covered in more detail. These issues frequently present a challenge in routine practice, and they also provide an example of how to discuss withholding or withdrawing treatments in general.

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Role of the Healthcare Provider

All clinicians play an essential role in defining and implementing the plan of care, and providing continuity of care as the goals evolve and change over time. The physician or possibly the nurse practitioner or physician assistant will often take the lead in initiating discussions about life-sustaining treatment, educating patients and families, helping patients and families deliberate, and making recommendations about the treatment plan. As part of this role, the clinician is responsible for ensuring that the patient's wishes are documented and supported by the appropriate medical orders. Advance directives may be in place and helpful, but may not necessarily make clear how to translate general goals or treatment preferences into treatment of the present medical conditions. Consequently, it is critical that physicians, nurse practitioners, and physician assistants all have the knowledge and skills necessary for discussions, negotiations, and implementation of decisions related to life-sustaining treatments.

Other members of the healthcare team play an essential role in formulating and implementing the plan of care around issues of artificial nutrition and hydration, and will need to be skilled in the issues related to these decisions as well. Nurses, social workers, chaplains, speech therapists, and nutritionists/dietitians share in the responsibility of educating the patient and family about artificial nutrition and hydration so that the patient and family can make an informed decision. Nurses and other members of the healthcare team are charged with implementing treatment orders.

Making decisions about artificial nutrition and hydration is fraught with intense emotions, and the entire healthcare team needs to be able to support patients and families emotionally and spiritually as they struggle with the implications of decision making and the realities of disease progression.

Legal Perspective

All states in the United States have statutes covering issues related to withholding or withdrawing life-sustaining treatments. The Quinlan case (1976) established that artificial nutrition could be withdrawn even from a patient in a persistent vegetative state.[1] In 1983, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research found that no treatments, including artificial nutrition and hydration, were obligatory.[2] This was confirmed in the US Supreme Court decision on the Cruzan case in 1990, which established that artificial hydration and nutrition are like other life-sustaining
treatments.[3] It was upheld again in the Florida courts in the case of Schiavo in 2005.

It is also legal and ethical to withhold or withdraw nutrition and hydration for the patient who lacks decision-making capacity.[4] States may differ in the degree of evidence that is required if the patient lacks decision-making capacity. For example, in New York and Missouri, there must be "clear and convincing evidence." In the other states, substitute decision makers can make the decision.

Institutional policies of many hospitals or other healthcare institutions tend to include considerations, perhaps drafted by ethics committees, to protect patients' rights and interests and considerations, or possibly crafted by risk management officers to protect the institution from risk. Institutional policies are often written in response to the general perceived legal imperative to, when in doubt, provide treatment to prolong life. Institutional policies may or may not be in the best interest of a particular patient. If the appropriate goals of care are other than "life at all costs," then the written plan of care needs to be specific enough to accomplish the intended goals.

Emergency medical technicians are regulated by statute, and sometimes by city ordinance. Although requirements vary, in general, emergency medical technicians are required to provide all resuscitative and life-prolonging treatments unless a do-not-resuscitate (DNR) order, which complies with state-specific ordinances, is in place to the contrary.

Although only physicians and advanced practice clinicians can write orders, it is the responsibility of the entire healthcare team to ensure that the patient's wishes (or parents' if the patient is a child) are followed across care settings. In the hospital, one major study demonstrated that the majority of patients in intensive care unit settings die without attention to issues of life-sustaining treatment.[3] Many of these patients have undergone some form of invasive medical treatment against their previously stated wishes.[5]

All too often, patients are transferred to the acute care setting, where inappropriate life-sustaining measures are administered because the appropriate treatment plan and medical care orders have not been completed and placed in the patient's chart. One study demonstrated that fewer than 25% of advance directive orders were carried over from the nursing home to the acute care
hospital.[6] The fact that medical care orders may not transfer across settings (eg, nursing home, ambulance, acute care hospital) also exacerbates the problem.

Life-Sustaining Treatments

Table 1. Life-Sustaining Treatments

Resuscitation Diagnostic tests
Artificial nutrition and hydration Elective intubation
Surgery Antibiotics
Dialysis Other treatments
Blood transfusions, blood products Future hospital or intensive care unit admissions


There is a wide range of life-sustaining treatments that may be considered for an individual patient and family. These include cardiopulmonary resuscitation, elective intubation and mechanical ventilation, surgery, dialysis, blood transfusions or administration of blood products, artificial nutrition and hydration, diagnostic tests, antibiotics, other medications and treatments, and future hospital or intensive care unit admissions.

After determining the general goals of care, the clinician discusses specific treatments with his/her patients and families and whether those treatments will possibly help achieve the patient's overall goal. Asking a patient's preference for a scenario-specific invasive intervention vs an alternative noninvasive intervention may help the clinician to get a general idea of a patient's priorities for making treatment decisions. Decisions about surgery and antibiotics are often strongly predictive of other invasive and noninvasive decisions, respectively.[7]

Culture

Culture plays a role in decisions to withhold or withdraw care. For example, many studies have shown that nonwhite patients are less likely than white patients to agree to DNR orders or to withhold or withdraw care, and are less likely to have advance care directives.[8-10] In Asian cultures, filial piety, the obligation of children to care for their parents in gratitude for the parent's caring and sacrifices, is a central value. Making a decision to withhold or withdraw life support from a parent may be seen as unfilial.[11] If the integrity of the family as a whole is valued more than the wishes of an individual family member, even the patient who would not want life support may expect the family to do everything possible to prolong his or her life. To do otherwise would bring dishonor on the family.

Different cultures may have varying views of the role of suffering. Although many healthcare providers may support withholding life support at the end of life as a compassionate act that prevents unnecessary suffering, not all patients share this value. Some cultures view suffering as redemptive and something to be endured as a test of faith rather than avoided. The idea that only God knows when it is time to die may also affect how patients view the use of life-sustaining therapies.

Religion

Various religions have espoused specific opinions about the use of artificial hydration and nutrition. Most teach that when death is inevitable and not due to the absence of hydration or nutrition, withholding both can be appropriate. However, some religious leaders teach that human beings must do all in their power to prolong life. In situations of conflict, it is wise to engage leaders or teachers of the religious faith in question.

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