A point of view: nutrition and care of terminally ill patients.

Care of terminally ill patients with regard to nutrition and other life-sustaining measures has received increased attention in recent years. This is because of technological advances that make it possible to maintain physiologic function of many organ systems for long intervals oftime after higher centers of the brain are no longer functional. This has occurred as an unwanted side effect of new technologies and treatments for reducing morbidity. The simple availability of life-prolonging technologies has led to their use in circumstances in which recovery is highly unlikely. Reasons for this include the uncertainty of prognosis for some patients when treatment is started, and the fact that the wishes of patients with regard to treatment options are sometimes unknown. Respect for life and the desire to help, even when all seems lost, occasionally results in desperate attempts to stem the inevitable. Unfortunately, well-intended therapies sometimes result in patient and family suffering that might be avoided if more attention was given to truth telling and respect for the person ofthe patient. Many compassionate persons concerned with health and human dignity are deeply disturbed by these circumstances. They are fully aware ofthe generally accepted duties ofthe physician to comfort the sick, cure if possible, do no harm, and respect the person of the patient. As a consequence there is debate as to what should be done for the terminally ill. The issue has been examined by thoughtful scholars of vanous persuasions who have approached the problem from ethical, religious, and legal points of view. Included in this effort have been practitioners who are frequently responsible for the care ofpatients with terminal illnesses. Their observations and reasoned opinions reaffirm the duties of physicians toward patients and provide a basis for interpretation of those duties as they pertain to the terminally ill. The ultimate responsibility for care of the patient must rest with the physician. The physician and all members of the health care team must be cognizant of and in agreement with the physician’s responsibilities. How the physician fulfills these responsibilities will depend on his or her ethical and moral background and training and the social climate in which he or she is working. It behooves us as teachers and mentors to make certain that trainees are educated with respect to the physician’s duties to the patient, and to the considerations that direct the physician in the fulfillment of his or her responsibilities. As part of this process, practicing physicians must act as role models and assure that the most vulnerable of those among us receive thoughtful and compassionate care in their time of greatest need. Until now I have said nothing about the propriety of any particular treatment. I view all treatments that involve technology as artificial, and those that involve comforting and making use of normal physiology as natural. Such a distinction has helped me in evaluating patients and planning therapies. I recognize, however, that some applications oftechnology that are relatively simple are so commonly used by physicians as to be considered natural by some medical and lay personnel. Interpretation ofthe blurred boundaries between natural and artificial can present difficulties in decision making. Because each patient is an individual with unique needs and wishes, there can be no hard or fast rules in the care of the terminally ill. Clearly, the physician has the responsibility for steering the care of the patient through the shoals of harm to the safe harbor of compassion and mercy, a task that can be daunting indeed. It is from such understanding that we must consider the central topic of this discussion. From a narrow perspective, nutntion is limited to the provision of food and water. In a broader and metaphorical sense, however, nutrition includes food for the spirit. This is provided through attention and thoughtfulness by members of the health care team, and by family, friends, and clergy. I prefer this broader definition of nutrition because it includes what humans do so well for each other through communication, attention, and love. It is also consistent with the most fundamental duty of the physician, respect for the person ofthe patient. This includes respect for the cornpetent directives of the patient, even as the physician, in turn, would wish respect under the same circumstances. It is my beliefthat patients should never be deprived ofthis aspect of nutrition. Attention to these needs will fortify the patient so that he or she can face the final episode of life with some equanimity. Nutrition has deep symbolism in all societies. I believe that fundamentally this relates to the mothergiving life to her infant by first nurturing the infant in her womb, then feeding her offspring from her breast. Giving nutrition to another is giving life. These concepts underlie the appreciation of nutrition as a