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ESPEN guideline on ethical aspects of artificial nutrition and hydration
Clinical Nutrition xxx (2016) 1
Contents lists available at ScienceDirect
Clinical Nutrition journal homepage: http://www.elsevier.com/locate/clnu
Letter to the Editor
ESPEN guideline on ethical aspects of artificial nutrition and hydration
Dear Editor, I read with interest the paper by Druml et al. [1] concerning the ethical aspects of nutrition and hydration and I generally agree with its content. I compliment with the authors for their statements which are well-balanced and respectful of the multicultural traditions which characterize the present European population. I have, however, a minor concern regarding statement 20 about hydration in terminal illness: out of the quoted papers [2e5] supporting the lack of benefit of hydration, one [2] was retrospective and without a comparative group, the other [3] was a simple report of a discussion, the Cochrane review [5] regarded the medically assisted “nutrition”, not the medically assisted “hydration”, and only one [4] was a RCT. Unfortunately, the authors of the RCT [4] used a suboptimal solution, the normal saline, to rehydrate their patients. Normal saline solution may be appropriate when the goal of fluid administration is “resuscitation” or “replacement”, much less when its purpose is “maintenance” and its use in this trial may invalidate the results. In fact, as also emphasized in the recent guidelines of the National Institute of Clinical Excellence (https://www.nice.org.uk/Guidance/ CG174), normal saline has a rather acid pH, is slightly hyperosmolar and may not be suitable for “maintenance” purposes since the high sodium content could promote a degree of unnecessary sodium and water retention and the high chloride content will promote some degree of hyperchloraemia. This may then lead to hyperchloraemic acidosis and/or significant reductions in renal blood flow and glomerular filtration rate as well as gastrointestinal mucosal acidosis and ileus. It would have been better to meet the water requirements with a 5% glucose solution and sodium and chloride needs by a balanced solution as Ringer acetate or the Hartmann's solution. A final concern regards a potentially too rigid application of the statement 1 which says that “nutrition and hydration are a medical intervention that requires specific rules: 1. an indication for a medical treatment and 2. The definition of a therapeutic goal to be achieved”. Whereas I obviously agree with the general approach herewith depicted, the every-day practice shows that in some circumstances some kinds of artificial nutrition (i.e. administration of some oral
supplements, subcutaneous hydration, infusion of isotonic fluids in patients who already harbour an intravenous line etc.) may be viewed more as a basic support which in some way is always due, rather than a medical therapy. Anyway, it should be clearly realized that when most scientific societies stated that artificial nutrition-hydration is a medical therapy, they directly legitimated themselves to give such definition and this may be not acknowledged by the relatives who take care of the patient and are equally entitled to define which is the role of nutrition-hydration in some special settings. Conflict of interest None. Financial support None.
References [1] Druml C, Ballmer PE, Druml W, Oehmichen F, Shenkin A, Singer P, et al. ESPEN guideline on ethical aspects of artificial nutrition and hydration. Clin Nutr 2016 Jun;35(3):545e56. [2] Bruera E, Belzile M, Watanabe S, Fainsinger RL. Volume of hydration in terminal cancer patients. Support Care Cancer 1996 Mar;4(2):147e50. [3] Bruera E, MacDonald. To hydrate or not to hydrate: how should it be. J Clin Oncol 2003 May 1;21(9 Suppl):84se5s. discussion 86s. [4] Bruera E, Hui D, Dalal S, Torres-Vigil I, Trumble J, Roosth J, et al. Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebocontrolled randomized trial. J Clin Oncol 2013 Jan 1;31(1):111e8. [5] Good P, Richard R, Syrmis W, Jenkins-Marsh S, Stephens J. Medically assisted nutrition for adult palliative care patients. Cochrane Database Syst Rev 2014 Apr 23;4:CD006274. http://dx.doi.org/10.1002/14651858.CD006274.pub3.
Federico Bozzetti University of Milan, Milano, Italy E-mail address: [email protected]. 10 June 2016
DOI of original article: http://dx.doi.org/10.1016/j.clnu.2016.02.006. http://dx.doi.org/10.1016/j.clnu.2016.07.001 0261-5614/© 2016 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Please cite this article in press as: Bozzetti F., ESPEN guideline on ethical aspects of artificial nutrition and hydration, Clinical Nutrition (2016), http://dx.doi.org/10.1016/j.clnu.2016.07.001
Contents lists available at ScienceDirect
Clinical Nutrition journal homepage: http://www.elsevier.com/locate/clnu
Letter to the Editor
ESPEN guideline on ethical aspects of artificial nutrition and hydration
Dear Editor, I read with interest the paper by Druml et al. [1] concerning the ethical aspects of nutrition and hydration and I generally agree with its content. I compliment with the authors for their statements which are well-balanced and respectful of the multicultural traditions which characterize the present European population. I have, however, a minor concern regarding statement 20 about hydration in terminal illness: out of the quoted papers [2e5] supporting the lack of benefit of hydration, one [2] was retrospective and without a comparative group, the other [3] was a simple report of a discussion, the Cochrane review [5] regarded the medically assisted “nutrition”, not the medically assisted “hydration”, and only one [4] was a RCT. Unfortunately, the authors of the RCT [4] used a suboptimal solution, the normal saline, to rehydrate their patients. Normal saline solution may be appropriate when the goal of fluid administration is “resuscitation” or “replacement”, much less when its purpose is “maintenance” and its use in this trial may invalidate the results. In fact, as also emphasized in the recent guidelines of the National Institute of Clinical Excellence (https://www.nice.org.uk/Guidance/ CG174), normal saline has a rather acid pH, is slightly hyperosmolar and may not be suitable for “maintenance” purposes since the high sodium content could promote a degree of unnecessary sodium and water retention and the high chloride content will promote some degree of hyperchloraemia. This may then lead to hyperchloraemic acidosis and/or significant reductions in renal blood flow and glomerular filtration rate as well as gastrointestinal mucosal acidosis and ileus. It would have been better to meet the water requirements with a 5% glucose solution and sodium and chloride needs by a balanced solution as Ringer acetate or the Hartmann's solution. A final concern regards a potentially too rigid application of the statement 1 which says that “nutrition and hydration are a medical intervention that requires specific rules: 1. an indication for a medical treatment and 2. The definition of a therapeutic goal to be achieved”. Whereas I obviously agree with the general approach herewith depicted, the every-day practice shows that in some circumstances some kinds of artificial nutrition (i.e. administration of some oral
supplements, subcutaneous hydration, infusion of isotonic fluids in patients who already harbour an intravenous line etc.) may be viewed more as a basic support which in some way is always due, rather than a medical therapy. Anyway, it should be clearly realized that when most scientific societies stated that artificial nutrition-hydration is a medical therapy, they directly legitimated themselves to give such definition and this may be not acknowledged by the relatives who take care of the patient and are equally entitled to define which is the role of nutrition-hydration in some special settings. Conflict of interest None. Financial support None.
References [1] Druml C, Ballmer PE, Druml W, Oehmichen F, Shenkin A, Singer P, et al. ESPEN guideline on ethical aspects of artificial nutrition and hydration. Clin Nutr 2016 Jun;35(3):545e56. [2] Bruera E, Belzile M, Watanabe S, Fainsinger RL. Volume of hydration in terminal cancer patients. Support Care Cancer 1996 Mar;4(2):147e50. [3] Bruera E, MacDonald. To hydrate or not to hydrate: how should it be. J Clin Oncol 2003 May 1;21(9 Suppl):84se5s. discussion 86s. [4] Bruera E, Hui D, Dalal S, Torres-Vigil I, Trumble J, Roosth J, et al. Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebocontrolled randomized trial. J Clin Oncol 2013 Jan 1;31(1):111e8. [5] Good P, Richard R, Syrmis W, Jenkins-Marsh S, Stephens J. Medically assisted nutrition for adult palliative care patients. Cochrane Database Syst Rev 2014 Apr 23;4:CD006274. http://dx.doi.org/10.1002/14651858.CD006274.pub3.
Federico Bozzetti University of Milan, Milano, Italy E-mail address: [email protected]. 10 June 2016
DOI of original article: http://dx.doi.org/10.1016/j.clnu.2016.02.006. http://dx.doi.org/10.1016/j.clnu.2016.07.001 0261-5614/© 2016 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Please cite this article in press as: Bozzetti F., ESPEN guideline on ethical aspects of artificial nutrition and hydration, Clinical Nutrition (2016), http://dx.doi.org/10.1016/j.clnu.2016.07.001