The Royal College of Physicians has published (10 March 2021) a guide to practical care and clinical assistance. Its particular focus is on the complexities that can arise around nutrition and hydration towards the end of life.
The guidance, applying the law within England & Wales but offering clinical principles which will also be applicable within different legal frameworks in Scotland and Northern Ireland, updates the previous Oral feeding difficulties and dilemmas published in 2010, particularly in relation to recent changes in the law governing procedures for the withdrawal of clinically assisted nutrition and hydration (CANH) and other life-sustaining treatments.
It was developed by a working party with representation from a wide range of specialties, including neurology, dietetics, speech and language, gastroenterology, law, ethics, and care of older people. (I was one of the two lawyers involved)
Eating and drinking are essential for maintenance of nutrition and hydration but are also important for pleasure and social interactions. The ability to eat and drink hinges on a complex and coordinated system, resulting in significant potential for things to go wrong.
Decisions about nutrition and hydration and when to start, continue or stop treatment are some of the most challenging to make in medical practice. The newly updated guidance aims to support healthcare professionals to work together with patients, their families and carers to make decisions around nutrition and hydration that are in the best interests of the patient. It covers the factors affecting our ability to eat and drink, strategies to support oral nutrition and hydration, techniques of clinically assisted nutrition and hydration, and the legal and ethical framework to guide decisions about giving and withholding treatment.
The guidance is primarily for medical and healthcare professionals, particularly those involved in caring for people who have eating and drinking difficulties, including gastroenterologists, ward nurses, geriatricians, dietitians, speech and language therapists, neurologists, palliative care teams, care home and community nurses.
Updated throughout, it includes a new chapter on dietary modifications and a series of illustrative examples of patients to help guide practice. From my perspective, one of its most important innovations is that it includes practical guidance to address one of the most difficult areas that other guidance in this area has all too often shied away from: what to do where the patient’s wishes (either capacitous or incapacitous) are to be provided with food and drink in a way which professionals feel that they cannot accommodate because of the risk. The framework proposed seeks to assist in securing against undue risk aversion on the one hand whilst on the other hand recognising that professionals have their own rights.