In 1988 the American Nurses' Association (ANA) issued a policy statement on the nurse's role in withholding and withdrawing food and fluids from patients. Recently a new statement has been issued by the ANA, and that statement reflects a definite shift in the deference that a nurse should afford a patient's decision to refuse artificial sustenance (ANA, 1992).
ANA 1988 Guidelines The 1988 guidelines
identified that, "Since competent, reflective adults are generally in the best position to evaluate various harms and benefits to themselves in the context of their own values, life projects, and tolerance of pain, thenacceptance or refusal of food and fluid should usually be respected (emphasis added)... It is important, however, to guard against the possibility that respect for a competent patient's right to refuse food and fluid could lead to indifference or a misplaced respect for patient autonomy (emphasis added)." The nurse was encouraged to investigate the patient's reasons for the decision to refuse food and fluid and cautioned that, "it is not enough simply to fulfill the obligation to respect the wishes of competent persons" (ANA, 1988).
If the parient were no longer competent to make health-care treatment decisions, and had written a living will or a durable power of attorney for health care, the guidelines indicated that these documents could be "taken as aids in discerning the patient's view" and "should carry great weight in caregivers' discussions with the patient's family or surrogate (decision maker)" (ANA, 1988). This treatment of the patient's legal statement of healthcare treatment preferences ignored the purpose of drafting the legal documents and the patient's underlying right of autonomy and selfdetermination.
A Shift in the ANA Position __________
The new task force paper has revised the ANA position and now requires that, "Since competent, reflective adults are generally in the best position to evaluate various harms and benefits to themselves in the context of their own values, life projects, and tolerance of pain, their acceptance or refusal of food and fluid should be respected (emphasis added). This ethical judgment is now well established through legal precedents affirming the right of competent patients to refuse treatment, including nutrition and hydration"(ANA, 1992).
The new position paper has also now gone beyond the earlier indifference shown a patient's legal advance directive. The 1992 document identifies that, "Advance directives such as living wills or the legal assignment of durable power of attorney are indications of choices and values and should be followed. Thus, advance directives, including those involving artificial nutrition and hydration should be followed (emphasis added)" (ANA, 1992).
The new position statement is certainly timely, if not long overdue. The legal recognition of an adult's right to personal autonomy in health-care treatment decision making is well established. Living wills and durable powers of attorney for health-care are legal documents specifically designed to allow adults the opportunity to state their decisions in advance or name a surrogate to act, if and when they are unable to make essential healthcare treatment decisions.
The new position statement identifies that nurses must appreciate the patient's legal right to have decisions recognized, respected, and honored.
- American Nurses' Association Committee on Ethics.
- Guidelines on withdrawing or withholding food and fluid.
- Kansas City, MO; Author, 1988.
- American Nurses' Association
- Task Force on End of Life
- Decisions. Position statement on foregoing artificial nutrition and hydration. Kansas City, MO; Author, 1992.