Clinical Ethics and Nutrition Support

Nutrition support should be considered optional when this therapy is not in congruence with an individual's wishes based on quality of life goals, during the end-of-life period. Ethical dilemmas, dealing with nutrition therapy, are often due to lack of early communication between individuals, their family, and healthcare providers. Landmark young adult ethical court cases, dealing with nutrition therapy, reveal that this is not just a topic for the elderly. Healthcare literacy, multicultural populations, and different faiths add to the diversity of perspectives on healthcare decisions dealing with withholding or withdrawing nutrition therapy. These dilemmas are preventable if action steps are taken to improve the current healthcare clinical ethics model. Healthcare decision-making in advance should be considered by the individual and their family as an opportunity to communicate and plan for the future rather than a taboo topic. Healthcare facilities need to develop a proactive, integrated, structured process for healthcare ethical decision-making with measurable outcomes and shared best practice. Resources and toolkits are available to educate both the healthcare professional and the public on advance care planning.


INTRODUCTION
Modulating nutritional therapeutics in various stages of life and disease states to improve outcomes is readily recognized.However, to withhold or withdraw nutrition therapies can result in ethical dilemmas [1].There is a difference between delayed initiation nutrition treatment via feeding tubes (gastrointestinal tract or intravenous) in an acutely ill individual versus intentional withholding or withdrawing nutrition therapy due to a person's preferences and quality of life goals during the end-of-life period.Conflict prevention requires action.Communicating common goals focused on the individual, early before the decisionmaking process is required, may result in averting ethical dilemmas.

BACKGROUND
Clinical ethics healthcare, involving nutritional therapeutics/nutrition therapy, has evolved over the past four decades with interprofessional hospital bioethics committees, legislation promoting advance directives, palliative care team development, ethical guidelines, and ethics position and practice papers published by national healthcare organizations [2][3][4].Despite these advancements, ethical dilemmas continue to occur involving life-sustaining treatments, including nutrition therapy.Lack of communication between patients and their families, and healthcare providers concerning wishes for end-of-life care and quality of life goals, before the illness and healthcare *Address corresponding to this author at the PO Box 1770, Studio City, CA 91614, USA; Tel: 818-419-5016; E-mail: denisebairdschwartz@gmail.com crisis, is a challenging problem.The solution to this communication deficit will be multifactorial and will require a paradigm shift by all the stakeholders [2,4].

STAKEHOLDERS AND ISSUES
Stakeholders in this process begin with the individual and their family, and then include healthcare professionals/providers, healthcare facilities, and healthcare systems.
Baby boomers and their parents, perhaps are the first generations to face these potential ethical dilemmas, with the technology advancement in medical therapies, including nutrition therapies.Medical treatment options are available to prolong life or perhaps extend the dying process.This is not an issue only for the elderly and their adult children, but should be addressed when a person is age of majority as indicated in Figure 1.Concepts addressed include opportunity awareness communication, research options, discussion of wishes, document completion, and review and modification of decisions and documents.
Landmark adult ethical court cases, dealing with nutrition therapy, involving unfortunate individuals in their 20s, resulted in difficult situations for these young adults and their families.Although these court cases have increased awareness of the need for advance care planning, there remains a deficit in individuals documenting their wishes in writing and communicating this information for decision-making in the various healthcare facility settings [4].
Mismatched family expectations and unrealistic healthcare technology capabilities can lead to ethical conflict.Healthcare literacy, multicultural population, and different faiths further add to the diversity of concepts dealing with perspectives on an individual's illness and the decision-making process [5][6][7][8].
Nutritional therapeutics dealing with enteral and parenteral nutrition and aspects of these therapies, such as route, timing, and substrates are provided and assessed in the hospital setting.Complexities of patient wishes and quality of life goals are not always addressed.A culture change will be required involving preventive clinical ethics to improve enhanced patientcentered care based on outcome research and patient education, but requires involvement by the individual and their family [9][10][11][12][13].
The need for early ethical decision-making is especially evident in practice settings where timely nutrition intervention, especially critical care, is recommended to optimize healthcare outcomes.Nutrition, even administered through a tube, can provide a sense of caring.For individuals and their families these nutrition therapies become more difficult to withdraw after being initiated, than to be withheld.Individuals and their family view nutrition differently compared to healthcare professionals who recognize that artificial nutrition is a medical treatment [2,4].

FACILITATING EARLY COMMUNICATION
Is it the responsibility of the individual, family or healthcare provider to start the conversation about healthcare wishes for the end-of-life?How does this question get communicated and who is responsible?Essentially these questions deal with communication at different periods and settings in one's life.Early communication before the illness or hospital healthcare crisis gives the individual the opportunity to reflect on the decision-making process, to determine options, to make decisions while not under pressure.For some individuals having this conversation after the illness starts or healthcare crisis occurs could be perceived as taking away the person's hope for a cure.Yet a realistic conversation allows the individual to express their wishes, which will be the guide to maintain patientcentered care throughout the illness.
Cultivating a culture of awareness of the benefit of this early communication is essential to open up dialogue and prevent ethical dilemmas.indicates the focus in this decision process should be the individual, but all stakeholders have a responsibility in bringing awareness of the problem and achieving a solution.

CHANGING HEALTHCARE CLINICAL ETHICS MODEL AND PERSPECTIVE
Asking the question "When is nutritional therapeutics optional?"causes a simple shift in perspective that opens the door for a focus on deeper concept discussion between individuals, families, and healthcare professionals/providers.Perhaps this concept is what is needed in healthcare to shift the way life is approached deliberate and attentive to the individual's wishes.Figure 3

RESOURCES AND TOOLS FOR ADVANCE CARE PLANNING
Resources are available for healthcare providers and the public to increase knowledge in this important aspect of healthcare that would be useful when determining the appropriate use of medical therapies at a particular period in one's life.
Toolkits have been created to enhance the communication process and start the conversation.Table 2 presents sample sources for toolkits to  promote concepts that help individuals and their family better understand advance care planning.

ENGAGING THE PUBLIC IN THE PROCESS
The importance of starting the conversation by individuals and family to prevent the clinical ethics healthcare dilemmas is essential for the individual to remain in control, as much as possible, during the healthcare decision-making process.Engaging the public in the process with early communication remains a key to preventing ethical dilemmas.Breathe by Anne Bland is an example of a book written by a healthcare professional, under a pen name, about a true powerful story to help individuals begin dialogue with family members about end-of-life healthcare decisions [15].Intended for both the non-healthcare professional and the healthcare clinician, to serve as a personal example of how intertwining intimate stories dealing with family relationships, faith, and values can be a tool to start these sensitive conversations.
Figure 4 shows that advance care planning should be considered an opportunity for planning rather than a taboo topic.

CONCLUSION
Nutrition therapy ethical dilemmas remain an ongoing problem with various stakeholders and issues to be addressed.Lack of early communication about quality of life goals and end-of-life care is at the center of these ethical dilemmas.Resources and toolkits are available for educating individuals, family, and healthcare professionals seeking this information.Engaging the public in this topic is essential to improve patient-centered outcomes and achieve preventive ethics.

Figure 1 :
Figure 1: Cycle of healthcare decision-making for quality of life goals and end-of-life care.
depicts the current healthcare clinical ethics model and how options outside the box could move this process on to a new improved model.

Figure 2 :
Figure 2: Building on the communication process and stepping up to the plate.

Figure 3 :
Figure 3: Changing the healthcare clinical ethics model thinking outside the box.

Figure 4 :
Figure 4: Changing the public's perspective on advance care planning.