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Bioethics Notebooks XXVii 2016/1st
Clinical Cases in Clinical Practice

Bioethics Notebooks XXVII 2016/1ª.
Copyright Bioethics Notebooks


Morales Meseguer General University Hospital Hematology and Medical Oncology
Avda. Marqués de Los Vélez, s/n. 30008 Murcia

1. Description of the clinical case
A 45-year-old male patient diagnosed 1.5 years ago
with undifferentiated carcinoma of the rectum,
treated with chemotherapy, chemo-radiotherapy,
surgery with finding of peritoneal metastases with
incomplete resection, and two other lines of
chemotherapy, He has started intermittent parenteral
nutrition three months ago (hospital admission three
nights a week), with clinical improvement and some
weight gain.
She was admitted to the hospital for pain in the
flank and left lower limb, and the CT scan showed a
large abscess in the left psoas and multiple peritoneal
implants with small bowel loops dilated at multiple
points, indicating entrapment at various levels due to
peritoneal disease. On admission, radiological drainage
of the abscess was performed, an- tibiotic and
analgesic treatment was administered and total
parenteral nutrition was indicated, in addition to oral
feeding that was tolerated, which was scarce.
The evolution is torpid, with initial improvement
but with no final resolution of the abscess, and with
progressive establishment of complete intestinal
obstruction, causing continuous nausea and vomiting,
which are more bearable than those of the abscess.
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Bioethics Notebooks XXVii 2016/1st
vomiting. Throughout the hospitalization, it becomes
increasingly evident that the patient will not leave
the hospital because of the impossibility of providing
the care he requires at home, and that life
expectancy is several weeks at best. He maintains a
completely normal level of consciousness, and a
progressively worse general condition, with
hypoproteinemia and generalized edema.
At one point in the course of the patient’s
evolution, we considered the continuation of
parenteral nutrition, which provided a high volume of
fluid, worsening the edema. However, the patient is
conscious, pain-free, weak but with good symptom
control, and absolutely unwilling to talk about the
situation. After discussing the case among the
responsible physicians, and with certain doubts, the
conclusion is reached that paren- teral nutrition is
only prolonging the final process, and in agreement
with the family it is decided to suspend it, leaving a
small amount of glucose saline as a daily infusion. The
patient maintains the nasogastric tube and the
impossibility of enteral feeding. Almost a week went
by without improvement or worsening. At the
weekend, the doctor in charge of the patient, as the
outcome did not seem imminent, decided to resume
parenteral nutrition. That night, the patient suffered
acute pulmonary edema and died 24 hours later.

Bioethics Notebooks XXVii 2016/1st
Clinical Cases in Clinical Practice

2. Ethical considerations
This is a patient diagnosed with an incurable
neoplastic disease, in an irreversible situation, with no
other possibility of specific treatment. Due to
complications of the disease that make enteral feeding
difficult, he has been dependent for months on
intravenous feeding three nights a week. He is
admitted for a complication that seems solvable, in a
situation that does not seem to be imminent death, so
the basic treatment of the complication is indicated,
and the minimum necessary support, which includes
parenteral nutrition in this patient. In other cases of
advanced incurable and irreversible disease with short
life expectancy, parenteral nutrition is considered a
disproportionate means (it requires a central
intravenous line, continuous admission, repeated
analyses to adjust glucose and electrolyte intake, the
risk of infection is high and so is the cost). But in this
particular patient, whose oral feeding is insufficient,
this type of nutrition has been considered justified for
several months.
During hospitalization, with progressive worsening
and decreasing life expectancy, as well as the onset of
adverse side effects due to the same nutrition, it
seemed justified to withdraw it, considering that this
withdrawal would not be the cause of death. However,
given the chronification of the situation, and without the
possibility of oral administration, we raised the ethical
problem of the patient actually dying due to lack of
nutrition, and -with doubts- we decided to reinstate it. On
the other hand, neither the patient nor the family have
expressed any opinion on this issue, nor have they
expressed any desire to shorten the process (which
would probably not change the ethical approach to the
case, but would at least allow us to take into account
the patient’s wishes and values).
This results in water overload which, together with
extreme weakness and other circumstances, eventually
leads to lung flooding and death.
We believe that the decision was appropriate, both at
the time of withdrawal and at the time of reinstitution of
parenteral nutrition. Although in retrospect, had we
known that restarting parenteral nutrition would
precipitate the outcome, or that life expectancy was so
short, we would not have done so.

1. Description of the clinical case
2. Ethical considerations

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