Clinically assisted nutrition and hydration (CANH) are essential interventions used to provide nutrients and fluids to adult patients who are unable to meet their nutritional needs orally (British Medical Association (BMA), 2023). This can arise due to a variety of medical conditions, including neurological disorders, severe dysphagia, or end-stage illnesses such as advanced cancer or dementia. CANH interventions encompass a range of methods, including enteral feeding, parenteral nutrition and intravenous fluids, tailored to the individual patient's clinical circumstances and nutritional requirements (Brindle et al, 2023).
The provision of CANH raises complex ethical considerations that extend beyond clinical efficacy and medical indications (Royal College of Physicians (RCP) and BMA, 2018). Decisions regarding CANH involve balancing the benefits and burdens of treatment, respecting patient autonomy and preferences, and considering the overall quality of life for patients and their families (McCann, 2023). Given the potential impact of CANH on patient wellbeing and end-of-life care, addressing the ethical issues of CANH decision-making is paramount to ensuring compassionate and patient-centred care (Royal College of Nursing (RCN), 2023).
Advanced clinical practitioners (ACPs) are health professionals educated to master's level or equivalent, possessing the skills and knowledge to expand their scope of practice to better meet the needs of the people they care for (Evans et al, 2020). ACPs are deployed across all healthcare settings and operate at a level of advanced clinical practice that integrates the four ACP pillars: clinical practice, leadership and management, education, and research (Hill et al, 2022). ACPs can undertake the role of providing CANH if it is within their scope of practice, and they possess the appropriate skills and knowledge.
ACPs, as experienced health professionals with advanced skills and expertise in patient care, play a crucial role in navigating the ethical complexities associated with CANH decision-making. Their role extends beyond traditional clinical duties to encompass facilitating discussions about CANH options, exploring patient preferences and values, and engaging in shared decision-making processes with patients, families, and multidisciplinary healthcare teams (Lynch, 2023). ACPs are uniquely positioned to integrate ethical principles into clinical practice, providing holistic and patient-centred care that respects the dignity and autonomy of patients facing decisions about CANH interventions. As such, understanding the role of ACPs in navigating ethical dilemmas related to CANH is essential for promoting ethical decision-making and optimising patient outcomes in clinical practice.
Overview of the use of clinically assisted nutrition and hydration
CANH and an ageing population
In the UK, the number of people aged over 65 stands at approximately 10 million and is rapidly growing, and this figure is expected to reach around 19 million by 2050 (Rochford, 2021). Despite increasing life expectancy, the prevalence of conditions such as cancer and dementia is rising, leading to a decline in healthy life expectancy. Malnutrition is a significant concern, with an estimated 1.3 million individuals aged over 65 at risk (Rochford, 2021). Upon admission to hospital or care home, one-third of this demographic is found to be malnourished or at risk (Russell, 2024). CANH poses ethical challenges for clinicians, particularly in light of evolving health and social demographics (Carter, 2020). This issue is deeply emotive for patients, their families, carers, and clinicians, given that food and water are fundamental necessities for sustaining life.
CANH interventions may include enteral feeding methods such as nasogastric tubes, gastrostomy tubes, or jejunostomy tubes, as well as parenteral nutrition delivered intravenously (Carter, 2020; Schwartz et al, 2021). Each type of intervention is selected based on the patient's clinical condition, nutritional needs and goals of care, with the aim of maintaining or improving the patient's nutritional status and overall wellbeing.
Indications for CANH in adult patients
CANH may be indicated for adult patients with various medical conditions that compromise their ability to consume adequate nutrition orally (Lam et al, 2023). These may include severe dysphagia resulting from neurological disorders such as stroke, traumatic brain injury, or neurodegenerative diseases such as Parkinson's disease or amyotrophic lateral sclerosis (ALS). Additionally, CANH may be considered for patients with advanced cancer, end-stage organ failure, or other debilitating illnesses that impair their ability to ingest food or fluids orally (Jarrett, 2020). The decision to initiate CANH is guided by clinical assessments of the patient's nutritional status, prognosis, and goals of care, with input from the patient, family members, and healthcare providers.
Responsibilities of ACPs in CANH decision-making processes
ACPs play a pivotal role in CANH decision-making processes by using their advanced clinical skills and expertise to assess patients' nutritional needs, evaluate the appropriateness of CANH interventions, and engage in shared decision-making with patients and their families (Health Education England (HEE), 2020). ACPs are responsible for conducting comprehensive assessments of patients' medical conditions, including their nutritional status, swallowing function, and cognitive capacity (Mann et al, 2023). Based on these assessments, ACPs collaborate with the multidisciplinary team (MDT) to develop individualised care plans that align with patients' goals of care and preferences regarding CANH (HEE, 2020).
ACPs facilitate a collaborative approach to CANH decision-making by involving patients, families, and MDTs, which may include nutrition teams, physicians, ward nurses and nutrition specialist nurses, dietitians, speech and language therapists and social workers (HEE, 2020). ACPs serve as advocates for patients' autonomy and preferences, ensuring that their voices are heard and respected throughout the decision-making process (McKeown, 2022). ACPs also collaborate closely with other health professionals to ensure comprehensive and holistic care for patients requiring CANH (HEE, 2020). By fostering open communication, sharing information, and soliciting input from all stakeholders, ACPs promote transparency, trust and shared decision-making in CANH decision-making processes (Anantapong et al, 2020).
Ethical challenges faced by ACPs in CANH discussions and decision-making
ACPs encounter various ethical challenges when facilitating CANH discussions and decision-making, including navigating conflicts between patients' autonomy and best interests, managing disagreements among family members regarding treatment preferences, and addressing constraints or limitations in healthcare resources. ACPs can use the checklist provided in Table 1 as a tool to facilitate decision-making regarding the best interests of their patients. ACPs should balance the ethical principles of autonomy, beneficence, non-maleficence, and justice, as described by Beauchamp and Childress (1979), while addressing the challenges inherent in CANH decision-making to ensure that decisions are made ethically, transparently and in the best interests of patients (Cranmer and Nhemachena, 2013). The Beauchamp and Childress principles represent a robust ethical foundation, guiding ACPs in making transparent, patient-centred decisions that prioritise the best interests of patients (Beauchamp and Childress, 1979; Bailey, 2018).
| Criteria | Explanation |
|---|---|
| Avoid discrimination and assumptions | Ensure that decisions are not influenced by prejudices or assumptions based on the person's age, appearance, condition, or behaviour |
| Consider potential regain of capacity | Evaluate whether the person is likely to regain capacity in the future and assess if the decision can be postponed until they are able to participate in the decision-making process |
| Encourage participation | Actively involve the person in the decision-making process by creating opportunities and providing support to enable their participation to the fullest extent possible |
| Ensure decisions are non-motivated by desire for death | Ensure that decisions regarding life-sustaining treatment are not motivated by a desire to bring about the person's death, but rather focus on promoting their wellbeing and quality of life |
| Consider all relevant circumstances | Take into account all relevant factors and circumstances, attempting to identify the considerations the person lacking capacity would consider if they were able to make the decision themselves |
| Explore the person's views, wishes and beliefs | Gather information about the person's past and present wishes, feelings, beliefs and values that may influence their decision-making, including consulting with family, carers and those with lasting power of attorney |
Although CANH constitutes a medical intervention (Rochford, 2021), ACPs can undertake this responsibility within their scope of practice (HEE, 2020). However, it is imperative to acknowledge the pivotal role of nutrition teams within the trust or health board setting. These teams play a crucial role in facilitating collaboration among the various health professionals to deliver holistic care to patients requiring CANH (Nightingale et al, 2020). By harnessing the expertise of nutrition teams and fostering interdisciplinary teamwork, ACPs can ensure comprehensive and patient-centred management of CANH (Barrett et al, 2021).
ACPs may face personal moral distress or professional dilemmas when advocating for patients' preferences in situations where there are conflicting opinions or limited resources available (Fourie et al, 2015). To address these challenges, ACPs rely on their communication skills, ethical reasoning abilities, and collaboration with the multidisciplinary team to navigate complex ethical dilemmas and promote patient-centred care in CANH decision-making.
Ethical principles and theories in CANH decision making
Autonomy: respect for patient autonomy and decision-making capacity
Respecting patient autonomy is a fundamental ethical principle in healthcare decision-making, including decisions regarding CANH (Crocombe and Rochford, 2023). Autonomy recognises patients' rights to make informed choices about their care based on their values, beliefs, and preferences (Killackey et al, 2020). If patients have capacity, they are able to make decisions about treatments or to refuse them. Table 2 summarises the matters to consider when obtaining valid consent. In the context of CANH, autonomy entails providing patients with comprehensive information about their condition, prognosis and treatment options, including the risks, benefits, and alternatives to CANH (Malek et al, 2021). Healthcare providers must ensure that patients have the capacity to understand this information and make decisions free from coercion or undue influence. Additionally, respecting autonomy requires honouring advance directives or other expressions of patients' treatment preferences, even if they conflict with healthcare providers' recommendations or societal norms (Choi, 2022).
| Criteria | Explanation |
|---|---|
| Understanding of medical treatment | Can the person comprehend the purpose and nature of the medical treatment or research intervention in simple language? |
| Awareness of benefits, risks, and alternatives | Does the person grasp the primary benefits, potential risks, and available alternatives associated with the proposed treatment or intervention? |
| Awareness of consequences of non-treatment | Can the person grasp the broad consequences of not receiving the proposed treatment or intervention? |
| Retention of information | Is the person capable of retaining the provided information for a sufficient duration to make an informed decision? |
| Ability to make a free choice | Does the person have the capacity to make a decision without feeling coerced or under pressure? |
Beneficence: maximising benefits and minimising harm in CANH provision
The principle of beneficence requires healthcare providers to act in the best interests of their patients and to maximise benefits while minimising harm (Nicholas et al, 2024). In the context of CANH decision-making, beneficence entails carefully weighing the potential benefits of nutrition and hydration support against the risks of complications or burdens associated with CANH interventions (Hayes et al, 2024). Healthcare providers must consider the patient's overall medical condition, prognosis, and goals of care when determining whether CANH is likely to improve the patient's nutritional status, quality of life or clinical outcomes. Additionally, beneficence involves providing compassionate and patient-centred care throughout the CANH process, including monitoring for signs of discomfort, adjusting interventions as needed, and supporting patients and families in coping with the challenges of CANH.
Non-maleficence: avoiding harm and suffering associated with CANH interventions
The principle of non-maleficence necessitates healthcare providers to refrain from causing harm or unnecessary suffering to their patients (Sattar et al, 2024). In the context of CANH decision-making, non-maleficence requires healthcare providers to carefully consider the potential risks and complications associated with CANH interventions and to take steps to mitigate or avoid harm whenever possible. Therefore, ACPs collaborate with the nutrition team, including clinical specialist dietitians and nutrition nurse specialists or practitioners. ACPs can leverage the expertise of these professionals to ensure comprehensive patient care (HEE, 2020). This may involve assessing the patient's medical condition and nutritional needs, selecting the least invasive and most appropriate method of CANH delivery, and closely monitoring for signs of complications such as aspiration, tube dislodgement, or metabolic imbalances. Additionally, ACPs must be prepared to re-evaluate the appropriateness of CANH interventions over time and to withdraw or withhold CANH if it is no longer providing benefit or if the burdens outweigh the benefits for the patient.
Justice: fair allocation of CANH resources and considerations of distributive justice
The principle of justice requires fair and equitable distribution of healthcare resources and consideration of societal values in decision-making (Chakraborty and Achour, 2024). In the context of CANH, justice entails ensuring that access to nutrition and hydration support is based on clinical need, patient preferences, and available resources, rather than arbitrary factors such as socioeconomic status or personal characteristics (Poku, 2024). Healthcare providers must be mindful of the limited resources available for CANH interventions and strive to allocate these resources in a manner that maximises overall societal welfare. Additionally, considerations of distributive justice may involve addressing disparities in access to CANH services among different patient populations and advocating for policies or interventions that promote equitable access to nutrition and hydration support for all patients in need.
Ethical decision-making in CANH is informed by a variety of ethical theories and principles, including principlism, utilitarianism and virtue ethics (Smajdor et al, 2022):
Legal and ethical frameworks for CANH decision making
Relevant laws, regulations and guidelines governing CANH in the UK
In the UK, decisions regarding CANH are guided by a combination of legal statutes, regulations and professional guidelines (Huxtable, 2024). The Mental Capacity Act 2005 provides the legal framework for assessing and making decisions on behalf of individuals who lack the capacity to make decisions for themselves (Beale et al, 2024). The Act emphasises the importance of acting in the best interests of the individual while respecting their autonomy and preferences (Foo et al, 2024). In addition, the Act establishes the role of lasting power of attorney (LPA) and advance decisions to refuse treatment (ADRT), which allow individuals to express their wishes regarding medical treatment, including CANH, in advance.
The Court of Protection, as established under the Mental Capacity Act 2005, plays a crucial role in overseeing decisions about CANH for individuals lacking capacity (Wicks, 2019). By ensuring that decisions are made in the person's best interests, the Court provides a safeguard against inappropriate or unwarranted provision of CANH. This involves a thorough assessment of the individual's circumstances, taking into account medical, social and personal factors to determine whether CANH is appropriate and aligns with the person's preferences and values. Similarly, the Care Quality Commission (CQC) enforces standards related to nutrition, hydration, and overall quality and safety of care within healthcare settings (Gray et al, 2021). By monitoring and regulating healthcare providers, the CQC ensures that CANH is administered appropriately and in accordance with established guidelines and best practices (Holdoway, 2022). This includes assessing the competency of health professionals involved in CANH provision, maintaining proper protocols for CANH delivery and monitoring, and addressing any deficiencies or deviations from accepted standards to safeguard the wellbeing of individuals receiving CANH.
In the UK, the British Association for Parenteral and Enteral Nutrition (BAPEN) comprises specialists in nutrition (White, 2017; BAPEN, 2022). BAPEN plays a pivotal role in shaping guidelines and standards pertaining to CANH (Carter, 2020). Through its expertise and advocacy efforts, BAPEN contributes significantly to the review of relevant laws, regulations and guidelines governing malnutrition in the UK (Elia, 2015). Its input ensures that policies align with current evidence-based practices and prioritise the wellbeing of patients requiring nutritional support. By collaborating with BAPEN, policymakers and health professionals can access valuable insights and guidance to enhance the quality and efficacy of CANH provision across the UK healthcare system (BAPEN, 2022).
The General Medical Council (GMC) provides ethical guidance for health professionals through its good medical practice guidelines (GMC, 2024). These guidelines emphasise the importance of patient-centred care, shared decision-making, and respecting patient autonomy in all aspects of medical practice, including CANH decision-making. Additionally, the BMA and Nursing and Midwifery Council (NMC) offer specific guidance on CANH decision-making, outlining principles for assessing capacity, determining best interests, and involving patients and families in decision-making processes (NMC, 2016; BMA, 2023). Table 3 illustrates five case studies and their ethical dilemmas in CANH decision-making and their resolution in the UK.
| Case study | Ethical dilemma | Resolution | Link to the Mental Capacity Act 2005 |
|---|---|---|---|
| Mrs A's advance decision | Conflict between expressed wishes and best interests | Mrs A has an advance decision refusing CANH. However, her current medical condition necessitates CANH for her survival. The Court of Protection reviews the case, considering medical evidence and Mrs A's previously expressed wishes, ultimately authorising CANH in her best interests | The case underscores the importance of reconciling a person's previously expressed wishes, as outlined in an advance decision, with their current best interests as determined under the Mental Capacity Act 2005. The Court of Protection ensures that decisions align with the principles of the Act, prioritising the individual's best interests |
| Mr B's family disagreement | Disagreement among family members regarding treatment | Mr B's family members have differing views on whether CANH should be provided. The Court of Protection intervenes to mediate the dispute, ensuring that decisions are made in Mr B's best interests, considering medical evidence and the values and preferences of all parties involved | The case highlights the role of the Court of Protection in resolving conflicts and making decisions on behalf of individuals lacking capacity, as mandated by the Mental Capacity Act 2005. The Court ensures that decisions are consistent with the principles of the Act, promoting the individual's best interests while respecting their autonomy and dignity |
| Miss C's quality of life concerns | Balancing quality of life with prolonging life | Miss C, who lacks capacity, has a terminal illness and refuses CANH, citing concerns about quality of life. The Court of Protection carefully weighs the benefits and burdens of CANH, consulting health professionals and considering Miss C's expressed wishes, ultimately respecting her autonomy, and refusing CANH | This case illustrates the application of the best interest's principle under the Mental Capacity Act 2005, wherein decisions regarding medical treatment, including CANH, must consider the individual's values, beliefs, and preferences, even when those preferences may result in a decision to refuse treatment |
| Mr D's best interests assessment | Determining the best course of action when capacity is fluctuating | Mr D experiences fluctuating capacity due to a progressive neurological condition. The Court of Protection conducts ongoing assessments of his best interests, taking into account his evolving wishes, medical prognosis, and quality of life considerations, to guide decisions regarding CANH provision | This case underscores the importance of the ongoing best interest's assessment required under the Mental Capacity Act 2005 for individuals with fluctuating capacity. The Court ensures that decisions regarding CANH align with Mr D's best interests as determined through a comprehensive evaluation process consistent with the principles of the Act |
| Mrs E's end-of-life care plan | Aligning CANH provision with goals of care in end-of-life scenarios | Mrs E, nearing the end of life, has an advance care plan emphasising comfort-focused care. The Court of Protection ensures that CANH provision aligns with Mrs E's goals of care, emphasising symptom management and dignity in dying, rather than aggressive life-sustaining interventions | This case highlights the intersection of end-of-life care planning and decision-making under the Mental Capacity Act 2005, wherein decisions regarding CANH provision must align with the individual's expressed wishes and values as outlined in advance care plans or other relevant documents. The Court ensures that decisions respect Mrs E's autonomy and dignity in accordance with the principles of the Act |
The case of Tony Bland
To understand the ethical principle further, the Tony Bland case is explored as it stands as a seminal example of the ethical complexities surrounding CANH decision making (Szawarski and Kakar, 2012). This landmark case, which unfolded in the late 1980s, not only highlights the intricate medical and ethical dilemmas inherent in CANH but also sparked profound discussions and debates that continue to shape the landscape of medical ethics today. Tony Bland, a young man from Liverpool, was tragically caught up in the Hillsborough disaster of 1989, which resulted in severe brain damage leaving him in a persistent vegetative state (PVS) (McLean, 2016). As his condition deteriorated, his medical team faced the ethical dilemma of whether to continue providing CANH, given his irreversible state and lack of meaningful consciousness.
Ethical principles and theories
The following principles are relevant in this case:
Ethical dilemmas and considerations
The Tony Bland case presented numerous ethical dilemmas and considerations that reverberate through the field of medical ethics:
The Tony Bland case serves as a poignant reminder of the profound ethical dilemmas inherent in CANH decision making. It underscores the importance of robust ethical frameworks, interdisciplinary collaboration, and compassionate decision making in navigating the complex terrain of medical ethics. As health professionals continue to navigate these challenges, the legacy of cases such as Tony Bland's remains a guiding light in the pursuit of ethical and compassionate patient care. His has become the test case for the lawfulness of ‘elective’ withdrawal of life support in the form of CANH in an adult patient in the UK. Szawarski and Kakar (2012) provide a useful summary of the case.
Strategies for communication and shared decision-making with patients and families
Effective communication and shared decision-making are key components of patient-centred care in CANH decision-making, particularly when patients lack decision-making capacity (Wheelwright et al, 2023). Healthcare providers can employ various strategies to facilitate communication and decision-making, including using plain language, visual aids, and decision support tools to enhance understanding. In cases where patients lack capacity, healthcare providers must engage with surrogate decision-makers, such as legally appointed representatives or family members, to determine the patient's best interests and preferences regarding CANH (Rochford, 2023). Open and honest communication, empathy and active listening are essential for building trust and rapport with patients and families, fostering collaborative decision-making, and ensuring that treatment decisions reflect patients' values and preferences.
Cultural, religious and personal beliefs in CANH decision-making
In CANH decision-making, healthcare providers must consider the cultural, religious and personal beliefs of patients and families. Cultural and religious beliefs may influence patients' views on life-sustaining treatments, end-of-life care, and the acceptability of withholding or withdrawing CANH interventions. Healthcare providers should engage in culturally sensitive and respectful discussions with patients and families to understand their beliefs and values regarding CANH and to address any concerns or misconceptions they may have. Additionally, healthcare providers must adhere to legal and ethical guidelines when considering withholding or withdrawing CANH interventions, ensuring that decisions are made in accordance with patients' best interests, the principles of beneficence and non-maleficence, and relevant legal statutes, such as the Mental Capacity Act 2005 in the UK.
Health professionals should adhere to a comprehensive range of policies and guidelines governing the withholding and withdrawing of treatments, including CANH interventions. The GMC provides ethical guidance for health professionals, emphasising considerations for patients' best interests, maintaining open communication, and respecting autonomy and wishes, (GMC, 2024). Moreover, the NMC and the RCN offer specific guidance for nurses, highlighting the importance of ethical practice, effective communication, and patient advocacy in decision-making (NMC, 2018; RCN, 2023). Additionally, organisations such as the BAPEN contribute expertise in medical nutrition, offering guidance on the ethical and practical aspects of CANH provision (BAPEN, 2022). Integrating these policies and guidelines alongside medical ethics principles ensures that CANH decisions are made ethically, transparently, and in alignment with patients' values and preferences.
Patient-centred approaches to CANH decision-making
Strategies for effective communication and shared decision-making with patients and families
Effective communication and shared decision-making are fundamental aspects of patient-centred care in CANH decision-making. Research has shown that employing strategies such as active listening, empathy, and clear communication can significantly improve patient outcomes and satisfaction (Harris, 2020). Additionally, guidelines from organisations such as BAPEN emphasise the importance of engaging patients and families in discussions about CANH options, providing comprehensive information, and facilitating shared decision-making processes (BAPEN, 2022). By adhering to evidence-based strategies and guidelines, healthcare providers can promote patient autonomy, satisfaction and trust in CANH decision-making.
Consideration of patients' cultural, religious, and personal beliefs
Cultural, religious, and personal beliefs play a significant role in shaping patients' attitudes towards healthcare interventions, including CANH (Purnell, 2021). By respecting these, healthcare providers can ensure that CANH decisions are made in a manner that honours patients' dignity, autonomy, and cultural diversity, ultimately enhancing the quality of care and promoting positive outcomes for patients and families (Hordern, 2021).
End-of-life considerations and palliative care in CANH
Transitioning from curative to palliative care in CANH decision-making and advance decisions
As patients near the end of life, there may come a point when the focus of care shifts from curative to palliative goals. ACPs play a crucial role in facilitating this transition by engaging in discussions with patients, families and the MDT about the goals of care and the potential role of CANH in the context of palliative care. ACPs ensure that patients' advance directives, including ADRTs and LPAs, are respected, honouring their wishes regarding CANH and other medical interventions. By advocating for patient-centred care and facilitating discussions about end-of-life preferences, ACPs support patients and families in making decisions that align with their values and goals.
Ethical considerations in withdrawing or withholding CANH at the end of life for people who lack capacity
Ethical considerations surrounding the withdrawal or withholding of CANH at the end of life for individuals who lack capacity require careful deliberation and adherence to ethical principles, as explained above (Robertsen, 2022). ACPs collaborate with other members of the healthcare team to assess the patient's clinical condition, prognosis, and goals of care, considering whether CANH interventions align with the patient's best interests and overall quality of life. ACPs also ensure that decisions regarding CANH withdrawal or withholding are made in accordance with legal and ethical frameworks, including the Mental Capacity Act 2005, which emphasises the importance of acting in the patient's best interests and respecting their previously expressed wishes.
Role of ACPs in providing compassionate end-of-life care and supporting patients and families during the CANH decision-making process
ACPs play a vital role in providing compassionate end-of-life care and supporting patients and families throughout the CANH decision-making process. ACPs offer emotional support and guidance to patients and families, helping them navigate the complexities of end-of-life care and make informed decisions that reflect their values and preferences. ACPs also collaborate with palliative care teams to ensure that patients receive holistic and supportive care, addressing their physical, emotional and spiritual needs. By advocating for patient-centred care and facilitating open communication, ACPs promote dignity, comfort, and quality of life for patients at the end of life, fostering a compassionate and supportive environment for patients and families during the CANH decision-making process.
Future research
In future research on CANH ethics, it is essential to explore the collaborative relationships between ACPs and the wider MDT responsible for CANH care, including specialists such as nutrition nurses and nutrition teams. These collaborative relationships play a crucial role in ensuring comprehensive and holistic care for patients receiving CANH interventions. Research should investigate the dynamics of these relationships, examining how they impact CANH decision-making processes and patient outcomes. Additionally, future studies should explore the specific contributions of nutrition nurses and nutrition teams in CANH decision-making, making use of their specialised knowledge and expertise in day-to-day practice. Areas for further research may include evaluating the effectiveness of interdisciplinary protocols for CANH discussions, assessing the utility of decision support tools tailored for ACPs and nutrition specialists, and exploring the experiences of patients and families involved in CANH decision-making processes. By addressing these areas, future research can advance understanding of CANH ethics and enhance the role of ACPs and specialised health professionals in promoting patient-centred care and optimal outcomes in CANH management.
Recommendations and conclusion
The involvement of ACPs in CANH decision-making processes holds significant implications for clinical practice, including the promotion of patient-centred care, shared decision-making, and adherence to ethical principles. To enhance ethical decision-making in CANH, recommendations include the development of standardised protocols and decision support tools for ACPs, ongoing education and training in CANH ethics, and interdisciplinary collaboration among health professionals. Additionally, healthcare organisations should prioritise resources for palliative care services, advance care planning, and supportive care for patients and families facing decisions about CANH. By integrating these recommendations into clinical practice, healthcare providers can ensure that CANH decisions are made ethically, transparently, and in the best interests of patients, ultimately enhancing the quality of care and promoting positive outcomes for patients and families.