Can tube feeding be stopped in a CMO (Comfort Measures Only) patient at the request of their POA (Power of Attorney)?

Tube Feeding Can Be Stopped in CMO Patients at the Request of a POA

Yes, tube feeding can be stopped in a patient with Comfort Measures Only (CMO) status at the request of their Power of Attorney (POA), as artificial nutrition is considered a medical intervention that can be withheld or withdrawn when it no longer serves the patient's goals of care.

Understanding Artificial Nutrition as a Medical Intervention

Artificial nutrition, including tube feeding, is not basic care but rather a medical intervention that requires clear indication and consent:

• The ESPEN guidelines explicitly state that "medically assisted nutrition and hydration are medical interventions and not only basic provision of food and fluids" 1
• In the terminal phase of life, artificial nutrition (enteral nutrition, parenteral nutrition, and parenteral fluids) is strongly recommended against 1
• When there is no treatment goal anymore, therapies are not indicated (futile) and should be withheld or withdrawn 1

Decision-Making Process for Stopping Tube Feeding

When considering stopping tube feeding in a CMO patient:

1. Verify CMO status: Confirm that the patient has a legitimate CMO order indicating the focus is on comfort rather than life prolongation

2. Confirm POA authority: Ensure the POA has the legal authority to make healthcare decisions and is acting in accordance with:

   • The patient's previously expressed wishes
   • The patient's best interests
   • Any existing advance directives 1

3. Consider the clinical context:

   • For patients in the terminal phase, artificial nutrition is not recommended 1
   • In advanced dementia, tube feeding has not been shown to improve survival, quality of life, or prevent aspiration 1
   • Careful hand feeding is recommended as an alternative to tube feeding when appropriate 2

Ethical Considerations

The decision to stop tube feeding should be guided by these principles:

• Quality of life must always be taken into account in any medical treatment including artificial nutrition 1
• When there is no clear benefit to continuing artificial nutrition, the burden may outweigh any potential benefit
• The American Geriatrics Society position statement confirms that tube feeding is "a medical therapy that an individual's surrogate decision-maker can decline or accept in accordance with advance directives, previously stated wishes, or what it is thought the individual would want" 2

Potential Pitfalls and Caveats

1. Emotional concerns: Stopping tube feeding may be emotionally challenging for family and staff who associate nutrition with care and life

   • Use the term "comfort feeding" rather than "stopping artificial nutrition" to avoid negative connotations 1

2. Cultural and religious considerations: Different cultures and religions may have varying perspectives on artificial nutrition at the end of life 1

3. Misconceptions: Families may fear that stopping tube feeding will cause suffering

   • Educate that terminal patients rarely experience hunger or thirst, and when they do, it can often be managed with oral care and small amounts of fluids 1

4. Legal concerns: If there is disagreement about the patient's wishes, consider:

   • Ethics consultation
   • Clinical ethics committee review
   • Second opinions 1

Implementation of Stopping Tube Feeding

When stopping tube feeding in a CMO patient:

1. Document the decision-making process clearly in the medical record
2. Develop a comfort care plan that includes:
   • Oral care to prevent dryness
   • Offering small amounts of food/fluid as tolerated for comfort
   • Appropriate symptom management
3. Provide emotional support to the family and explain that stopping tube feeding:
   • Is consistent with the CMO goals
   • Will not cause suffering
   • Is an accepted medical practice for patients at the end of life

Remember that stopping artificial nutrition does not mean stopping care - it means shifting to comfort-focused care that may be more appropriate for a patient with CMO status.