AAP approves withdrawal of artificial nutrition from children in certain cases

For nearly two decades, the medical and legal consensus has been that it is permissable to withdraw life-sustaining artificial hydration and nutrition from adult patients in a persistent vegetative state. But should that standard apply to children, too?

Yes, it should, but only if their parents agree, according to a new position statement issued by the American Academy of Pediatrics' Committee on Bioethics and published in the August Pediatrics (link).

There are as many as 35,000 pediatric patients living in a persistent vegetative state, according to the AAP report. The academy's statement says there are other "limited circumstances" under which it may be morally permissible for physicians to withdraw medically provided nutrition and fluids because those interventions can impose more burden than benefit to pediatric patients.

Cases where putting an end to feeding is ethically appropriate can include children with severe nervous system malformations or prenatal injury such as anencephaly, children with minimal consciousness, pediatric patients with terminal illnesses and infants with total intestinal failure.

The clinical difference between making this ethically difficult call in pediatric cases versus adult patients is that it is often harder to predict how children may fare neurologically, said Douglas S. Diekema, MD, MPH, lead author of the position statement. He said withdrawing artificial hydration and nutrition is especially sensitive when it comes to children.

"It feels different when it's a child who's your patient versus a 45-year-old," said Dr. Diekema, director of the Treuman Katz Center for Pediatric Bioethics at Seattle Children's Hospital. "Also, there is a social significance to feeding in terms of parents taking care of their children, and that sometimes carries over to our thinking and to discussion of medically provided fluids and nutrition."

Even if a pediatric patient is in a persistent vegetative state, stopping feeding is not "morally required," the AAP says. Further, doctors and hospitals should not go against parents' wishes. But when there is disagreement among doctors and family, an ethics consultation should be arranged to help communicate with family and try to reach accord or refer the patient elsewhere, the academy said.