title: [Withdrawal of artificial nutrition and hydration in severe stroke: medical, legal and ethical considerations].
abstract: In the majority of cases, severe stroke is accompanied by difficulty in swallowing and an altered state of consciousness requiring artificial nutrition and hydration. Because of their artificial nature, nutrition and hydration are considered by law as treatment rather basic care. Withdrawal of these treatments is dictated by the refusal of unreasonable obstinacy enshrined in law and is justified by the risk of severe disability and very poor quality of life. It is usually the last among other withholding and withdrawal decisions which have already been made during the long course of the disease. Reaching a collegial consensus on a controversial decision such as artificial nutrition and hydration withdrawal is a difficult and complex process. The reluctance for such decisions is mainly due to the symbolic value of food and hydration, to the fear of "dying badly" while suffering from hunger and thirst, and to the difficult distinction between this medical act and euthanasia. The only way to overcome such reluctance is to ensure flawless accompaniment, associating sedation and appropriate comfort care with a clear explanation (with relatives but also caregivers) of the rationale and implications of this type of decision. All teams dealing with this type of situation must have thoroughly thought through the medical, legal and ethical considerations involved in making this difficult decision.
authors.affiliation: Service de neurologie, comité d'éthique, centre hospitalier, route de Saint-Hilaire, 1060, chemin de la Madeleine, 11010 Carcassonne, France. Electronic address: ctannier@hotmail.com.
authors.forename: C
authors.initials: C
authors.lastname: Tannier
authors.affiliation: Service des urgences cérébrovasculaires, groupe hospitalier Pitié-Salpêtrière, 47-83, boulevard de l'hôpital, 75651 Paris cedex 13, France.
authors.forename: S
authors.initials: S
authors.lastname: Crozier
authors.affiliation: Service de neurologie et neurovasculaire, groupe hospitalier Paris-Saint-Joseph et université Paris-Descartes, 185, rue R.-Losserand, 75674 Paris cedex 14, France.
authors.forename: M
authors.initials: M
authors.lastname: Zuber
authors.affiliation: 43 bis, rue Desnouettes (B241), 75015 Paris, France.
authors.forename: Y
authors.initials: Y
authors.lastname: Constantinides
authors.affiliation: Conseil national de l'ordre des masseurs-kinésithérapeutes, 120-122, rue Réaumur, 75002 Paris, France.
authors.forename: E
authors.initials: E
authors.lastname: Delezie
authors.affiliation: Centre de sociologie des organisations, CNRS/FNSP, 19, rue Amélie, 75007 Paris, France.
authors.forename: E
authors.initials: E
authors.lastname: Gisquet
authors.affiliation: Service de psychiatrie de liaison, organizzazione sociopsichiatrica cantonale, via Tesserete 67, 6942 Lugano, Suisse.
authors.forename: N
authors.initials: N
authors.lastname: Grignoli
authors.affiliation: Service de neurologie, hôpital Sainte-Anne, 1, rue Cabanis, 75014 Paris, France.
authors.forename: C
authors.initials: C
authors.lastname: Lamy
authors.affiliation: Service des urgences cérébrovasculaires, groupe hospitalier Pitié-Salpêtrière, 47-83, boulevard de l'hôpital, 75651 Paris cedex 13, France.
authors.forename: F
authors.initials: F
authors.lastname: Louvet
authors.affiliation: Service de neurologie, CHU, rue Henri-Le-Guillou, 33033 Rennes, France.
authors.forename: J-F
authors.initials: JF
authors.lastname: Pinel
mesh_terms: D003657:Decision Making; D005440:Fluid Therapy / Q000941:ethics / Q000706:statistics & numerical data; D006801:Humans; D044623:Nutrition Therapy / Q000941:ethics / Q000706:statistics & numerical data; D009752:Nutritional Status; D010166:Palliative Care / Q000941:ethics / Q000331:legislation & jurisprudence / Q000379:methods / Q000706:statistics & numerical data; D011788:Quality of Life; D012720:Severity of Illness Index; D013315:Stress, Psychological / Q000628:therapy; D020521:Stroke / Q000628:therapy*; D013727:Terminal Care / Q000941:ethics / Q000331:legislation & jurisprudence / Q000379:methods; D028761:Withholding Treatment / Q000941:ethics* / Q000331:legislation & jurisprudence*
keywords: Accident vasculaire cérébral; Artificial nutrition and hydration; Ethical reflection; Nutrition et hydratation artificielles; Réflexion éthique; Stroke