When you hear “the Code of Ethics,” what comes to mind? Maybe you think about making science-based decisions in practice or protecting individuals and various groups. However, I would guess that most of us simply think of how we define ethics. The Oxford dictionary defines ethics as the “moral principles that control or influence a person’s behavior.”¹ There are four principle related to bioethics:

1. Autonomy: respecting the choices of the individual

2. Beneficence: acting in the individual’s benefit

3. Nonmaleficence: preventing harm in favor of helping the individual

4. Justice: treating each case the same as other similar cases²

As Registered Dietitians (RD) and Dietetic Interns (DI), we constantly participate in ethical decisions when we provide patient-centered nutrition care and support, often as a member of an interdisciplinary team. 

In a recent Journal of the Academy of Nutrition and Dietetics (AND) article, three RDs, Denise Baird Shwartz, Mary Ellen Posthauer, and Julie O’Sullivan Maillet, discuss how bioethics relates to nutrition and hydration. The article mainly focuses on artificial nutrition and hydration (ANH). The RD must analyze the risks and benefits of initiating or withdrawing ANH. In addition, the RD is responsible for being a liaison between the ANH candidate and the candidate’s providers while communicating the individual’s preferences, discussing possible feeding complications, and addressing all appropriate feeding options.² 

Applying the concept of bioethics to practice can be difficult because every patient and situation is unique. However, the article provides guidelines and tips for applying bioethics to ANH. The article first highlights the Patient Self-Determination Act of 1990, which states that everyone who is able can decide what medical care they will accept or deny and who will do so if they are unable. These desires are most often compiled in a living will and must be recognized in practice. Another crucial element to providing ANH is to refrain from bias from day one of care. If any provider feels they cannot practice in such a way, they should remove themselves from a case if necessary. The article also notes that end-of-life care can be heavily influenced by the religious and cultural beliefs of the individual. It is not the role of the RD to decide yes or no on nutritional therapy in the end-of-life setting unless nutrition support is futile. There are also several resources for RDs in practice, such as the American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines and AND Practice Standards for Nutrition Support. These resources emphasize that quality of life should always be a consideration.² 

In light of the ongoing pandemic, there are additional elements to consider as we continue to care for patients amidst COVID-19. When considering ANH, recognize that the increased demands of a pandemic often cause a shortage of both resources and workforce. The article states that there are four key elements to decision making during a pandemic: “maximizing the benefits achieved with limited resources, treating people equally, promoting and rewarding instrumental value [..], and giving priority to the worst off.”² 

The article also provides in-depth explanations of applying bioethics for patient circumstances, including advanced dementia, disorders of consciousness, terminally ill individuals, as well as a case study on nutrition support decision making in a COVID-19 positive ICU patient.² 

Policies and procedures must be in place that support and guide ethical decision-making and build projects to improve these processes. RDs are crucial in these development and implementation processes as nutrition support is an essential aspect of medical care.²

Shwartz et al. provide an excellent resource for starting the conversation of bioethics in ANH and the role of the RD. Key take-aways from the article include:

 • The individual's preferences, needs, and values are the first and foremost guides for care.

 • Consider how nutrition support affects the individual’s everyday life, including physical and  psychological comfort.

 • In addition to hospitalized patients, ANH is often an element of care considered in palliative and end-of-life care. 

 • Consider limitations of the facility that may impact feeding.

 • The RD should be involved in every nutrition-related decision.²

For every decision made, it is our responsibility as healthcare professionals to ensure the decision is ethical. There are many resources to guide those making ethical decisions around ANH, including facility protocols, bioethics committees, and the 2018 ASPEN Standards for Nutrition Support: Adult Hospitalized Patients. With nutrition support being an area of everday living and medical technology, RDs can be the first step for the individual to accept other medical therapies that can improve overall patient care and outcomes.²

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