**Author details**

feeding tube consider the basic principles of professional ethics. Informed consent from an adult who is cognitively intact is imperative, and the benefits of the placement of enteral nutrition must outweigh the risk of the procedure, which should cause the patient no harm [89].

The concept of palliative care needs to be introduced as a real alternative for patients who are not considered candidates for PEG placement due to the presence of risk factors that place them at high risk for mortality. The World Health Organisation (2002) considers palliative care as "...an all-encompassing approach to care that begins months or years before death". PEG placement does not always benefit the patient, and although the actual PEG procedure does not harm the patient, the risk of mortality post placement is high, which in turn is harmful to the patient. The choice of refusing a PEG and remaining on oral intake as a form of palliative care should be made available to all patients and their caregivers, with provision of education and support for the decision they may make. The inclusion of a palliative care option for patients who do not wish to have a PEG placed would provide them with an alternative option, and it would also ensure that futile procedures are avoided which would uphold medical

The decisions around the recommendation of enteral nutrition, particularly in very ill patients who have a poor prognosis, are not easy for health care professionals to make. Clear guidelines that are based on evidence are crucial in order to help health care professionals navigate these

A role not often considered by SLTs is that of palliative care. The provision of artificial nutrition and hydration (ANH) to patients who are in the end stages of disease is debated, and can evoke emotional responses [106]. It is common for patients in the end stages of disease to have little or no oral intake [106]. Many practitioners may feel that depriving a patient of hydration and nutrition is unethical and can make health professionals uncomfortable [89,107]. A study of nurses' perceptions on ANH in palliative care yielded more clinical reasons for withholding of ANH than for providing it [106]. Reasons supporting provision of ANH were emotive, not

In practice, there comes a time, when a decision needs to be made about the hydration and nutrition needs of a patient in the end stages of disease. The SLT is often the professional who, based on the assessment of the patient's swallowing, is in a position to determine the feasibility of nutritional intake. It is important that the SLT and the inter-professional team are educated in the field of palliative care and ANH [106-107] to contribute to making an informed decision regarding a patient's options at end of life and reduce the number of inappropriate referrals

Based on a review of current literature some important points have been raised around the recommendation process for enteral nutrition in adult patients with dysphagia. The key focus in any decision making process for medical procedures should be on patient autonomy. If a

difficult decisions that are often clouded with human emotion.

for futile procedures with poor outcomes.

**9. Conclusion**

based on clinical fact and were not in the best interests of the patient [106].

ethics.

146 Seminars in Dysphagia

Nicoll Kenny1\* and Shajila A. Singh2

\*Address all correspondence to: nicollcbell@gmail.com

1 Chris Hani Baragwanath Academic Hospital, Speech Therapy and Audiology Department, Johannesburg, South Africa

2 University of Cape Town, Department of Communication Disorders, Cape Town, South Africa
