Tannier C, Crozier S, Zuber M, Constantinides Y, Delezie E, Gisquet E, Grignoli N, Lamy C, Louvet F, Pinel J-F
Service de neurologie, comité d'éthique, centre hospitalier, route de Saint-Hilaire, 1060, chemin de la Madeleine, 11010 Carcassonne, France.
Service des urgences cérébrovasculaires, groupe hospitalier Pitié-Salpêtrière, 47-83, boulevard de l'hôpital, 75651 Paris cedex 13, France.
Rev Neurol (Paris). 2015 Feb;171(2):166-72. doi: 10.1016/j.neurol.2014.09.009. Epub 2015 Jan 6.
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.
在大多数情况下，严重中风伴有吞咽困难和意识状态改变，需要人工营养和补液。由于其人工性质，营养和补液在法律上被视为治疗而非基本护理。停止这些治疗是由法律规定的不合理固执的拒绝所决定的，并且因严重残疾风险和极低的生活质量而合理。它通常是在疾病漫长过程中已经做出的其他 withhold 和 withdrawal 决定中的最后一个。就诸如停止人工营养和补液这样有争议的决定达成合议共识是一个困难而复杂的过程。对此类决定的不情愿主要源于食物和补液的象征价值、对在饥饿和口渴中“痛苦死亡”的恐惧，以及这种医疗行为与安乐死之间难以区分。克服这种不情愿的唯一方法是确保完美的陪伴，将镇静和适当的舒适护理与（向亲属和护理人员）清晰解释此类决定的理由和影响相结合。所有处理此类情况的团队都必须彻底思考做出这一艰难决定所涉及的医学、法律和伦理考量。
