Withdrawal of artificial nutrition in the persistent vegetative state: a continuous controversy

The withdrawal of life support from patients in persistent vegetative state (PVS) is a controversial issue, as highlighted by a continuous public deba te and recent judicial decisions. In Germany, a topic of particular interes t is the abatement of artificial nutrition. First, doubts have come up whet her every kind of technically delivered nutrition should be rated identical ly or whether a distinction between feeding tubes/gastrotomies and intraven ous administration should be made. Second, the question is left open whethe r artificial nutrition is part of basic care and as a consequence may never be discontinued, or if it has to be regarded as life-sustaining treatment which can be refused by surrogates on behalf of the nonautonomous patient. Most recently, controversial judicial decisions have dealt with the questio n if substituted judgement concerning abatement of artificial nutrition by surrogates or legal guardians is permitted or if the approval of a court is necessary. Forensic evidence is provided which indicates that the withdraw al of artificial nutrition in patients in the persistent vegetative state m ay become a contributing causative factor or even the immediate cause of de ath. The legal implications with regard to the above-mentioned issues of co ntroversy are discussed. (C) 2000 Elsevier Science Ireland Ltd. All rights: reserved.