Nutr Hosp

[Evaluation of the quality of life in artificial nutrition]

Year 1998
Zarazaga Monzon A. Culebras JM. Gomez Candela C. Cos AI.
Servicio de Cirugia, Hospital Universitario La Paz, Madrid. azarazaga@sinix.net
If we define quality of life as being the social, physiological, mental intellectual, and general well being of people, we realize that there is no known health care system that is able to guarantee that well being in all its possible aspects. When we as clinicians assess the positive effects of a treatment applied to a patient, we are not only assessing the offered quality of life, but also the quantity of life, so what we are really assessing is the usefulness. We could say, therefore, that while the quality of life is subjective, not exact, and cannot be quantified, the usefulness on the other hand, can and should be measured and quantified, even though, as this is a subjective assessment, it is somewhat difficult to quantify. The object of our publication is to find an appropriate method for assessing this parameter in the area that concerns us: artificial nutrition. Artificial nutrition is indicated when the patient cannot does not want to, or does not know how to eat in the natural manner. Therefore, in principle it could seem inhuman and even unethical to deny a vital support measure that is practically without any risks in a patient who cannot feed him-or herself. However, in a situation of limited resources, if the treatment were inappropriate we should consider that possibility. Under these circumstances we could consider that even a concept as essential as nutrition (in this case artificial) would lose its inalienable character. In order to assess usefulness, one must include parameters that can be quantified in percentages and whose results can be set out in units of time (years, months, or days). We use the concept of the individual usefulness, whose unit of time is the QALY (Quality Adjusted Life Years). In 1996 we made a personal modification of Rosser's Index, which was specific for evaluating the quality of life obtained by means of artificial nutrition. This consisted of substituting the assessment parameters of intensity of pain, by other that are specific in function of the limitation of the ingestion capacity presented by the patient who was subjected to AN. The third factor that corresponds to the concept of usefulness would be the index of beneficial applicability percentage of patients who benefit from the support. The combination of these three factors, applicability, life expectancy, and quality of life, would yield the usefulness of the procedure. In order to assess usefulness in all its aspects, one must also define intention, as this can be applied with three goals: essential or curative, complementary or adjuvant, and maintenance or merely palliative. We can say that the economical limitations and the cost of the therapeutic resources leads to rationing by the administration. In the face of this action, we would recommend a rational and reasonable restriction of the available resources, which lead to the so-called rationalization, a term that is more correct ethically and esthetically, than rationing. As a final conclusion we could state that ethics and economics help us to use the resources appropriately, without any contradictions, as the economy attempts to give the society the greatest possible degree of well being based on the available resources, and that is an ethical objective, The quantification of the benefits obtained by applying a treatment using measureable units, involves socio-economic concepts such as usefulness, cost/benefit, quality of life, etc. should not elicit rejection as though we were dealing with a merchandising of our ethical values. We clinicians are capable of assessing this together, both with regard to the obtained costs and benefits, and with regard to the final results, both intra- and extra-hospital, and using the appropriate tools, we can reach conclusions that can guide us objectively in making decisions, with the aim of optimizing our therapeutic actions.