In different healthcare institutions the question of feeding patients, particularly those who are seriously sick and expected to die soon, raises questions of moral and ethical nature thus making a decision making process very difficult for the caring staff. Such questions may include:
How can decisions of giving or withholding feeding and hydration be made?

What values and assumptions underlie these decisions?
Which courses of action are in the patient’s ‘best interest’, and how is this ‘interest’ determined?
How and when, if ever, should a decision not to feed or hydrate be made?
Can so basic a provision as food and water ever be considered as optional care?
In most of the healthcare institutions whether they are hospitals or senior homes, the decision making lies within the practice of the nurses who are usually faced with dilemmas. While doctors are more advanced in professional knowledge they rarely find themselves in the difficult situation of making the decision of withholding nutrition or giving it. However, there is sometimes a differentiation between nutrition as part of the care given to the patient and nutrition as a biological life sustaining process:
“In modern practice there is often an underlying tension between two different understandings of ‘nourishing’ the patient. First, nourishing as an intrinsic part of giving care, which falls within the realm of nursing. Second, nourishing as a biological and technical process, a life-sustaining treatment under the control of the medical or nutrition team (from which the nurse may be excluded).” (Hunt, 1994)
Yet the daily practice and the roles of nurses and doctors indicate that the nurses find themselves in the dilemma of making the decision more than other medical staff. In many cases where the withholding of nutrition is legally right and in the interest of the patient, the nurse still finds herself in the ethical and professional dilemma. She is not given the opportunity to discuss her opinion or given any information. As a result whatever decision she makes may be taken as wrong regardless of the fact that she was partially ignorant.
The dilemma is even more difficult when considering nutrition as a basic need or a medical treatment. For a seriously sick person one may accept withholding medication or a technological device that prolongs life unnecessarily, but it is not easy to withhold nutrition which is the basic need for healthy and unhealthy persons.
“Dresser asks, ‘Ought we to regard tube and intravenous feeding as forms of medical treatment, or should we classify them with more basic sorts of care?’” (Dresser, 1985)
The decision of withholding nutrition or hydration is a difficult ethical question that poses emotional stress on the nurses. Withholding medication or technological devices is justifiable and there is enough professional and legal guidance for healthcare staff to follow. Indeed, “Food and water are so central to an array of human emotions that it is almost impossible to consider them with the same emotional detachment that one might feel toward a respirator or a dialysis machine” (Lynn & Childress, 1983)
In this research I am going to study this issue in order to confirm or rule out the possibility of establishing a professional guidance that assists the nurses in decision making. This is expected to relief them from a lot of stress and confusion that are imposed as a result of dealing with the issue on personal terms rather dealing with it objectively according to professional guidance and standards.
The proposal for this research will be studied under the following headings:
1. Description of a case study
2.  Literature review
3.  Proposal
4.  Summary and Conclusions
Description of a Case Study
A case study either from literature or from the records of healthcare institution is expected to illustrate the extent of the problem and its importance. In addition this will emphasise the roles of nurses, relatives and patients in the decision making process. It would also highlight the difficulties facing nurses at different stages of care giving for seriously sick persons.
At this stage of building the skeleton of this research paper very little can be said about the case study until one has been adopted.
Literature Review
The literature generally confirms the importance of the problem and has been addressing the issues related to the problem of nutrition for sometime now. While it is suggested in the literature that in some cases of chronically ill persons the provision of nutrition is burdensome rather than beneficial, it is agreed that the interpersonal and inter-professional tensions of nurses are ignored. (Hunt, 1994)
It is also pointed out that the stressful environment in which nurses provide their professional care sometimes result in burnouts. The burnout case “evolves by a process involving three stages: (a) an imbalance between resources and demands, (b) the immediate short-term emotional response to the imbalance, and (c) changes in attitude and behavior such as negativism and emotional detachment” (Riordan & Saltzer, 1992). However, it is also indicated that there are personal differences here: while one may react to stressors by becoming a burnout another with personal hardiness may find the stressors only minor irritants. Riordan and Saltzer (1992) assert:
“Current literature points unanimously to a proactive approach in preventing burnout. This preserves organizational integrity by maintaining human resources and supplying cost-effective care while maintaining quality” (Riordan & Saltzer, 1992).
There are a number of suggestions for reducing stress and assisting nurses to cope with the environmental difficulties, though no specific guidelines or procedures are given for dealing with the problem of nutrition and hydration.
It is also indicated in the literature that nutrition and hydration in some terminal cases may only prolong the biological life which is thought to be burdensome for some patients and their families. As Hunt (1994) asserts: “Feeding may in some circumstances prolong the process of dying and may cause avoidable suffering to the dying patient.”
While generally the decision of using nutrition support for the terminally ill people is discussed as a problem facing nurses, some scholars relate the decision to dietitians.
“Clinical guidelines for nutrition support indicate that dietitians should be members of institutional ethics committees and should have an integral role in institutional policy development concerning nutrition support at the end of life“ (Langdon et al, 2002)
To put it in a nutshell the literature review confirms the dilemma facing healthcare professionals, particularly nurses, and families in dealing with the decision of providing nutrition and hydration or withholding it for chronically ill people whose illness is diagnosed as terminal. It is also confirmed that the decision making involves personal feelings, ethics, and sometimes legal consideration. Yet there are no clear professional guidelines that streamline the decision making in this issue in the professional practice. Rather there are observations of some acceptable practices.
Sometimes the distinction between ordinary and extraordinary is used as a means of reaching decision.
“However, there appears to be an increasing opinion that artificial feeding can be viewed as a’heroic’ method of treatment and is morally optional (Meyers and Grodin 1991, Hoefler and Kamoie 1994, Singer 1995, Gillick 2000). This optional treatment is referred to as ‘extraordinary’ and is more likely to be invasive, artificial or complex. Nevertheless, the Hastings Centre guidelines, cited in Meyers and Grodin (1991), stated that decisions over whether to provide artificial nutrition and hydration cannot be made solely on the distinction between ordinary and extraordinary methods of treatment. Despite this, Solomon et al (1993) demonstrated that 74 per cent of health professionals continued to use this distinction in termination of treatment decisions. It would also seem that the decision was significantly influenced by whether it was a decision to withdraw treatment or simply not initiate it in the first place. The Hastings Centre guidelines stipulate that this distinction should not be a consideration (Meyers and Grodin 1991)” (Young et al, 2002).
The problem of decision making in providing or withholding nutrition and hydration in the case terminally ill people is a dilemma for nurses until some professional steps are identified to make the decision an objective one made on the basis of professional judgement  rather than being a personal one affected by personal feelings, ethics, beliefs etc.
Since the aim of the study is to justify a professional basis for decision making, in this study we will attempt to investigate the possibility of establishing professional guidelines that may relief the burden on nurses. This will involve identifying criteria that make withholding nutrition more beneficial to the patient than prolonging his biological life. It should also be essential to identify professional means that enable healthcare staff to decide that a patient is not making any sense of life and advise families accordingly to participate in decision making. This should be important especially when the patient is suffering pain or given morphine regularly.
In order to be able to design a professional tool or procedure that assists nurses in decision making through this study or alternatively recommend further research on this issue, the study will be a non-experimental one designed to elicit the RN’s attitudes towards nutrition of chronically ill patients using survey instrumentation.
The sample will be full time RNs employed by a healthcare region in hospitals and nursing homes of the region. It is advisable to include also a sample of dietitians working in the same healthcare institutions. The RNs involved need to be well informed about the study and its aims and should be positively motivated to participate in the study.
It is also important for the study to be approved by a professional body that confirms the study question and methods are ethical.
The instruments of the study should be designed in a way that they measure the attitude of the study sample towards giving or withholding nutrition and hydration for a variety of terminally ill patients. It is also important to determine the internal consistency reliability for the questionnaires and structured interviews.
Summary and Conclusions
These will follow naturally from the analysis of data and discussions and will eventually constitute a recommendation: either a draft of a guideline for assisting nurses in decision making or alternatively suggestions for further research in order to identify a suitable professional tool for relieving the burden on nurses.
I am not going to list the references now since this is just a skeleton to discuss with your supervisor; unless you deem it necessary.
The word count may not be exactly 3500, but I think what has been written here is enough for your purposes. As soon as you give feedback on this I will start work on the proposal.

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