Enthusiasm for arranging death with dignity has resulted in many pioneering laws describing living wills, advanced medical directives, and the value of a personal attorney for health care. A North Carolina law (G.S. 90-321, 1991) uses a typical phrase, "... without extraordinary means or artificial nutrition or hydration will succumb...," that should be of keen interest to internists.
On first thought, the word artificial would seem to exclude all intravenous fluids and the nasogastric delivery of commercial formulas. But what makes the nutrition or hydration artificial? Is it the passageway or the unnatural complexity of the fluid? At what point does Ensure given by teaspoon, or plastic tablespoon, or syringe with a short plastic extension, become artificial? The addition of complex vitamins or needed electrolytes to normal saline might convert it into an artificial solution, but when speech therapists add thicket this might make an artificial gruel more natural.
Spudis EV. The Stengel Rule Applied to the Artificial Refeeding of Gastrostomy Drainage. Arch Intern Med. 1995;155(2):218. doi:10.1001/archinte.1995.00430020112020