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Decision Making about End-of-Life Artificial Nutrition and Hydration

These are some common questions asked by families and friends about giving food and fluids artificially when a loved one is approaching the end of life.

What is artificial nutrition (food) and hydration (fluid)? How is it given?
Artificial nutrition and hydration is a way of providing food and liquid to a person who cannot eat or drink. It may be used for various reasons. It may make sense to use it if the person has a condition that could improve or if the person has a condition which prevents swallowing.

Artificial food and fluid may be given in several ways: through a tube inserted through the nose into the stomach, through the wall of the abdomen into the stomach (requiring minor surgery); or through a special tube inserted into a vein, or into the subcutaneous tissue (just beneath the skin).

Are there side effects from giving artificial food and fluid?
Yes, side effects can occur. Tubes can damage the nose, throat, stomach, or intestine. If surgery is required, complications such as infection or bleeding can occur. IV lines can become uncomfortable if they become infected or if fluid leaks into the skin. Patients receiving artificial food and fluid may not be able to speak to say that they feel full or unwell, so bloating, cramps or diarrhea may occur. Vomiting may take place and the liquid may be inhaled into the lungs causing pneumonia. Confused patients can become anxious about a tube and try to pull it out which could cause the need to use restraints or sedation. For patients with abdominal cancer or renal failure, tube feeding or IV fluids can result in acute worsening of their condition.

Is artificial food and fluid different from ordinary eating and drinking?
Yes. It does NOT provide the comforts that come from the taste and texture of food and liquids taken by mouth. The nurse or caregiver controls when and how much will be given. Also, the social interaction that occurs with eating is not present.

For patients at the end of life, providing artificial food and fluid may prolong the dying process without contributing to the patient’s comfort. In fact, because of side effects, artificial food and fluid may cause more discomfort.

Will the withholding of artificial food and fluid lead to a long and painful death?
No. For patients at the end of life, death usually occurs within 3 to 14 days after artificial food and fluid is stopped depending on the patient’s condition. Reports based on the observaition of unconscious patients show that this process is quite peaceful. Caregivers have reported that the most common complaint is dry mouth which can be alleviated by sips of water, ice chips, moisturizer for the lips or other appropriate oral care. Symptoms that sometimes occur near the end of life, such as pain or nausea, are due to the disease itself and can be controlled.

Is there evidence that avoiding artificial food and fluid allows a more comfortable death?
Yes. Those who are experienced in caring for patients at the end of life have reported that patients who are not fed by tubes seem more comfortable than those who are. Symptoms such as nausea, vomiting, abdominal pain, loss of control of bowel and/or bladder function, congestion and shortness of breath decreased when artificial food and fluid are discontinued. Patients who can talk do not report hunger or thirst. In fact, it is common for patients to refuse food and fluid. Dry mouth is the only commonly reported symptoms and it can be managed with good oral care.

Can artificial food and fluid be stopped once it has been started?
Yes. Stopping treatment is both legally and ethically appropriate if it does not help the patient or is unwanted. However, caregivers often have a more difficult time stopping a treatment that has been started than simply not starting it.

Some questions to think about when making a decision:
1. What are the patient’s wishes?
2. What quality of life is important to the patient?
3. What is the goal or purpose for providing artificial food and fluid?
4. Will it bring about a cure or change the outcome?
5. Will it contribute to the patient’s comfort, or will it possibly cause increase discomfort?

Having a loved one die can make us feel powerless. But even when “nothing can be done” to cure the disease or change the condition, there is a great deal that can be done to help make a person’s last days comfortable and meaningful. It is important to remember that it is the patient’s comfort and wishes that must guide the decision making, not our own.

References:
“Questions and Answers: Artificial Nutrition and Hydration and End-of-Life Decisions Making” WebMD Medical Reference from the national Hospice and Palliative Care Organization www.webmd.com/content/pages/23/110914.htm

“Artificial Nutrition (Food) and Hydration (Fluids) at the End of Life”
Caring Connections – a program of the NHPC

Hospice Foundation of America (HFA)
www.hosipcefoundation.org/endoflifeinfo

“Information for Hospice of the Valley Families: Artificially Administered Food and Fluids”
Hospice of the Valley – Patient and Family Education
www.hospiceofthevalley.org

Reprinted from Flagstaff Medical Center’s Palliative Care Program.



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