"Artificial Nutrition and Hydration and End of Life Decision Making" was originally
published by Choice In Dying. This pamphlet explains, in part:
What is artificial nutrition and hydration?
Artificial nutrition and hydration is a form of life-sustaining treatment. It is a chemically balanced mix of nutrients
and fluids, provided by placing a tube directly into the stomach, the intestine or a vein.
Is artificial nutrition and hydration different from ordinary eating and drinking?
Yes. An obvious difference is that providing artificial nutrition and hydration requires technical skill. Professional
skill and training is necessary to insert the tube and to make decisions about how much and what type of feed to give. Skilled
management is also required to limit bad side effects.
Other important differences exist. Artificial nutrition and hydration does not offer the sensory rewards and comfort that
come from the taste and texture of food and liquids. Doctors and nurses, rather than patients themselves, control when and
how much will be "eaten". Finally, the social interaction that often accompanies eating and drinking is not present.
Will the withdrawal of artificial nutrition and hydration lead to a long and painful death?
No. For patients who are at the end of life, death normally occurs within 3 to 14 days after artificial nutrition an dehydration
is stopped (the time varies depending on how debilitated the patient was when treatment was discontinued). Reports based on
the observation of unconscious patients indicate that the process is quite peaceful, and no evidence exists that they are
aware of the process. Conscious patients who are elderly or neurologically impaired usually will slip quickly into a coma
(a sleep-like state that is inherently free of pain) and become similarly unaware.
Caregivers of the dying and patients themselves have reported that those who are near death are seldom hungry, and if feelings
of hunger occur, small amounts of food by mouth are usually all the patient wants. The most common complaint is dry mouth,
a condition that can be alleviated by sips of water, ice chips, lubricants for the lips or other appropriate oral care. On
rare occasions, patients may experience twitching or muscle spasms when hydration is withdrawn, but these symptoms can be
managed easily with sedatives. Symptoms that sometimes occur, such as sever pain or nausea, are due to the disease itself.
Supply artificial nutrition and hydration will not alleviate these symptoms and may even make them worse.
Is there evidence that avoiding artificial nutrition and hydration contributes to a more comfortable
Yes. Much of this evidence is based on observations by those who have had a great deal of experience caring for the dying,
such as hospice workers. They have noticed that patients who are not tube fed seem more comfortable than those who are. Caregivers
also have observed that symptoms such as nausea, vomiting, abdominal pain, incontinence, congestion, shortness of breath,
among others, decreased when artificial nutrition and hydration were discontinued making the patient more comfortable.
Is there evidence continued
For example, patients with pneumonia, one of the most common terminal events among the elderly or people with terminal
illness, will not suffer as much from coughing or shortness of breath due to the excess mucous production if they are not
receiving fluids. Medical observation has found no indications that patients who have suffered massive brain damage causing
permanent unconsciousness experience any pain when artificial nutrition and hydration is stopped.
Reports from conscious dying patients indicate that they increasingly experience a lack of appetite and thirst. In fact,
it is common for competent hospice patients and those suffering acute illness to refuse food and water. Dry mouth is the only
common reported symptoms, and this can be managed without resort to tubes.
Animal studies indicate that the body responds to lack of food by increasing the production of natural pain relievers (endorphins).
However, if food is supplied, the body stops producing endorphins and the benefit of this natural pain relief is lost.
Artificial nutrition and hydration is largely a 20th century technology. Historically, coma was nature' way
of relieving the suffering of the dying. However, the provision of artificial nutrition and hydration may prevent the development
of this natural anesthesia in some cases.
Is it ever appropriate to give artificial nutrition and hydration to patients who are at the end of life?
Yes. As with any medical treatment, tube feeding and hydration should be given if they contribute to the overall treatment
goals for the patient. These treatment goals should always focus on the patients wishes and interests. If the goal is to keep
the patient alive, then artificial nutrition and hydration may be essential treatment. But if the goal is to provide comfort
care only, artificial nutrition and hydration usually is not appropriate and may actually add to the persons discomfort.
Some individuals from personal or religious conviction may believe that nutrition and fluids always must be given no matter
what the condition or prognosis, or how much the patient may be suffering. Because the provision of food and water can have
enormous symbolic significance for some, it can have a powerful effect on decisions about the provision of artificial nutrition
and hydration. If the symbolic importance exists for the patient, caregivers should respect the patients wishes to continue
treatment. However, if the symbolic importance exists for the family and caregivers, but not necessarily for the patient,
the decision to continue artificial nutrition and hydration may need closer examination.
Choice In Dying is now called Partnership for Caring. The pamphlet "Artificial Nutrition and Hydration and End of Life
Decision Making", # QA200, may be ordered from them for $5.95: