ARTIFICIAL NUTRITION AND HYDRATION AT THE END OF LIFE

Pediatric polysomnography patient, Children's ...

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It is not necessary to feed a person when it no longer results in a better quality of life.  Surprised?  Yes, most people are.  The notion of withholding food runs contrary to our beliefs regarding care.  Just look at today’s babies.  When they cry, what do parents do to stop them?  If the diaper is dry, the next step is most likely to insert a feeding bottle into the mouth.  For adults, a get-together is not complete without food.  When we travel to faraway places, we often give food as “pasalubong” to our loved ones when we arrive back home.  No wonder why an advice of withholding feeding is often met with much contradiction from the family.  We equate food with good health, satisfactory care, and loving gestures.  So when we stop feeding, it is as if we no longer care.

Legally, all medical interventions can be refused by patients who still have the capacity to decide.  Artificial feeding is no exception, even if it results in death.  If relief of suffering and improvement of the quality of life can no longer be accomplished by nutritional supplementation and feeding, there is no reason to feed.  In an article published by the Palliative and Supportive Care Journal in 2006, it was also stated that there is no ethical or legal difference between withholding a  feeding tube versus placing the feeding tube and then later removing it.

—Despite increased nutrient delivery, trials show disappointing results in improving clinical outcome for chronically ill patients.  —Improvements in biochemical markers also inconsistently correlate with objective clinical benefits for artificial nutrition and hydration.  Minimal  benefit was also derived from enteral or parenteral nutrition in terminally ill cancer patients, other than for those with obstruction of the stomach or intestine.  Hunger is often not noted and relieved by giving the patient ice chips or small amounts of food and drink.  Dehydration is a normal component of the dying process that does not result in thirst or suffering.  In fact, treating dehydration may actually lead to more pain and difficulty.

There are some cases, however, when artificial feeding and hydration at the end of life may be warranted.  But we must always weigh the advantages and disadvantages of the intervention.  Also important to consider are the wishes of the family and the individualized goal for providing care.  Key principles to consider are autonomy (honoring the patient’s wishes), nonmaleficence (doing no harm), beneficence (doing what is in the patient’s best interest), and capacity (ensuring that the patient and the family understand the information needed to make a decision and provide consent).

It is important to understand that artificial feeding should always be considered relative to patient goals. Physicians and patients, with the patient’s family, must be prepared to discuss the options, bearing in mind the evidence that feeding will do to attain therapeutic goals.  If the viable option is to withhold feeding, don’t despair – it is totally acceptable.    Caring does not stop even if feeding and hydration are withheld.  After all, our ultimate goal is to provide a better quality of life and preserve the human dignity of our loved ones.

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