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Questions and Answers: Artificial Nutrition and Hydration and End of Life Decision Making

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 patient's 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 person's 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 patient's 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.

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Is it better to refuse artificial nutrition but to continue hydration?

No. Continuing hydration alone does not necessarily contribute to comfort. It may contribute to discomfort by extending the dying process and delaying the development of a peaceful coma. In addition, continuing hydration may aggravate other symptoms such as cough or shortness of breath. Because patients' intake of fluids decreases substantially at the end of life, any sensation of thirst or dry mouth is generally managed easily with sips of water, ice chips, and good oral care.

What does the law say about artificial nutrition and hydration?

Legally, artificial nutrition and hydration is considered a medical treatment that may be refused at the end of life. If the patient still has the capacity to make decisions, the patient can tell the physician what he or she wants. However, for patients who are too sick to communicate, certain states demand strong evidence that a patient would choose to refuse treatment before the state will permit treatment to be stopped.

Every state law allows individuals to refuse artificial nutrition and hydration through the use of an advance directive such as a living will or durable power of attorney for health care, which is used to appoint an agent or surrogate to speak for the patient. However, state laws vary as to what must be done to make wishes known. In many states nutrition and hydration is simply considered a medical treatment that may be refused in an advance directive. But in some states individuals are required to state specifically whether or not they would want artificial nutrition and hydration at the end of life. When there is uncertainty or conflict about whether or not a person would want the treatment, treatment usually will be continued.

Because caregivers' own views may be very different from the patient's views, it is wise for people to make their wishes about the use of artificial nutrition and hydration known in advance and to be sure that caregivers will honor them. This advance planning is important even if state law does not require it. Some states prohibit caregivers or agents from making decisions to stop the use of artificial nutrition and hydration unless they specifically know the patient's own wishes.

WebMD Medical Reference from the National Hospice and Palliative Care Organization

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