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

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 three to 14 days after artificial nutrition and hydration 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 dying people 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 On rare occasions, patients may experience twitching or muscle spasms when hydration is withdrawn, but these symptoms can be managed easily with sedatives.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 severe pain or nausea, are due to the disease itself. Supplying artificial nutrition and hydration will not alleviate these symptoms and may even make them worse.

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Is there evidence that avoiding artificial nutrition and hydration contributes to a more comfortable death?

Yes. Much of this evidence is based on observations by those who have had a great deal of experience caring for people who are 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. For example, patients with pneumonia, one of the most common terminal events among elderly patients or people with terminal illness, will not suffer as much from coughing or shortness of breath due to 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 commonly reported symptom, and it can be managed without resort to tubes.

Animal studies indicate that the body responds to a 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's way of relieving the suffering of people who were dying. However, the provision of artificial nutrition and hydration may prevent the development of this natural anesthesia in some cases.

WebMD Medical Reference from the National Hospice and Palliative Care Organization

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