Dehydration is common at the end of life. Many patients and families are understandably concerned when this occurs. It is normal to believe that fluid intake can improve overall health and well-being, but this is not always true in a hospice patient. Most people are surprised to learn that the natural process of dehydration at the end of life produces many positive effects. It is often the task of the hospice team to educate patients and families about this process.
“Medically provided hydration is viewed in law and ethics as a medical treatment, which means that, like other medical treatments, it can be withheld or withdrawn if it does not provide the desired benefit, or if the treatment creates a “disproportionate burden.” Treatments considered to be palliative, on the other hand, cannot be withdrawn. There is no ethical or legal distinction between withholding artificially provided hydration and withdrawing it after it has begun” [1]
At the end of life, when a person stops eating and drinking, it is usually because the illness has progressed to the point where food and fluids are no longer processed in the same way as in a healthier person. Forced nutrition will often have unintended consequences. Among these consequences are the overwhelming of the circulatory system and edema in the feet, ankles, lower legs and lungs.
Like other medical interventions, all forms of artificial nutrition and hydration:
Require the patient to undergo uncomfortable, and sometimes painful, procedures for the treatment to be started
Have known side effects such as infections, fluid overload, nausea, blood clots and even death
Have very little similarity to a person who is able to sit with family and socialize while enjoying a meal
We have learned to express our love for one another through the act of feeding and sharing of meals throughout our lives. Much of the anguish over decisions to start, withhold or discontinue artificial nutrition and hydration stems from a mistaken perception that administering artificial nutrition is equivalent to a meal with our family.
Studies have shown that the majority of dying patients rarely experience hunger or thirst. They do, however, experience dry mouth which is rarely resolved by artificial hydration. Dehydration in a Dying Patient is not Painful. Instead, some positive chemical changes occur that are thought to bring comfort to the dying patient:
Increased production of ketones enhances sleepiness and euphoria, as well as decreased urinary output
If a tumor is present, the edematous layer may shrink
Increased opioid peptide production causes increased endorphin levels and naturally occurring analgesia
Decreased gastric stimulation results in lack of hunger
Hypernatremia and uremia results in a clouding of sensorium
Quality of Life
Secretions in the lungs are diminished, so there is a reduction in cough and congestion
Decreased edema leads to increased comfort
Decreased fluid in the gastrointestinal tract may decrease nausea, vomiting, bloating and regurgitation
A dehydrated person has less urinary output so less need to go to the restroom. For very weak and frail patients, this increases quality of life and reduces the incidence of skin breakdown and usage of catheters, which can be irritating and cause infections
Artificial nutrition and hydration is a medical treatment with side effects and complications attached to its use. Decisions should be based on what, if any, benefits will occur and what possible side effects and burdens may be placed upon the patient.
References:
http://journalofethics.ama-assn.org/2010/07/cprl1-1007.html
http://aahpm.org/positions/anh
http://www.acponline.org/running_practice/ethics/manual/manual6th.htm#artificial
http://www.acu.edu.au/__data/assets/pdf_file/0017/53450/Ersek_article.pd