Segment Highlights - Artificial Nutrition and Hydration

Register | Register via mail/fax | Return to Artifical Nutrition and Hydration at the End of Life

Donate to HFA

Segment Highlights

Artificial Nutrition and Hydration at the End of Life

Segment I

Clinical Principles: Benefits and Burdens of Artificial Nutrition and Hydration

  1. There are some conditions and diseases where using artificial nutrition and hydration (ANH) clearly shows benefit, others where the evidence is neutral, mixed or inadequate; and a third class where best available evidence indicates it does not prolong life or achieve other goals important to the patient and may, in fact, do harm. Clinicians need to carefully assess and discuss the goals of care, the nature of the given disease, and the emotions and perceptions of patient, family and surrogate concerning the role of nutrition and hydration.
  2. Artificial nutrition and hydration can be a contentious issue in hospice and palliative care, as well as in other healthcare settings, and has been identified as one of the most common concerns to arise in end-of-life care.  It is critical to be aware of the latest research when assessing the burdens and benefits of ANH for a patient before withholding offering, or administering such treatment.
  3. Providing artificial nutrition through total parenteral nutrition (TPN) or enteral nutrition through a gastrostomy tube (G-tube) or jejunostomy tube (J-tube) are invasive medical procedures that pose increased risk of infection and other complications, including but not limited to aspiration, bed sores, bloating, constipation, and nausea.  Some patients, such those who have dementia or altered mental status, must be restrained during such treatment.  As such patients’ bodily systems deteriorate, the value of ANH and its attendant restraining measures may be questioned, as studies show for some patients, artificial nutrition and hydration neither provides nutritional benefit, prolongs life nor offers comfort. 

Segment II

Ethical Principles: The Role of Artificial Nutrition and Hydration in End-of-Life Care

  1. The Patient Self-Determination Act affirmed ANH as medical treatment and established the legal right to refuse any unwanted medical treatment, including ANH.  States may vary, however, in terms of the specificity required in an advance directive.
  2. There can be conflicts within families as well as between and among medical professionals and families in deciding whether to withhold or withdraw artificial nutrition and hydration.  In assessing the ethics of such situations, families and clinicians are obligated to consider any advance directives and the expressed wishes of the patient as well as ethical principles such as beneficence, nonmaleficence, autonomy, and justice. In addition, surrogates may oppose advance directives or medical decisions regarding ANH, posing an ethical and legal dilemma for both surrogates and providers.  In other cases, surrogates may be called upon to participate in decision making for people without capacity who have no prior existing oral or written directives.  In these situations, social service or medical professionals may be able to help surrogates to maximize the patient’s ability to participate in decision making. The role of treating individuals humanely in the decision making process must always be considered first.
  3. Cultural and religious beliefs may influence surrogate decision making or be in opposition to medical recommendations regarding withholding or withdrawing ANH. Misunderstanding of the medical aspects of ANH or misinformation about a religion’s statements about ANH may further complicate decision-making.

Segment III

Policy Around ANH: Its Value

  1. Transparent policies that clearly describe ANH , identify the burdens and benefits of such care, and outline the processes and policies applicable to artificial nutrition and hydration are essential for healthcare providers. Healthcare provider organizations with clear policies surrounding ANH can help staff navigate medical, communication and ethical issues that often arise around ANH.
  2. Specialists who work in end-of-life care have expertise in supporting patient and family decision making about ANH in serious illness and at end of life and should be called upon to provide expertise to other medical professionals.
  3. Staff should be trained to explain the benefits and burdens of ANH in end-of-life situations and be prepared to address families’ concerns, as well as offer possible alternatives such as comfort feeding by caregivers of food that is able to be swallowed without fear of aspiration.
  4. Healthcare organizations need to offer education for families to minimize misunderstanding and discord. Staff should be educated in collaborative models to share expertise and to minimize moral distress and anguish.
  5. Assisting families and staff to understand the ethical and medical issues inherent to ANH and to engage in the motional, cultural and spiritual aspects of ANH-related decisions will improve communication and minimize repercussions related to family discourse as well as subsequent grief reactions of family members and providers.

Back to top

Additional HFA Educational Programs
End-of-Life Ethics | Beyond Kübler-Ross: New Perspectives on Death, Dying, and Grief | Spirituality and End-of-Life CareLooking for resources from a past HFA Teleconference? Visit the Professional Resources section.