Nutrition and Hydration

By William Lamers, M.D. 
former Medical Consultant, Hospice Foundation of America

Donate to HFAThe notion of caregivers not providing normal amounts of food or water runs counter to all we have been taught in medical training, much less what we hold to be necessary in everyday society. Yet because of the advances of science we are now able to prolong the lives of persons who would not survive without external support, mechanical devices, or, at times, intravenous or central line (cut-down) nutrition and water. 

Physicians and bio-ethicists who work with dying persons have grappled with the dilemma of what is reasonable care for a dying person. There comes a time in some cases where even nutrition and hydration are considered extraordinary means of prolonging life, and such ordinary nutrients are discontinued. This is never done without great and careful consideration. The decision to withhold food and/or fluid is made only when it is apparent to the caregivers and family that further prolongation of life would only extend discomfort. This decision should be made with the patient, if able to understand, and the family being fully informed of all considerations. Ideally, the family is then involved in making the decision to withhold food and fluids. 

For persons in the final phase of illness, the withholding of food and fluids is not painful. To the contrary: the administration of food and fluids to dying persons can extend their general discomfort and frustrate their desire to just let go and allow nature to take its course.

In cases where people cannot swallow, it is standard care to apply moisture in some form to the lips and mouth regardless of whether or not the patient is ever able to swallow again. This is basic oral hygiene. This is comfort care. Applying moisture should be done even if a person with advanced illness is able to take oral fluids.

In instances when it is determined that the person is dying and it is further determined that hydration would only prolong the patient's discomfort, dehydration is not a painful process. Even those with total bowel obstruction who had been unable to retain any oral fluids and who voluntarily declined intravenous fluids do not complain of thirst or hunger. There is a side effect of starvation and dehydration in which one's metabolism changes and the resulting elevated level of ketones produces a mild sense of euphoria, so that hunger and thirst are not the problem we would imagine. This same phenomenon has been well documented in the self-imposed starvation of Irish prisoners in Northern Ireland who went on strict fasts to cause them to die, if possible, on certain Irish holidays. Once starvation begins, the ensuing metabolic shift eliminates the sense of hunger. The body feeds at first on fat reserves, and later on protein. 

It is this sort of information that underlies the bio-ethical support for withholding nutrition in those persons with advanced illness whose greatly impaired quality of life would not be improved, but only prolonged, by supplemental (intravenous or cut-down) methods of delivering nutrition and hydration. In no way is the withholding of food and fluids comparable to the methods or rationalizations employed by Dr. Kevorkian.

Note: Please realize that since we do not know the details of every case we are only speaking in generalities.

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