Forum.
SUMMARY
The human body adapts to fasting by metabolising fat, slowing down the metabolic rate and deriving water from the catabolism of body tissues, and to fluid restriction by reducing renal output of water. This reduces energy and fluid requirements. Terminally ill palliative patients who voluntarily refuse all fluid and food may survive for up to 20 days.
There is widely held view that artificial feeding is unlikely to benefit a dying patient. There are however diverse opinions regarding parenteral administration of fluids in palliative patients who are no longer able to take oral fluids, either for reasons related to their illness or because they have been administered sedating medications. There is little scientific evidence to guide decision-making, and further research is needed in this area. Guidelines that consider the issues exist, and may help decision-makers.
Administration of nutrition or hydration by artificial means is generally regarded to be a medical treatment and should be offered when it is medically appropriate. In palliative patients consideration should also be given to cultural, ethical and psychosocial factors. Each person must be assessed individually, taking account of all the relevant factors.
The following broad generalisations are proposed:
- Artificial nutrition is of limited or no medical benefit in the terminal phase
- Artificial hydration may be useful for symptom relief, especially delirium due to opioid accumulation
- Neither nutrition nor hydration is physiologically relevant if a patient is being sedated and death is imminent.
- If the sedation is intended to be transient, then hydration may be medically indicated
One of the most difficult situations is where deep, permanent sedation is given to a patient who is expected to survive for more than two weeks. Some would argue that, in this situation, dehydration may hasten death. Others would argue that giving fluids would neither prevent death, nor make it more comfortable, but merely prolong the dying process.
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