Artificial Nutrition and Hydration in End-of-Life Care

Artificial nutrition and hydration (more commonly known as �tube feeding�) is the introduction of nutritional formulas and water into a patient�s body by means of tubes, catheters or needles.   It can take various forms.  A needle may be inserted into a vein in the arm (peripheral intravenous feeding).  A cathether may be inserted into a central vein near the heart (central intravenous feeding/total parenteral feeding/hyperalimentation).  A thin plastic tube may be inserted through the nose into the stomach (nasogastric (NG) tube).  A tube may be surgically inserted through the abdominal wall into the stomach (gastrostomy tube) or through the abdominal wall into the small intestine (jejunostomy tube).

Artificial nutrition and hydration can be used in a variety of circumstances.  This article will discuss tube feeding in the case of dying patients.

Culturally, offering food is a sign of caring and hospitality.  We can think of mothers providing food for their infants.  Most people enjoy sharing a meal with family members and friends, especially on holidays and special occasions.  Food can be a part of religious rituals.  Thus it is not surprising that, when someone we love is unable to take food and drink naturally, we want to �feed� them in some way. [1]

However, a decrease and loss of appetite is a natural part of the body shutting down in the dying process.  With respect to the use of artificial nutrition and hydration for persons who are dying, physicians Joanne Lynn and Joan Harrold have offered this advice in their recent book Handbook for Mortals  Guidance for People Facing Serious Illness:

The evidence from medical research and experiences of clinicians suggest  that dying people are often more comfortable without artificial hydration, whether provided by a feeding tube or IV.  Until this generation, everyone who died a natural death died without artificially supplied fluids.  The stopping of eating and drinking has always been part of the last phase of a terminal condition.  Only recently have people been afraid that not providing food and fluid through a tube would cause someone to �starve to death.�  There is no medical or clinical evidence that not using a feeding tube or IV leads to a more painful death.  In fact, the research says just the  opposite. [1]

As Lynn and Harrold point out, there is increasing evidence that patients who are allowed to die without artificially supplied fluids die more comfortably than patients who receive  such treatment.  Natural dehydration can reduce the patient�s secretions and excretions,

thus relieving breathing problems and decreasing problems with vomiting and incontinence.  Less fluid in the body results in less frequent urination, and in turn, less risk of skin breakdown and bed sores.   Less fluid in the body means less pressure on tumors, and hence less pain for the patient. Indeed, the natural process of dehydration leads to death in ways that produce a sedative effect on the brain just before death, thus decreasing the need  for pain medication. [1, 2, 3]

Regarding artificial nutrition and hydration, the Ethical and Religious Directives for Catholic Health Care Services from the National Conference of Catholic Bishops (1994) states:

There should be a presumption in favor of providing nutrition and hydration  to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient. (no. 23)

The last stipulation should be carefully noted. It is considered morally permissible to forgo (withhold or withdraw) artificial nutrition and hydration when this procedure does not provide benefits to the patient sufficient to outweigh its burdens for the patient.

Noting that �some state Catholic conferences, individuals bishops, and the NCCB Committee on Pro-Life Activities have addressed the moral issues concerning medically assisted hydration and nutrition,� this document goes on to say:

These statements agree that hydration and nutrition are not morally obligatory either when they bring no comfort to a person who is imminently dying or when they cannot be assimilated by a person�s body. (Part Five, Introduction; italics added.)

Thus, clinical evidence that patients may well die more comfortably without artificially supplied fluids is very important and relevant in making our moral judgments about using or forgoing artificial nutrition and hydration in end-of-life care.

1. Joanne Lynn, M.D. and Joan Harrold, M.D., Handbook for Mortals Guidance for People Facing      Serious Illness (New York: Oxford Univesity Press, 1999).
2. Joyce C. Zerwekh, �The Dehydration Question,� Nursing 83 (Jan. 1983): 47-51.
3. American Dietetic Assocation, �Position of the American Dietetic Association: Issues in Feeding     the Terminally Ill Adult,� American Dietetic Association Journal 87 (Jan.-April 1987): 78-85 at     82.

Prepared by Janine Marie Idziak, Ph.D.   Health Care Consultant, Archdiocese of Dubuque, IA    July 2000
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