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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.
NOTES
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
This document may be reproduced.
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