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(HealthNewsDigest.com) – The desire not to initiate life-sustaining medical care — commonly called a DNR (do not resuscitate) — is widely respected by the medical community. The desire to withhold or withdraw nutrition and hydration at the end of life is far more controversial.
With the explosion of older adults in the US over the next few decades, end of life care will become an issue for the health care community. Ideally, end of life care should be outlined in a legal document by an individual before serious illness or the inability to communicate wishes occurs. Sadly, few terminally ill patients have such advanced medical directives in place – a legal statement of their wishes about life-sustaining medical care and artificial nutrition and hydration.
Feeding the sick is always viewed as an act of compassion and love. How can you consider withholding food or liquids from a dying patient? Herein lies a basic misunderstanding of the function of nutrition at the end of life by both medical staff and concerned family members. Many see withholding food and fluids at the end of life as a “passive” euthanasia. In fact, not feeding or providing beverages to a dying patient does not cause suffering and may contribute to a far more comfortable passage from life. Withholding food and fluids while providing sedatives, however, will result in a hastened death which begs the ethical, legal and moral questions of justifying this decision by the family and doctor.
Most dying patients who are competent to explain their needs report not wanting or desiring food or beverages. Lubricants or ice chips to moisten the lips and mouth provide more comfort than food. There is little evidence that end of life feeding extends life and it may decrease the quality of life. Not eating may actually contribute to less pain, more sleep, and in some cases a feeling of well-being. Dehydration affects the brain and the ability to feel pain. Dehydration in a terminally ill patient is often associated with fewer symptoms – less fluid in the body to create discomfort, and less nausea and vomiting. But, dehydration has also been associated with an increase in delirium and a decrease in consciousness.
The decision to feed and offer beverages at the end of life, either orally or through tube feedings is not solely based on science. Older patients with advanced dementia pose a unique challenge. They may not be terminal, in that death is not days or weeks away, but their dementia may be so advanced that swallowing is compromised. To prevent weight loss, even though the inability to swallow is recognized as a symptom of end-stage dementia, many older patients are given a feeding tube. This can cause agitation requiring mittens and restraints to prevent the patient from pulling out the tube. Feeding tubes often result in infection and further loss of dignity for a patient with already limited capacity to understand.
Religious belief and ethnic origin also influence end of life feeding decisions. The Catholic Church does not require extraordinary treatments for end of life care but in 2004, the Pope found that artificial feeding and hydration were not classified as extraordinary. A patient’s medical directive that is not in line with the Vatican cannot be honored at a Catholic health care facility.
In the Jewish faith withholding or withdrawing end of life feeding is unlikely. Orthodox Judaism believes food, even if given through a tube, is basic care for the dying. The only exception would be if the there is proof of “goses” (less than 72 hours until death) and further intervention would be futile or painful for the patient.
Islamic beliefs teach that death is neither to be feared nor resisted. But, death should not be hastened. Comfort in dying is important so the patient can pray. Though Muslim scholars advocate for withholding food and hydration at the end of life, families may resist this idea for fear of causing the patient pain.
Caucasians are more likely to be influenced by medical choices and are more apt to have a living will. African Americans and Mexican American are more likely to request any intervention that will prolong life. In most Asian cultures it is considered disrespectful to tell a patient they are dying and withholding food from an older person would never be allowed.
Members of the health care team need to understand and respect these varying viewpoints when treating older dying patients. There is no one approach that is the best in all situations and length of life may not be the best option. One thing family members should remember when they are forced to face end of life decisions – nutrition or the lack of it will not cause the person’s death. Disease or simple length of life will be the reason the patient dies.
For more information on end of life feeding decisions go to: Journal of Nutrition for the Elderly, Volume 29, Number 4, October-December 2010.
© NRH Nutrition Consultants, Inc.
Jo-Ann Heslin, MA, RD, CDN is a registered dietitian and the author of the nutrition counter series for Pocket Books with 12 current titles and sales of more than 8.5 million books. The books are widely available at your local or on-line bookseller.
Current titles include:
The Diabetes Counter, 4th Ed., 2011
The Protein Counter, 3rd Ed., 2011
The Calorie Counter, 5th Ed., 2010
The Ultimate Carbohydrate Counter, 3rd Ed., 2010
The Complete Food Counter, 3rd ed., 2009
The Fat Counter, 7th ed., 2009
The Healthy Wholefoods Counter, 2008
The Cholesterol Counter, 7th Ed., 2008
For more information on Jo-Ann and her books, go to The Nutrition Experts
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