Nutrition and hydration in the last days of life

Casarett, 2015 Good, 2014 Buchan, 2023

Most patients (and their family and carers) recognise that the desire and ability to eat and drink diminishes over a period of weeks to months as a patient’s health deteriorates. As patients enter the last days of life, their awareness and cognition, and their ability to communicate thirst or hunger are also frequently impaired. At this stage, many patients do not feel thirst or hunger but may have a dry mouth, which can be uncomfortable. If patients have a desire to eat or drink, they may continue to eat or drink.

Neither clinically assisted nutrition (eg enteral feeding, parenteral nutrition) or clinically assisted hydration (eg parenteral fluids) appear to be beneficial in the last days of life. These interventions can lead to problems associated with fluid overload, including lower limb oedema, cerebral oedema, respiratory secretions (and noisy breathing) and gastrointestinal secretions (with vomiting). Furthermore, the presence of medical equipment, such as intravenous lines and enteral feeding tubes, can focus care on the intervention rather than the patient, and make it difficult for the family to get physically close to the patient.

Conflict can arise when decisions need to be made about starting or stopping clinically assisted nutrition and hydration. Family and carers may fear that the patient will die of starvation or dehydration and ask for clinically assisted nutrition or hydration to be started or continued. From an ethical and legal perspective, clinically assisted nutrition and hydration are considered to be medical treatments; there is no medical, ethical or legal requirement that they be given in the last days of life unless they provide relief of symptoms.

Note: Clinically assisted nutrition and hydration are considered to be medical treatments; there is no requirement that they be given in the last days of life unless they provide relief of symptoms.

Explain to the patient’s family and carers that clinically assisted nutrition and hydration are unlikely to be beneficial when the patient is dying and may cause patient discomfort and prolong dying. If appropriate, explain that the patient’s lack of eating and drinking is a result (rather than the cause) of the dying process. Guidance for explaining the dying process and aspects of care in the last days of life to family members and carers includes an example explanation of changes in patient nutrition and hydration needs at the end of life. The family may be able to assist with mouth care, especially if the patient has a dry mouth.

Despite explanation and reassurance, some families continue to be very distressed that the patient is not receiving nutrition or fluids. Seek specialist palliative care advice for guidance, if needed. Some cultural and religious groups have strong beliefs on this issue; advice and support from someone of the same culture or faith (eg pastoral care worker, spiritual leader) may be useful. Occasionally, it may be helpful to trial subcutaneous fluids with a clear explanation about both the possible benefits and potential harms; determine a time limit for the trial.

For discussions about withdrawing or withholding treatment, see Decisions about withdrawing or withholding treatment in palliative care. For information on conflict resolution, see Differences in opinion and approach to conflict resolution in palliative care.

When clinically assisted enteral nutrition is stopped, remove the nasogastric tube because it can be uncomfortable for the patient. A gastrostomy or jejunostomy tube may be left in place and used to administer drugs (instead of subcutaneous administration), if appropriate.