This article appears in the May 2001edition of the Catholic Medical Quarterly
Ethical Decision-Making
in Palliative Care:
Artificial Hydration for people who are terminally ill
National Council for Hospice and Specialist Palliative Care Services
This paper has been prepared by a Joint Working Party between the National Council for Hospice and Specialist Palliative Care Services and the Ethics Committee of the Association for Palliative Medicine of Great Britain and Ireland
The paper is concerned with artificial hydration by nasogastric tube, gastrostomy, or subcutaneous or intravenous drip. It should be noted that good practice suggests decisions regarding artificial hydration should involve a multiprofessional team, the patient, and relatives and carers, but that the senior doctor has ultimate responsibility for the decision. However, a competent patient has the right to refuse artificial hydration, even if it may be considered of clinical benefit. Incompetent patients retain this right through a valid advance refusal.
-
A blanket policy of artificial hydration, or of no artificial hydration, is ethically indefensible.
-
Towards death, a person's desire for food and drink lessens. Study evidence is limited (see References) but suggests that artificial hydration in imminently dying patients influences neither survival nor symptom control. As such it may constitute an unnecessary intrusion.
-
Thirst or dry mouth in people who are terminally ill may frequently be caused by medication. In such circumstances artificial hydration is unlikely to alleviate the symptom. Good mouth care and reassessment of medication become the most appropriate interventions.
-
Appropriate palliative care will involve consideration of the option of artificial hydration, where dehydration results from a potentially correctable cause (e.g over treatment with diuretics and sedation, recurrent vomiting, diarrhoea and hypercalcaemia).
-
It is a responsibility of the clinical team to make assessments concerning the relevance of hydration to the experience of individual patients. The appropriateness of artificial hydration should be judged on a day-to-day basis, weighing up the potential harms and benefits. The practicalities of appropriate provision will vary according to setting, but good practice will require that patients needing artificial hydration are transferred to a unit equipped to provide such care.
-
Relatives at the bedside of dying patients frequently express concern about lack of fluid or nutrient intake. Health care professionals may not subordinate the interests of patients to the anxieties of relatives but should, nevertheless, strive to address those anxieties.
The appropriateness of artificial hydration continues to depend on regular assessment of the likely benefits and burdens of such intervention.
References:
-
Oliver D. Terminal dehydration (letter). Lancet 1984:11:631.
-
Burge F. Dehydration symptoms of palliative care patients. J Pain Symptom Manage 1993: 8: 454-64.
-
Ellershaw J.E, Sutcliffe J.M, Saunders C.M. Dehydration and the dying patient. J Pain Symptom Manage 1995 10(3): 192-197.
-
Craig G.M. On withholding nutrition and hydration in the terminally ill: has palliative medicine gone too far? J Med Ethics 1994: 20: 139-43.
-
Regnard C, Mannix K. Reduced hydration or feeding in advanced disease - a flow diagram. Palliative Medicine 1991: 5: 161-64.
-
Dunphy K et al. Rehydration in palliative and terminal care: if not, why not? Palliative Medicine 1995: 9: 221-8.
-
Rosner F. Why nutrition should not be withheld from patients. Chest 1993:104: lR92-96.
-
Fainsinger R.L, MacEarchern T, Miller M.J et al. The use of hypodermoclysis for rehydration in terminally ill cancer patients. J Pain Symptom Manage 1994: 9: 298-302.
-
Billings J.A. Comfort measures for the terminally ill: is dehydration painful? J Am Geriatr Soc 1985: 33: 808-10.
-
Printz L.A. Terminal dehydration: a compassionate treatment. Arch Intern Med 1992: 152: 697-700.
-
Sommerville A. Cessation of treatment, non-resuscitation, aiding suicide and euthanasia. In: Fisher F, Macdonald N.J, Weston R. Medical Ethics Today: its practice and its philosophy. London, BMJ Publishing Group, 1993:165, 170-7 1.
-
Andrews M, Bell E.R, Smith S.A, Tischler J.F, Veglia J.M. Dehydration in terminally ill patients: is it appropriate palliative care? Postgrad Med 1993: 93: 201-08.
-
Tattersall M.H. Hypercalcaemia: historical perspec tives and present management. Support Cancer Care 1993:1:19-25.
-
Twycross R.G, Lichter I. The terminal phase. In: Doyle D, Hanks G, MacDonald N. eds. Oxford Textbook of Palliative Medicine, Oxford, Oxford University Press, 1993: 653-54.
JOINT WORKING PARTY BETWEEN THE NATIONAL COUNCIL FOR HOSPICE
AND SPECIALIST PALLIATIVE CARE SERVICES
AND
THE ETHICS COMMITTEE
OF THE ASSOCIATION FOR PALLIATIVE MEDICINE
OF
GREAT BRITAIN AND IRELAND
Mrs B Biswas, Matron, LOROS, Leicestershire Hospice, Leicester
Dr K Dunphy, Macmillan Consultant in Palliative Medicine, Macmillan Runcie Day Hospice,
St Albans.
Dr J Ellershaw, Medical Director, Marie Curie Centre, Liverpool
Dr M. Minton, Consultant in Palliative Medicine, Sir Michael Sobell House Palliative
Care Unit, The Oxford Radcliffe Hospital
Mr D Olivi�re, Macmillan Lecturer in
Social Work and Palliative Care, School of Social Work and Health Sciences, Middlesex
University, Enfield
Mr D Praill, Chief Executive, Help the Hospices, London
Dr F Randall, Consultant in Palliative Medicine, Macmillan Unit, Christchuch Hospital,
Dorset
Dr G Rathbone, Consultant in Palliative Medicine, LOROS, Leicestershire
Hospice, Leicester
Dr T Tate, Consultant in Palliative Medicine, The Margaret
Centre, Whipps Cross Hospital; Consultant in Palliative Medicine, St Bartholomew
s Hospital, London.
National Council for Hospice and Specialist Palliative Care
Services
7th Floor, 1 Great Cumberland Place
London W1H
7AI
Tel: 0207 723 1639
A Company limited by guarantee number 2644430
Registered
Charity No 1005671