Artifical Nutrition and Hydration

BarbPick · Jan 23, 2004

I have done my share of end of life care. From my forensic courses, I was taught that starvation and lack of hydration is an excrutiating method of death. Granted this topic was taught by a Forensic Patholigist along with other methods of ending people's lives at the hand of another. I have changed my living will to make sure I will have hydration and morphine in my personal end of life care.

I can only speak about my personal wishes.

aimeee, BSN, RN · Jan 23, 2004

The medical proxy should be given all the information regarding the likihood of benefit before making the decision. Unfortunately, these decisions are usually made in the hospital and they are often not well informed before they are asked to make it.

My observations coincide with those presented by Dr. Weissman below on the End-of-Life Physician Education Resource Center site:

Fast Fact and Concept #010; Tube Feed or Not Tube Feed?

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Title: Fast Fact and Concept #010; Tube Feed or Not Tube Feed?

Author(s): Hallenbeck, J.; Weissman, D.

This Fast Fact reviews data concerning the effectiveness of non-oral feeding in chronically ill and dying patients. Can be used during ward rounds or as a handout for a teaching conference.

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Educational Objective(s)

Review effectiveness data of non-oral feeding in dying and seriously ill patients

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Tube feeding is frequently used in chronically ill and dying patients. The evidence base for much of this use is weak, at best. In the bullets below are summarized some of what is known (and not known) about tube feeding for specific indications.

Tube feeding as a means to prevent aspiration pneumonia . . .

- No study has demonstrated a reduction in the incidence of pneumonia through tube feeding.

- No randomized control studies have been published. Three retrospective cohort studies comparing patients with and without tube feeding demonstrated no advantage to tube feeding for this purpose.

- Swallowing studies, such as videofluoroscopy, lack both sensitivity and specificity in predicting who will develop aspiration pneumonia. Croghan's (1994) study of 22 patients undergoing videofluoroscopy demonstrated a sensitivity of 65% and specificity of 67% in predicting who would develop aspiration pneumonia within one year. In this study, no reduction in the incidence of pneumonia was demonstrated in those tube fed.

- Swallowing studies may be helpful in providing guidance regarding swallowing techniques for populations amenable to instruction.

- Numerous observational studies have been published, demonstrating a high incidence of aspiration pneumonia in those who have been tube fed.

Tube feeding to prolong life via caloric support . . .

- Data is strongest for patients with reversible illness in a catabolic state (such as acute sepsis).

- Data is weakest in advanced cancer. No improvement in survival has been found (few exceptions noted below).

- Non-randomized, retrospective studies have found no survival advantage in patients with dementia.

- Tube feeding may be life-prolonging in select circumstances:

A) Patients with proximal GI obstruction and a high functional status

B) Patients receiving chemotherapy/XRT involving the proximal GI tract

C) Certain patients with AIDS and wasting syndromes

Tube feeding to enhance quality of life/reduce suffering . . .

- Where true hunger and thirst exist, quality of life may be enhanced (such as in very proximal GI obstruction).

- Most actively dying patients do NOT experience hunger or thirst (although dry mouth is a common problem).

- Dry mouth is NOT improved by tube feeding (or IV hydration).

- A recent literature review using palliative care and enteral nutrition as search terms found no studies demonstrating improved quality of life through tube feeding. (Limited to a few observational studies.)

- Tube feeding may adversely affect quality of life through increased need for physical restraints, infections, pain, indignity cost and the denial of the pleasure of eating.

Summary

Tube feeding should always be considered relative to patient goals. Physicians should be prepared to discuss tube feeding as an option bearing in mind what evidence (or lack thereof) exists that tube feeding will help reach such goals.

REFERENCES: Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia. JAMA. 1999; 282:1365-1369., Finucane TE, Bynum JP. Use of tube feeding to prevent aspiration pneumonia. Lancet. 1996; 348:1421-24., Ahronheim JC. Nutrition and hydration in the terminal patient. Clinics in Geriatrics. 1996; 12(2): 379-391., Croghan JE, Burke EM, Caplan S, Denman S. Pilot study of 12-month outcomes of nursing home patients with aspiration on videofluoroscopy. Dysphagia. 1994; 9(3):141-146.

Fast Facts and Concepts are developed and distributed as part of the National Internal Medicine Residency End-of-Life Education project, funded by the Robert Wood Johnson Foundation.

Copyright Notice: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman, D. Fast Fact and Concepts #10: Tube Feed or Not Tube Feed? June, 2000. End-of-Life Physician Education Resource Center http://www.eperc.mcw.edu.

renerian, BSN, RN · Jan 24, 2004

Mine forbids artificial feedings of any kind/never a gtube. I have seen so many people try to make dying people eat. Sometimes they get gross edema, aspiration/vomiting. Not always bad. If a person wants to eat I help them, if they do not, I do not force them.

renerian

Mazzi · Jan 24, 2004

I have been a hospice nurse for seven years and whole heartedly believe from what I have seen, that force feeding a dying pt. is very uncomfortable. When the body is ready to die, it tells itself to shut down. If you go ahead and feed the body, and go against what it truly wants there is discomfort. Hospice thought is COMFORT MEASURES ONLY. Does this sound comforting to you? The problems is the familys of the pt. It has been ingrained in us from early years that you have to eat to live. This is where it becomes difficult. Most people do not fully understand the dying process. A lot of MD's also do not understand this. Advanced directives, living wills, and medical POA information needs to be educated to anyone, everyone that will listen. I have become an advocate for the dying person and do my best to educate the family. But remember you must know the patients wishes!!!! I find most do not want to eat, do not what tube fed, but does not what to make the family feel bad by not eatting. So educate, educate, educate.

After you see your first patient die of aspiraton pneu, congestion, you will understand more of what it is to die with excess fluid on board. The DEATH RATTLE (or terminal bubbling as I like to call it) is very very hard to listen to for both family and RN's.

Research also shows pain is lessened when the body is dehydrated. If you want more infor on this PM me.

renerian, BSN, RN · Jan 24, 2004

Yes I have heard this out of many of my loves one while they were dying. Yes it is awful to hear your loved one making this sound. Haunting.

renerian:o

Wren · Jan 30, 2004

The health care directives that hubby and I wrote for ourselves have very explicit instructions to NOT hydrate or feed us if we are ever at the terminal stage of a disease and are unable to take fluids or foods normally. I've worked in Hospice for years and I have seen much more suffering caused for the dying by family members who insist of feeding and hydrating their loved ones. The fluid especially just overwhelms the body (as noted by others) and I am convinced that it makes dying more uncomfortable.