Nutrition and Hydration

Artificial nutrition and hydration is defined as the nutritional and hydration support of an invasive nature requiring the placement of a tube into the alimentary tract or parenterally via intravenous or subcutaneous means.
Decisions on artificial nutrition and hydration must be made on an individual basis. Communications with patient and family is an important component of this decision.

• Most terminally ill patient do not benefit from artificial nutrition and hydration whether in survival or symptoms.
• Discuss ideas, concern and expectations of family and patient regarding artificial nutrition and hydration. Most families have unfounded fears about thirst and hydration which can be addressed by the team.
• Monitor drug dosages and consider reducing doses as patient takes less fluid progressively.
• Mouth care, including oral cleaning, ice chips, artificial saliva and lip moisturizer should be part of routine care.
• Check regularly for bowel output, which may still be present despite having no oral intake.
• Use of time limited trial of hydration may be useful in some cases. Have clear goals about intended outcomes and consider stopping if these goals are not achieved after a stated period of time or when burdens outweighed benefits (e.g. increased respiratory secretions or peripheral oedema).

Common Questions and Possible Responses

Advantages of hydration	Some evidence suggests that artificial hydration for patients with intestinal obstruction or delirium secondary to opioid toxicity may be useful.
Disadvantages of hydration	Artificial hydration can cause fluid overload, throat/respiratory secretions and peripheral oedema. There is a need for IV/SC cannula to deliver hydration.
What if patients feel thirsty?	Most of the thirst sensation results from dry oral mucosa and lips. Patients with good oral care are less likely to feel thirsty. Studies have shown that artificial hydration does not affect thirst sensation in terminally ill patients.
Will patients die hungry?	Patient towards the end of life have decreased oral intake and poor appetite. This is part of the natural process of dying and patients do not feel hungry at this stage. In fact, force feeding them may result in vomiting.
Will patients starve to death?	There is a lack of evidence to suggest this. Patients who are terminally ill will die from their underlying condition rather than from starvation.

• Good P, Cavenagh J, Mather M, Ravenscroft P. Medically assisted nutrition for palliative care in adult patients. Cochrane Database Syst Rev.2008;4.
• Bruera E, Hui D, Dalal S, Torres-Vigil I, Trumble, J, Roosth J, et al. Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial. J Clin Oncol. 2012;31(1):111-118.
• Hum A, Koh M. Symptoms: Nutrition and hydration. In: Hum A, Koh M, ed. The Bedside Palliative Medicine Handbook. SG, Singapore: Armour Publishing; 2013:53-55.