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Providing hydration at the end of life: ethics and practice

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AUTHOR
Robert Becker, MSc, RMN, RGN, DipN (Lond), FETC, CertEd (FE),
is Macmillan senior lecturer in palliative care, Shrewsbury and holds a joint teaching appointment between Severn Hospice Shropshire and Staffordshire University Faculty of Health, Royal Shrewsbury Hospital.

RECOMMENDATIONS FOR NURSING PRACTICE

  • A blanket policy in any clinical area of artificial hydration, or of no artificial hydration, is ethically indefensible.
  • Start discussion early, where possible, with the patient and family to determine the patient’s wishes.
  • Establish whether the patient has an advance directive. This may provide clear guidance to help decision-making and has legal validity in the UK.
  • Reassure the patient and family that the comfort of the patient is paramount at all times and that stopping fluids is not stopping care.
  • Where dehydration results from a potentially correctable cause – for example overtreatment with diuretics, recurrent vomiting, diarrhoea or hypercalcaemia – artificial hydration may be a valid option in the short term.
  • Decisions on whether to artificially hydrate should be judged on a day-to-day basis, with the potential harms and benefits being weighed up.
  • Regular mouth care and pressure relief should be given.
  • The patient should be listened to and supported at all times.
  • Remember: Healthcare professionals must be tactfully resistant to sacrificing the interests of the patient to ease the emotional distress of the relatives.

There is evidence of considerable differences in clinical practice in the use of hydration at the end of life. While some healthcare professionals see it as a crucial part of the management strategy, others consider it an unnecessary burden and believe that allowing natural dehydration rarely causes a patient distress and may even be beneficial.

There is only a small body of research on this issue, so clinical experience appears to provide the basis for most current practice. However, what the research that does exist clearly tells us, is that in circumstances when a person is conscious and requesting fluids, these should never be denied. Conversely, if a person is slipping in and out of consciousness and the healthcare team agrees that death is likely to occur in the next few hours or days, hydrating a patient artificially by any means can have a negative and burdensome effect on their quality of life.

Natural dehydration can be seen as a normal part of the dying process and there are many instances when patients who are dying may choose to give up eating and drinking as they become weaker. The logic against artificial hydration relates to simple physiology: putting fluids artificially into a body that is slowly closing down means that the kidneys will not be able to process that fluid with the consequent effects of peripheral or pulmonary oedema and dyspnoea.

Ethical Position

A patient who is competent has the right to refuse artificial hydration, even if it may be considered of clinical benefit to them. Those patients who are incompetent retain this right of refusal through a valid advance directive.

Allowing natural dehydration to occur at the end of life and actively resisting artificial hydration, where appropriate, is not synonymous with an active intent to end life and influences neither survival nor symptom control.

Conclusion

The evidence that now exists against artificial hydration if an individual is close to death is compelling.

Clear and useful guidance on this subject is readily available from the National Council for Palliative Care (2007). Where this is sensitively applied, the dignity and comfort of the individual who is dying is quite clearly enhanced and healthcare professionals can be confident in their practice.

References

National Council for Palliative Care (2007) Artificial Nutrition and Hydration: Summary Guidance. London: NCPC.

Further Reading

Joint Working Party between the National Palliative Care Council and the Ethics Committee of the Association for Palliative Medicine of Great Britain and Ireland (1997) Ethical Decision-Making In Palliative Care: Artificial Hydration For People Who Are Terminally Ill.

Bavin, L. (2007) Artificial rehydration in palliative care: is it beneficial? International Journal of Palliative Nursing;13:9, 445-449.

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