My Loved one doesn’t want to drink much anymore.
Traditionally food and water are thought of as fundamental to existence. Offering food and water to loved ones is an expression of our caring for them. The thought of not offering (or insisting) feels cruel. But, people close to death may be more comfortable if dehydrated, and hydration may cause suffering.
The American Medical Association states that, “In some cases, terminally ill patients voluntarily refuse food or oral fluids.” In such cases, patient autonomy (still maintaining the right to make decisions for oneself) must be respected, and forced feeding or aggressive rehydration should not be employed. Emphasis should be placed on renewed efforts at pain control and other comfort care.
Knowing that this is a normal phase for a terminally ill loved one to enter is difficult and often families resist this transition. There can be an emotional impact on family members and the realization that their loved one is close to death can be heart breaking. This is a wonderful time to turn to the hospice nurse, social worker and chaplain for support, education and advice.
The nurse can help families discuss the advantages and disadvantages of encouraging food and water or introducing artificial hydration which include IV fluids and hypodermoclysis (injection of fluids into subcutaneous tissue).
Advantages to Providing Artificial Hydration
There is little benefit, but it is worthy to note some research
Study of 100 palliative care patients hydrated by hypodermoclysis concluded this therapy can be useful for achieving better symptom control. Three patients reported improved cognitive function and some showed less restlessness.
Advantages to not Providing Artificial Hydration
Dehydration is a normal end of life process that probably offers a natural anesthetic during the last days of life.
Improved physical care-giving and physical well-being
Decreased swelling and edema
Less gastro-intestinal fluid and fewer bouts of vomiting
Reduction in pulmonary (lung) secretions (fluid) with less coughing, choking and need for suctioning
Increased naturally occurring opioid peptides or endorphins providing a heightened state of well-being
Less repetitive needle sticks and IVs
IV’s may restrain the patient and act as a barrier from the family
May decrease fluid around tumors, resulting in less pressure and pain
Fluids may increase cognition of an individual in pain and make her/him more aware of pain
So, if the decision has been made to not offer IV fluids, other types of artificial hydration and not to pressure a terminally ill patient to eat and drink if they refuse, what does a family do to ensure that their loved one is comfortable?
Mouth care is one of the most important interventions to prevent suffering in a patient nearing death.
Some steps to follow are:
Dip a soft toothbrush or oral swab (provided by hospice company or can be purchased at a local pharmacy) in fluid and allow patient to suck on and gently swish around her/his mouth.
Rinse her/his mouth frequently.
Spraying normal saline solution into the mouth frequently can provide comfort.
Use a room humidifier, air conditioner or fan (ensure patient does not get too cold)
If the patient is willing, sipping slowly on Chamomile tea can be very soothing to a dry mouth.
Often and generously apply lip lubricant.
Offer small, frequent sips of liquid, ice chips or popsicles.
Choice of fluids should be patient driven and she/he should be given several options.
Do not offer fluids if patient is unable to swallow – risk of aspiration (fluid going into the lungs)
Issues of hydration and end of life are complex and involve physical, psychosocial and social concerns as well as ethical dilemmas. The primary goal of end-of-life care is comfort of the patient and also family. Whenever it is possible, the terminally ill patient should be involved in all aspects of her/his care. Dehydration is a normal part of the end-of-life process but is still sad and difficult for families to watch. Seek the help of the hospice team and always remember that caregivers still need to take time for themselves to eat, drink and rest.