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Stopping artificial nutrition and hydration at the end of life
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Stopping artificial nutrition and hydration at the end of life

Disclosures: Marion Danis, MD Nothing to disclose. Robert M Arnold, MD Nothing to disclose. Diane MF Savarese, MD Nothing to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.

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All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2016. | This topic last updated: Nov 02, 2015.

INTRODUCTION — Palliative care aims to relieve suffering in all stages of disease and is not limited to the end of life. Patients in palliative care range from fully functional (especially if newly diagnosed with an incurable illness) to extremely limited (particularly at the end of life). Palliative services, including setting patient-centered achievable goals for medical care and aggressive symptom management, should be routinely offered alongside curative and disease-modifying treatments for patients with serious illnesses.

Medically-assisted nutrition and hydration should be considered medical interventions rather than a basic provision of comfort. Promoting early discussions with the patient and family about the goals of care and treatment choices, including the expected benefits and burdens of artificial nutrition and hydration based upon the best available evidence, is ethically appropriate, respects family and patient autonomy, and facilitates informed decision making.

This topic will address the role of artificial nutrition and/or hydration specifically as it applies to patients in palliative care who are in the last days or weeks of life. The issues involving the cessation of hydration and/or nutrition are most relevant to patients at the end of life, where there is little evidence that nutrition or hydration offers any benefit.

The role of artificial nutrition in patients not at the end of life is discussed elsewhere. (See "The role of parenteral and enteral/oral nutritional support in patients with cancer" and "Nutrition support in critically ill patients: Parenteral nutrition".)

In addition, the ethical and legal issues surrounding withholding and withdrawing of other forms of medical treatment at the end of life are discussed elsewhere. (See "Ethical issues in palliative care" and "Legal aspects in palliative and end of life care", section on 'Medical interventions that can be stopped'.)

DEFINITIONS — The following definitions will be used in addressing both interventions:

Artificial nutrition involves non-oral enteral or parenteral delivery of nutrients. Enteral approaches include nasogastric (NG), percutaneous endoscopic gastrostomy (PEG), percutaneous endoscopic gastrostomy jejunostomy (PEG-J), or gastrojejunostomy tubes. Parenteral delivery can involve peripheral intravenous access or central venous access. (See "Nutrition support in critically ill patients: Enteral nutrition" and "Nasogastric and nasoenteric tubes" and "Nutrition support in critically ill patients: Parenteral nutrition".)

Artificial hydration involves the provision of water or electrolyte solutions by any route other than the mouth. This can be achieved by intravenous, subcutaneous, dermal (dermoclysis), and rectal (proctoclysis) administration.

FLUID DEFICITS AT THE END OF LIFE — Fluid homeostasis is the maintenance of a relatively constant and stable composition of body fluids. It is achieved in normal individuals by matching daily water intake to fluid losses. The average amount of water lost (and consumed) per day in the average adult is about 2500 mL. The most important means by which the body loses water is through the kidney. Hormonally-controlled mechanisms regulate water balance by controlling the rate of urinary excretion of water and electrolytes. Other sources of fluid loss include the GI tract, lungs, and skin (insensible water loss), which account for approximately 800 to 850 mL of water per day. (See "Maintenance and replacement fluid therapy in adults", section on 'Water balance'.)

Fluid deficits in terminally ill patients are frequently multifactorial in etiology. However, regardless of the cause, the end result is total body water depletion and decreased renal function. There are two broad categories of fluid deficit disorders, dehydration and hypovolemia, which may present separately or together (see "General principles of disorders of water balance (hyponatremia and hypernatremia) and sodium balance (hypovolemia and edema)"):

Dehydration, which results from total body water depletion

Hypovolemia results from loss of both salt and water mainly from the extracellular (intravascular) space

Clinical manifestations — The dying process is characterized by diminished oral intake, progressive fluid deficits, and progressive accumulation of drugs (including opioids) and their metabolites, which can cause new symptoms or exacerbate existing ones (eg, fatigue, dizziness, myoclonus, sedation, and hallucinations [1,2]). This in turn leads to a further decline in the individual’s ability to obtain and/or drink fluids. During this process patients have diminished awareness which may decrease their perception of thirst and hunger as they naturally progress toward coma and death.

While clinicians commonly associate several signs and symptoms with dehydration (eg, hypernatremia, thirst, anorexia, nausea and vomiting, fatigue and irritability) or hypovolemia (eg, diminished skin turgor, orthostatic hypotension, and dizziness), they may not be highly specific in terminally ill patients [3-8]. As examples:

A cross-sectional study of 88 terminally ill cancer patients in an inpatient palliative care program found that the sensation of thirst was not only associated with dehydration and hyperosmolality, but also with several other features of terminal illness including overall poor general condition, stomatitis, oral breathing, and the administration of opioids [7].

A cross-sectional survey of 52 inpatient palliative care patients found no association between thirst and commonly used objective measures (eg, fluid intake, plasma osmolality, or serum sodium and urea measurements) [6].

In contrast, a study of 68 cancer patients who were observed during the last 48 hours of their lives showed that state of consciousness was inversely correlated with serum sodium and urine osmolality [8].

OVERVIEW OF THE ISSUES — As clinicians, patients, and families collaborate in the care of dying patients they should recognize and respect the varied perspectives each contribute to decisions about the use and cessation of nutrition and hydration.

Data consistently show that offering artificial nutrition and hydration for patients who are expected to die within days to weeks generally is not beneficial, and there is evidence that forgoing nutrition and hydration is common at the end of life [9]. At the same time, there are culturally divergent approaches to end-of-life decision making worldwide that influence choices about the use of artificial nutrition and hydration in terminally ill patients [10].

Some families may view nutrition and hydration as a source of support and a sign of respect and caring, rather than a medical intervention, even when provided by artificial means. Clinicians should recognize that for such families, the decision to continue nutrition and hydration may not be viewed solely as a medical decision.

Defining goals of care — The major goal of artificial nutrition should be to provide nourishment to patients whose quality of life or life expectancy can be improved. Unfortunately, goals such as these may not be realistic for patients at the end of life.

The administration of artificial nutrition and/or hydration has also been used in an effort to prevent or reverse distressing symptoms (such as difficulty swallowing) in patients at the end of life. However, decisions about artificial nutrition and hydration should be handled separately from decisions about symptom management. (See "Swallowing disorders and aspiration in palliative care: Assessment and strategies for management".)

Challenging treatment choices such as whether to start artificial nutrition and/or hydration arise commonly in patients in the terminal phase of a serious illness, and high-quality discussions about what is important to them promote good decision-making and patient-centered care. Understanding the patient’s values, preferences, and care goals in the context of a serious illness allows the clinician to align the care provided with what is most important to the patient. Discussing goals of care is a unique skill that should be separated conceptually from talking about prognosis or delivering bad news. While discussions about goals of care may involve some of the same principles as other difficult communication tasks, these discussions demand a different framework.

Artificial nutrition — Although there are data to support the use of artificial nutrition in cases where patients desire to prolong life at earlier stages of a serious illness, there is a lack of well-designed studies to assess the benefit of artificial nutrition at the end of life [11]. Coupled with the potential for harm, we do not advocate the routine use of enteral or parenteral nutritional support in patients receiving palliative care.

Artificial nutrition appears to be of benefit to some patients with chronic illnesses, such as amyotrophic lateral sclerosis [12] and those in a permanent vegetative state (PVS) [13]. In these populations, nutrition can extend survival by months to years. In addition, patients with cancer who are unable to eat due to cancer- or treatment-related complications (eg, patients with head and neck cancers, those undergoing intensive radiation therapy, those undergoing hematopoietic stem cell transplant, and those with gastrointestinal obstruction at their initial presentation), may benefit from parenteral nutrition, particularly when they are newly diagnosed [14]. (See "Gastrostomy tubes: Uses, patient selection, and efficacy in adults" and "Nutrition support in critically ill patients: Enteral nutrition", section on 'Complications' and "Nutrition support in critically ill patients: Parenteral nutrition", section on 'Complications'.)

Beyond these clinical settings, studies indicate that artificial nutrition has no effect on prolonging life or improving functional status in the setting of many advanced illnesses [15]. Representative findings in the literature include the following:

Patients with advanced cancer often have clinical evidence of muscle wasting, known as cancer cachexia. While patients who are not in the terminal phase of cancer may benefit from nutritional support and other medical therapies for cancer cachexia [16], low-quality evidence indicates that the administration of enteral or parenteral nutrition in the last days to weeks of life rarely changes the course of the disease [17,18]. In a 2006 review of the literature on the role of artificial nutrition in patients with terminally ill cancer, the authors find little evidence to support its use [17]. However, there have been no randomized trials to help inform the risks and benefits more clearly in this population.

Preclinical work suggests that the lack of benefit with parenteral nutrition in patients with cancer cachexia may be related to the release of cytokines that decrease protein synthesis and increase protein degradation [19,20]. Similar mechanisms relating to cachexia may exist in other diseases [21]. (See "Pathogenesis, clinical features, and assessment of cancer cachexia" and "The role of parenteral and enteral/oral nutritional support in patients with cancer".)

Studies in patients with advanced dementia indicate that artificial nutrition does not prolong life [22-26], improve overall function [27], prevent aspiration [28,29], or reduce pressure sores [30]. Although high-quality data are lacking, multiple observational [22-25] and retrospective [29] studies consistently demonstrate the lack of benefit to artificial nutrition for these patients. While one might expect pressure sores to be reduced (in light of the importance of good nutritional status for wound healing), it is likely that immobility and incontinence undermine the potential benefit of tube feeding [31]. (See "Gastrostomy tubes: Uses, patient selection, and efficacy in adults".)

Artificial hydration — Multiple ethical analyses addressing the appropriateness of offering artificial hydration have provided the ethical arguments for and against using artificial hydration and affirm the importance of respecting patient preferences [32-35]. However, we do not advocate the routine administration of artificial hydration as a means to maintain intravascular volume for patients at or near the end of life. Multiple studies demonstrate routine hydration generally does not improve outcomes for patients near the end of life (table 1).

The limited value of artificial hydration was most convincingly shown in a 2013 randomized trial that included 129 patients with advanced cancer receiving hospice care, who were randomly assigned to receive parenteral hydration (1 L of normal saline over four hours daily) or placebo (100 mL per day) [36]. The primary objective of this study was to prevent the onset of delirium. The main results were:

There was no difference between treatment and control groups in delirium scores or dehydration symptoms (a composite score of fatigue, myoclonus, sedation, and hallucinations), at day four or day seven.

There was no statistically significant difference in overall survival (median, 21 versus 15 days for patients undergoing hydration or placebo, respectively).

Patients in both groups noted improvement in symptoms of dehydration at day four, suggesting these benefits may be more related to either the increased frequency of visits and assessments by research nurses or a placebo effect rather than the provision of fluids.

While this study is the best thus far to show that hydration had little impact on symptoms or survival for patients at the end of life, these results should be interpreted cautiously, as some patients may find a potential six-day increase in survival at the end of life meaningful. In addition, it should be noted that this trial excluded patients with severe dehydration (eg, those presenting with hemodynamic instability or altered mentation) and patients with a diagnosis other than end-stage cancer. Therefore, it is not clear if we can extrapolate these results to other populations.

However, patients and their families have strongly held beliefs about assisted hydration, and these beliefs inform their interactions with health care professionals. In a separate report from this trial, interviews were conducted among patients on the hydration arm (n = 85) and their caregivers (n = 84) [37]. The main finding was that among this group, artificial hydration was viewed as a means to enhance comfort, quality of life, and dignity by reducing symptoms (eg, fatigue) and increasing alertness. Although these findings must be interpreted cautiously, since the views of patients who did not receive hydration (and their family members) were not ascertained, they emphasize the importance of taking the patient’s specific diagnosis, wishes, and hopes into consideration when discussions about the role of artificial hydration arise [38].

Impact of palliative care location — The administration of artificial hydration may depend on where the patient is living out his or her final weeks of life. The vast majority of patients with advanced cancer who die in acute care hospitals receive hydration until shortly before death [1,32], while most patients who die in hospice or at home receive no fluids [3,39].

This finding is at least partly related to reimbursement issues. For example, in the US, without a need for IV therapy, utilization rules from third party insurers make it difficult to justify billing solely for inpatient hydration; in addition, the per diem hospice funding mechanism makes the administration of parenteral fluids outside of an inpatient facility difficult to finance. (See "Hospice: Philosophy of care and appropriate utilization in the United States", section on 'Structure'.)

VOLUNTARY CESSATION OF INTAKE — Voluntary cessation of nutrition and hydration includes the decision to stop normal eating and drinking or artificially-administered nutrition and hydration. The voluntary cessation of intake is a medically and legally acceptable step that patients or their families (on behalf of patients who are no longer competent) may choose as a response of last resort for patients at the end of life facing intolerable suffering [40-43]. It is also considered an ethically superior alternative response of last resort to euthanasia or physician assisted suicide [40].

Clinicians should be aware that some religions, particularly Catholicism, may view voluntary cessation of eating and drinking as an intentional shortening of life that is forbidden [44]. While Catholic scholars criticize voluntary cessation of eating and drinking, they do recognize that the tendency of dying patients to stop eating and drinking should not automatically be interpreted as an act intended to hasten death, but rather as an understandable and acceptable response to anorexia, nausea, or discomfort [45].

While everyone stops eating and drinking at some point prior to death, voluntary cessation with the intent of hastening death is unusual [42]:

A systematic review of voluntary stopping of eating and drinking (VSED) reported a prevalence of 2.1 percent of deaths per year (on average 2800 deaths annually). Among 16 studies included in the systematic review, the main reasons for patients hastening death by VSED were: readiness to die, life perceived as being pointless, poor quality of life, a desire to die at home, and the wish to control the circumstances of death.

In one survey of over 300 hospice nurses, approximately 30 percent reported that they had taken care of a patient who had made this choice within the prior four years [46]. The overall incidence was very low, with only 126 out of 40,000 patients were identified by these nurses’ reports. The main results were:

Compared with an even smaller number of patients who chose physician assisted suicide (n = 55), those choosing to cease oral intake were significantly older (74 versus 64 years, respectively) and were less likely to have been evaluated by a mental health professional (9 versus 45 percent).

Among 102 patients who ceased eating or drinking and were followed until death, the quality of the dying experience, as rated by nurses, was very good (8 on a scale of 0 to 9). Although they were perceived to have had a similar level of pain and overall quality of death compared with those who chose physician assisted suicide, the nurses perceived them as having suffered less. The topic of physician assisted suicide is discussed separately. (See "Euthanasia and physician-assisted death".)

The prevalence of forgoing artificial nutrition and hydration may be higher in Europe than in the US. In a comparison of six European countries (Belgium, Denmark, Italy, the Netherlands, Sweden, and Switzerland), in which a total 20,480 of deaths were reviewed, the percentage of deaths that were preceded by a decision to forgo artificial nutrition and hydration (ANH) varied from 2.6 percent in Italy to 10.9 percent in the Netherlands [47]. In a national lookback study conducted in the Netherlands, clinicians received a questionnaire about end of life decisions for 6600 patients in three age groups: 17 to 64, 65 to 79, and 80 and older. Treatment of some sort was foregone for 37 percent of patients and withholding of artificial nutrition and hydration was the most frequently withheld treatment in all age groups. Withholding artificial hydration/nutrition was significantly higher (OR 2.04) for the group aged 65 to 79 when compared to the youngest patients [9].

WITHHOLDING AND WITHDRAWAL OF ARTIFICIAL NUTRITION AND HYDRATION — While the withdrawing of artificial nutrition and/or hydration may cause more emotional distress for clinicians as well as for patients and their families than the withholding of such a treatment, there is no ethical or legal distinction between them.

In the US, the Patient Self Determination Act (PSDA) clearly established the right of an individual patient or the patient’s next of kin or designated surrogate in the United States to decide whether or not to forgo medical interventions (ie, life-sustaining or life-prolonging treatment), including the rights not to have artificial nutrition and/or hydration administered (withholding) and to stop the administration of such support measures (withdrawal) [48]. However, there are legal and ethical issues that must be considered in decisions regarding the withholding or withdrawal of artificial nutrition and/or hydration. (See "Legal aspects in palliative and end of life care" and "Ethical issues in palliative care".)

Legal issues — It is important for clinicians to be familiar with the state regulations where they practice. Patients who wish to forgo artificial nutrition and hydration should be encouraged to complete advance directives, in addition to a living will, that comply with the specific requirements of their state. The National Hospice and Palliative Care Organization provides state-specific information and advance directive forms at Caring Connections [49].

Within the US, federal regulators take no stand on the right to refuse artificial nutrition and hydration and leave this issue to be decided under state law [43]. However, the laws regarding whether artificial nutrition and hydration are medical interventions (rather than basic provisions of comfort) vary on a state level. In states that deem these to be provisions of comfort (rather than “life-sustaining” or “life-prolonging” interventions), patient wishes as covered by the PSDA may not specifically apply. A listing of all state living will statutes is available online. In addition, further information including a state-by-state list of medically supplied nutrition and hydration legal cases and attorney general opinions is available [43].

Ethical issues — The ethical principles governing decisions to treat with, withhold or withdraw from artificial nutrition and hydration in the US are well articulated [50]:

Autonomy – According to the principle of autonomy, adults have a moral right to follow a life path of their own choosing, with the authority to control their own bodies and be protected from unwanted intrusions. Competent adults have the right to decide for themselves whether to stop eating and drinking and whether or not they would like to withdraw or withhold artificial nutrition and hydration.

Decisions for patients who lack decision-making capacity should be made in accord with advance directives and/or persons designated by the patient to hold durable power of attorney. When no advance directive exists, family members should decide, bearing in mind what they believe the patient would want under the circumstances. (See "Assessment of decision-making capacity in adults".)

Beneficence and nonmaleficence – The concepts of beneficence and nonmaleficence require that the clinician’s actions must benefit the patient and avoid harm, when possible. Therefore, decisions to withhold or stop artificial nutrition and hydration in patients approaching the end of life should be informed by evidence regarding its benefits and risks, and should also take into account the wishes of the patients and their families.

Length of survival after stopping nutrition and hydration — In general, patients who go without nutrition or hydration in the context of a terminal illness only live for a short time. As examples:

In the survey of nurses’ experiences discussed above, hospice patients who stopped eating and drinking died an average of 10±7 days after stopping, and 85 percent of patients died within 15 days [46]. (See 'Voluntary cessation of intake' above.)

A separate study of 178 Dutch nursing home patients with dementia who had nutrition and hydration withdrawn reported that 59 percent died within one week [51]. Patients who were deemed to be more severely ill, had dyspnea, or apathy were more likely to die within the week. Patients with restlessness were less likely to die within a week. The duration of survival for the group is shown in a table (table 2).

REHYDRATION — For patients who are not undergoing hydration at the end of life, progressive signs or symptoms of dehydration can be troubling, both to the patient, his or her family, and caregivers. In response, clinicians may be asked to initiate fluids or nutrition in an effort to rehydrate the patient with hopes to provide symptomatic relief if not prolong life.

Although there is only low-quality evidence available, we do not advocate rehydration in these situations because there appears to be no symptomatic benefit associated with rehydration and it may introduce other adverse effects for patients at the end of life. A 2014 systematic review reported there were insufficient data to determine whether artificial hydration was of benefit in this setting [11,52]. Subsequent studies not included in the systematic review also illustrate the lack of benefit with rehydration:

In one trial, 42 patients were randomly assigned to subcutaneous hydration (42 mL per hour daily) or no hydration [53]. All patients received subcutaneous haloperidol and metoclopramide. Compared with no hydration, there was no additional benefit seen in terms of thirst or chronic nausea at 24 hours, though nausea had improved at 48 hours among those receiving hydration. However, hydration had no impact on the risk for delirium.

A separate observational study evaluated 226 terminally ill patients with an abdominal malignancy and had clinical evidence of dehydration [54]. Of these patients, 59 received hydration in the final three weeks of life. Compared with patients who were not rehydrated, those undergoing hydration had less symptomatic deterioration (14 versus 35 percent, respectively). However, patients who underwent rehydration also had a significantly higher incidence of edema, ascites, and pleural effusion (44 versus 29 percent, 29 versus 8 percent, and 15 versus 5 percent, respectively).

Despite the lack of benefit, patients (or their families) may request a trial of hydration, particularly to help manage delirium. Given that such fluids are unlikely to harm the patient and the qualitative data suggest that it is of psychosocial benefit to families, many clinicians will agree to a trial. This approach is discussed in more detail below. (See 'Trial of rehydration' below.)

Burdens — The burdens of rehydration in patients with advanced terminal illness run counter to the goals of palliative care. These include [55,56]:

Vomiting and/or diarrhea, due to increased gastrointestinal fluids

Respiratory distress, including a choking and a drowning sensation, due to increased pulmonary fluid

Onset or worsening of peripheral edema

Increased urine output, which may require catheterization

However, while relatively large hydration volumes can worsen or lead to pleural effusion and/or excess bronchial secretions, low volumes (<1000 mL daily) appear to be safely tolerated [54,57,58].

Beyond the issue of volume to be infused, the practical aspects of maintaining intravenous (IV) access presents another unnecessary imposition for patients receiving hospice care because IV sites may be difficult to maintain in the home environment, especially if they are peripherally inserted rather than a centrally-placed catheter. Reasons for this include:

Pain associated with needle insertion

The need for frequent site changes

Potential difficulty in locating sites of venous access for patients without central access and those who lose central access

The need for specific training in surveillance and care

Potential restrictions on mobility

Furthermore, the presence of an IV may increase agitation, and prompt a need for restraints, especially if patients experience delirium.

Impact on target symptoms — Whether rehydration has an impact on symptoms attributed to fluid deficits is unclear and studies have yielded conflicting results.

Thirst – The correlation between thirst and hydration status in terminally ill patients is modest, at best. The sensation of thirst is an insufficiently specific indicator of hydration status in terminally ill patients [7,59]. In addition, there is a lack of high-quality data to ascertain whether IV fluids (or fluids administered via an enteral feeding tube) relieve thirst in patients with advanced disease, such as cancer [59,60]. In contrast, thirst symptoms can be alleviated with simple measures such as stopping medications with anticholinergic side effects and administering good lip and mouth care [3-5,59].

Delirium – Although delirium may be a sign of dehydration, it can also be due to other factors, including the accumulation of opioid metabolites and other drugs (due to worsening renal function as one approaches the end of life) [2]. Delirium is one of the most devastating symptoms for dying patients, their families, and health care professionals [61]. Patients with agitated delirium appear to suffer, and even patients who have recovered from delirium and were never agitated remember the experience as very distressing [58,62]. (See "Overview of managing common non-pain symptoms in palliative care", section on 'Delirium'.)

Although dehydration should be a potentially treatable cause of delirium, a large randomized trial evaluating the role of hydration in patients at the end of life did not show it improved or prevented symptoms, including delirium. (See 'Artificial hydration' above.)

Sedation and drowsiness – Sedation and drowsiness are common in terminally ill patients and may be in part related to accumulation of sedative opioid metabolites, particularly in patients with reduced renal function. In observational studies, hyperosmolarity (suggestive of dehydration) was a significant contributor to somnolence [57]. Parenteral hydration also may potentially increase the excretion of drug metabolites. While several preliminary studies and one small randomized trial suggest a benefit for hydration in reducing sedation [58,63,64], the most rigorous randomized trial discussed above showed no improvement in symptoms (including sedation) with the administration of IV fluids [36]. (See 'Artificial hydration' above.)

APPROACH TO MEDICAL DECISION MAKING — The two important questions to consider in the decision-making process regarding hydration at the end of life include [34]:

What are the views and preferences of the patient and family?

What are the individualized goals of care?

We believe it is inappropriate to use artificial hydration and/or nutrition in a terminally ill patient to prevent or treat thirst, hunger, or an emotional concern that a loved one will “dehydrate to death.” As an example, more than two-thirds of patients with advanced cancer complain of thirst or dry mouth, yet in contrast to healthy individuals, thirst seems unrelated to dehydration and serum sodium, and is unrelieved by fluid therapy [65]. The emotional issues of family members, stemming from their concerns of seeing their loved one suffering from starvation and dehydration, must be acknowledged and addressed [37]. Discussions should include simple explanations of common symptoms associated with the dying process, including the frequency of delirium and its causes.

Many symptoms such as thirst, dry mouth, and fatigue are not specific for hydration status, and hydration is not likely to be of any benefit. There is no evidence that hydration reduces the risk of (or worsening of) fatigue, sedation, myoclonus, or hallucinations [36]. Patients and their families should be made aware of the data showing a lack of benefit of artificial hydration at the end of life. In addition, they should be reassured that it is ethical to withhold and withdraw artificial hydration.

Most palliative care clinicians promote the use of mouth care, including sips of water, when desired, rather than parenteral hydration in this setting [55]. This allows the family to feel like they are doing something for the patient and to be involved in his/her care.

PRACTICAL STRATEGIES FOR MANAGING PATIENTS WHO HAVE STOPPED NUTRITION AND HYDRATION — When a patient stops eating and drinking or artificial nutrition and hydration are withdrawn, clinicians should be attentive to comfort. These include the following:

Monitor drug dosages, particularly pain medications, because dehydration may be accompanied by reduced consciousness and reduced drug elimination.

If the patient is able, continue or encourage oral intake if it is compatible with the overall goals of care and comfort. Efforts to encourage oral intake should include hand-feeding, providing sufficient time to feed the patient; selecting food that has appropriate temperature taste and consistency (using thickeners as needed); offering foods with strong flavors; using techniques such as placing the food well into the mouth; varying the size and frequency of the meals; promoting good cough after each swallow to reduce aspiration; and avoiding distractions while eating [66].

If the effort to eat and drink becomes too draining or is not welcome, the patient should not be pressured to make this effort. To alleviate symptoms of dry mouth and thirst, mouth care should be administered, including oral cleaning, ice chips, popsicles, and the use of artificial saliva [67]. To moisten the lips, petroleum jelly, water-based lubricants, or lip moisturizers can be applied.

In this situation, it is also important to attend to family concerns. Families who consider nutrition and hydration to have symbolic value that extends beyond the bounds of medical care should have their point of view respected so long as it does not conflict with the patient’s previously expressed wishes. In general, families and loved ones appreciate an explanation of what is happening with their loved one as it relates to the dying process, and find reassurance that symptoms can be palliated. The family should be helped to understand that artificial nutrition and hydration is a medical treatment that is often not indicated when the patient is dying and will not improve the patient’s condition. Giving the family a realistic estimate of the time until death can prepare them to handle the ensuing time [46,51]. (See 'Length of survival after stopping nutrition and hydration' above and "Survival estimates in advanced terminal cancer".)

Trial of rehydration — Despite the lack of benefit, patients (or their families) may request a trial of hydration, particularly to help manage delirium. Given that modest amounts of fluid are unlikely to harm the patient and the qualitative data suggest that it is of psychosocial benefit to families, many clinicians will agree to a trial. The specific mode of hydration should be tailored to the specific patient’s situation. However, artificial hydration should be discontinued if there is no perceived improvement. (See 'Rehydration' above.)

Before the trial is undertaken, it should be made clear that symptoms may not respond to fluids and that hydration can be associated with risks (eg, peripheral or pulmonary edema). Adequate hydration usually can be accomplished with much lower volumes (≤1000 mL per day) than are routinely recommended for medical and surgical patients [1,32]. This finding may be due to decreased body weight, which results in:

Decreased absolute water requirements

Decreased insensible water losses as a consequence of reduced physical activity

Decreased clearance of free water because of an increase of anti-diuretic hormone (ADH) due to chronic nausea and cachexia, although only a small proportion of patients develop a full-blown syndrome of inappropriate secretion of ADH [68].

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

Basics topics (see "Patient information: Medical care during advanced illness (The Basics)" and "Patient information: Advance directives (The Basics)")


Medically-assisted nutrition and hydration should be considered medical interventions rather than basic provisions of comfort. (See 'Introduction' above.)

Fluid deficits in terminally ill patients are frequently multifactorial in etiology. However, regardless of the cause, the end result is total body water depletion and decreased renal function. (See 'Fluid deficits at the end of life' above.)

The major goal of artificial nutrition should be to provide nourishment to patients whose quality of life or life expectancy can be improved. In addition, the administration of fluids has been used in an effort to prevent or reverse distressing symptoms in this population. These goals suggest that decisions about the use of artificial nutrition and the use of artificial hydration may arise separately and the merits of these interventions may need to be evaluated separately. (See 'Defining goals of care' above.)

For patients at the end of life, we suggest not providing artificial nutrition (Grade 2C). (See 'Artificial nutrition' above.)

For most patients at the end of life, we suggest not providing artificial hydration, particularly those with end-stage cancer (Grade 2B). However, decisions regarding artificial hydration should take into account the patient’s values and preferences as some patients may find any gain in survival as clinically meaningful. (See 'Artificial hydration' above.)

The voluntary cessation of nutrition and hydration is a medically, ethically, and legally acceptable step that patients or their families may choose. Such voluntary cessation is reported to consistently occur among a small minority of patients in many countries in North America and Europe. At the same time, clinicians should be aware that some religions, particularly Catholicism, may view voluntary cessation as an act to intentionally shorten life that is forbidden. (See 'Voluntary cessation of intake' above.)

Patients who wish to forgo artificial nutrition and hydration at the end of life should be encouraged to complete advance directives that comply with the specific requirements of their state. (See 'Withholding and withdrawal of artificial nutrition and hydration' above.)

The approach to decision making about the role of artificial nutrition and/or hydration in the terminally ill patient should take into account the views and preferences of the patient and family and the individualized goals of care. (See 'Approach to medical decision making' above.)

When a patient stops eating and drinking or artificial nutrition and hydration are withdrawn, clinicians should be attentive to comfort. Many terminally ill patients or families decline nutritional intervention and rehydration when the benefits and risks are thoroughly and respectfully explained. (See 'Practical strategies for managing patients who have stopped nutrition and hydration' above.)

Families who consider nutrition and hydration to have symbolic value that extends beyond the bounds of medical care should have their point of view respected so long as it does not conflict with the patient’s previously expressed wishes. (See 'Practical strategies for managing patients who have stopped nutrition and hydration' above.)

If a patient at the end of life or his or her family request a trial of rehydration, it should be provided, so long as they recognize that symptoms may not respond to fluids and that hydration is associated with certain risks (eg, peripheral or pulmonary edema). If symptoms do not respond to this trial, rehydration should be discontinued. (See 'Trial of rehydration' above.)


The author is employed by the National Institutes of Health Department of Bioethics. (Note that the author's work for UpToDate was conducted as an outside activity, unrelated to her official duties as a federal employee. In addition, her views as expressed in her writings for UpToDate are her own and do not necessarily reflect official policy of the NIH or the US Department of Health and Human Services.)

We are saddened by the death of J Andrew Billings, MD, who passed away in September 2015.

UpToDate wishes to acknowledge Dr. Billings' many contributions to palliative care, in particular, his work as our Editor-in-Chief and Section Editor for Non Pain Symptoms: Assessment and Management.

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