Posted on 12/01/2024 3:16:53 PM PST by DoodleBob
There are few treatment decisions more difficult for families and loved ones to make than those surrounding the use of artificial nutrition and hydration in the seriously or terminally ill person:
“Should nutrition be given intravenously if my wife’s gut isn’t working right?”
“Should intravenous fluids be given to my father when he stops drinking and becomes dehydrated?”
“Should a feeding tube be placed if my mother can’t swallow without choking?”
Family members agonize over these questions, especially if they are not given clear explanations about the effectiveness or lack of effectiveness of various available treatments, and what kind of burdens, side effects and complications each treatment can place on the patient and the caregivers. Myths and misconceptions abound.
This article will define and describe in a straightforward manner what each treatment is, when each treatment might be useful, when each treatment is not likely to be useful, and the known burdens, side effects and complications of each treatment.
But first, let us dispel the myth that artificial nutrition and hydration is not really a medical treatment at all but rather basic care, like giving a meal to someone.
Like many medical interventions, all forms of artificial nutrition and hydration:
What is meant by “artificial nutrition and hydration”?
Artificial nutrition and/or hydration is a treatment intervention that delivers fluids and/or nutrition by means other than a person taking something in his/her mouth and swallowing it.
There are several different types of artificial nutrition and hydration, broadly divided into two major categories:
What is being given to a person who receives “artificial nutrition and hydration?”
The nutrients and/or fluids being given varies greatly according to the type of artificial nutrition and hydration and the needs of each patient:
Initially, these treatments were intended to be used temporarily, for short periods of time, until a person with a reversible problem regained the ability to eat and drink normally. Their use has become both more widespread and applied for longer periods.
Recently the scientific community has taken a closer look at the use of artificial nutrition and hydration to see if there is good evidence that these treatments are useful. There have been some surprising findings! Myths that have been held about the usefulness of artificial nutrition and hydration are being challenged, particularly as they have been used for persons who have incurable disease, in persons who have neurologic or brain disorders, and in the frail elderly person.
Let’s take a look at some of these myths:
Myth: A person who gets aspiration pneumonia (pneumonia which develops because contents of the mouth are seeping down the trachea into the lungs) because of difficulty with swallowing and choking needs to have a gastrostomy tube placed to prevent recurrence of the aspiration pneumonia.
Fact: There is no good evidence that demonstrates that gastrostomy tubes, or tubes into the small intestine, prevent aspiration pneumonia in a person who has difficulty swallowing. In fact, there is good evidence in persons with advanced Alzheimer’s disease that gastrostomy tubes actually cause more harm than if no tube had been placed. Other evidence shows that tube feeding may actually increase episodes of aspiration pneumonia. Careful feeding by hand is a better alternative.
Myth: Artificial nutrition speeds wound healing in a person who is unable to eat normally.
Fact: There are no good studies demonstrating that artificial nutrition and hydration speeds wound healing. In fact, if a person is incontinent (unable to control urination and/or defecation) they may suffer from increased skin breakdown due to constant moisture and the irritation of urine and/or feces on the skin.
Myth: Persons with cancer cachexia (a condition where the person keeps losing weight and does not eat well) should receive total parenteral nutrition (TPN) to maintain weight and strength.
Fact: Medical science has been unable to show any benefit from TPN use in patients with cancer cachexia: It does not keep a person from losing weight, does not improve a person’s nutrition, and does not help the person gain strength and energy. Some studies even show shortened survival in persons with cancer cachexia who are treated with TPN.
Myth: A dying person who has become dehydrated due to lack of fluids experiences extreme thirst, pain and distress.
Fact: Dehydration in a seriously ill person with a terminal condition, and in the frail elderly, is not painful. In fact, frail elderly persons have a blunted sense of thirst, which allows them to slip rather easily into a dehydrated state. This is generally characterized by increased sleepiness and less mental alertness without other signs of distress. In the dying patient, studies have shown that the majority never experience thirst, or only initially, and the thirst that occurs is easily alleviated by small amounts of fluids or ice chips given by mouth, and by lubricating the lips.
Myth: A person with advanced disease or a terminal illness who stops eating will “starve to death” painfully.
Fact: When a person with advanced disease or a terminal illness stops eating, usually it is because his/her disease has progressed to the point where the person is no longer able to process food and fluids as does a healthy person. Forcing this person to eat, or starting artificial nutrition and hydration does not help the person to live longer, feel better, feel stronger, or be able to do more. In fact, such a person given artificial nutrition and/or hydration will often feel bloated, nauseated, and/or develop diarrhea. Studies have shown that the majority of dying patients never experience hunger, and in those who do, small amounts of food and fluids, offered whenever the person wants, relieves the hunger.
What is known about the side effects and complications of artificial nutrition and hydration?
Complications and side effects vary by the type of artificial nutrition and hydration used:
Are there any beneficial effects of dehydration?
Dehydration can actually have several potential benefits for a person who is at the end stages of his/her life:
Are there any situations in the seriously ill where artificial nutrition and hydration are helpful?
There are situations where artificial nutrition and hydration, in a specific person and in specific situations, are likely to be more beneficial than harmful:
From time immemorial, human beings have expressed their love for one another through the act of feeding and sharing meals. Much of the anguish over decisions to start, withhold, or discontinue artificial nutrition and hydration stems from a mistaken feeling that the act of administering artificial nutrition and hydration is equivalent to the nurturing acts of feeding our babies or serving a meal to our family.
Artificial nutrition and hydration is a medical treatment, with intended beneficial effects but many side effects and complications attached to its use. Decisions about its use need to be based on a dispassionate look at what, if any, benefits will occur, what side effects and burdens are likely to occur, and what the individuals’ and families’ goals are for the treatment.
When artificial nutrition and hydration is more likely to be burdensome than helpful, it should be avoided or discontinued. Nurturing can be expressed in more helpful ways, such as gentle presence, touch, talking with the person (regardless of his/her ability to respond), keeping the person’s lips and mouth moist, gently massaging the skin using lubricants, praying with the person, or playing favorite music selections. These alternative ways of nurturing can be very powerful and moving for both the person with the life-threatening illness and his/her loved one.
About the author: Dr. Cheryl Arenella does health care consulting for programs focused on improving end-of-life care. She has over 20 years of experience in the field of Hospice and Palliative Medicine. She is a former trustee of the American Board of Hospice and Palliative Medicine and served for many years as a Medical Director for a large Medicare certified hospice, where she provided medical oversight, direct patient care and administrative program support.
How about a CPAP machine?
A pneumatic compression device?
Water that is brought to me in a cup because I can not walk? Is that "Artificial water"?
Breakfast in Bed? Are the cubs bringing me Artificial Nutrition every Mother's Day?
In my thirties I nearly die of dehydration from food poisoning. I was like a fire hose with two opposing nozzles as various semi solids and fluids raced towards the light. When I got to Urgent Care in Sedona, AZ and that saline fluid hit my veins it was sweet, sweet relief. I can tell you with authority that the simple invention of the saline IV drip is the most fabulous life-saving invention ever invented, bar none.
I am right there with you brother! The powers that be are messaging to us “The moment you cannot provide for yourself we will kill you.”
Like many medical interventions, all forms of artificial nutrition and hydration:
If this is basic care then kill me. Kill me with kindness. Palliative care.
My father is slowly losing his life in a senior wing of a hospital. We’ve given the instructions to keep him comfortable and to medically treat him for any issues, but not do anything that will extend life unnecessarily. If he slips into a coma, let him go.
I think that’s the way it is supposed to be at the EOL.
And I draw the line there.
You want to kill someone, use a knife to open up their chest and pull their heart out. Own it.
Do not torture them to death and pat yourself on the back about how "humane" you are.
“Myth: A dying person who has become dehydrated due to lack of fluids experiences extreme thirst, pain and distress.
Fact: Dehydration in a seriously ill person with a terminal condition, and in the frail elderly, is not painful. In fact, frail elderly persons have a blunted sense of thirst,...”
Just how could this fact be determined? Not being snippy, I honestly won’t to know how a frail elderly person was able to convey his or her blunted sense of thirst to medical staff. Maybe the pain and distress caused mental confusion where the person could not articulate just how thirsty they truly were.
When the time comes for me I’m going to use Euthanasia to end my life. We are all going to go sometime and I’m not going to needlessly suffer.
From the demons who said starving to death was euphoric. Terry Shiavo can not be reached for comment.
My faith does not permit suicide. I understand others will take an active role in their own death but I could not make such a choice. Besides by the time I am on the threshold of death it may be mandatory to select an ice flo.
We had direct experience with this philosophy with my wife who has advanced Parkinson’s, got COVID, then pkeumonia and lost her ability to swallow. After weathering the pneumonia and COVID, The first hurdle was the distinct pressure to not install the permanent feeding tube and to let her expire. We refused and had the GI tube installed. Release from the hospital was either to rehab or hospice so we elected to try hospice. Again the medical pressure was to restrict the flow of food into her feeding tube and,”let her go”.
We dropped hospice and have been self caring for her with around the clock help.
Medicare stops paying when you drop hospice. So we pay for all the care she gets out-of-pocket. It’s worth it.
She’s home and comfortable but we’ll keep her alive as long as she can survive. We know it’s not long but it’s the right thing to do.
Don’t worry if a terminal person is refusing water. Dehydration actually decreases pain because dehydrated nerve endings have a hard time transmitting pain signals. Every person should fill out a form with their doctor stating what they do and do not want done. Everyone should have a medical power of attorney to make sure wishes are followed. I am not in favor of assisted suicide per se, but I am in favor of keeping a dying person as comfortable as possible.
Perform strange and occasionally uncomfortable procedures that may result in injury or death.
Have known side effects and potential complications, including serious infections, fluid overload, nausea/vomiting and diarrhea, electrolyte and mineral imbalances, and even death;
Have indications (use of the treatment for patients with similar conditions has been usually more beneficial than harmful);
Have contraindications (use of the treatment for patients with similar conditions has been usually more harmful than beneficial); (allergies and what have you)
Hold very little similarity to a person being inside the womb and taking their nourishment through the umbilical cord.
Feeding is obviously an artificial way to cling to a life that should have ended when the cord was cut.
No one should have to suffer this loss of dignity.
And let's not even talk about what happens AFTER you eat.
My mom, at the age of 101, died at my home. It was just me and the occasional hospice worker. Before she slipped into a coma she lost all interest in eating, despite my requests that she just try a little nibble if she could. Thirst was a big problem, but she could not swallow without choking, which I tried to alleviate with ice chips, Popsicles, and wet sponges, even after she lost consciousness. Hospice assured me that morphine was making her comfortable, but I don’t know. I was pretty much alone. It was the worst experience of my life (just a year ago). Mom is a believer in Jesus, so I know she is happy and well, but not a day goes by that I don’t wonder if I did everything right.
I’ve done a fair amount of hospice work in the last 25 years.
The article is excellent. However, it does not address the most important factor, i.e. clarity of mind.
When I’m caring for a dying person I strive for a balance between two things. First is to minimize pain. Second is to maintain clarity of mind.
My experience is that most nurses give too high of a dose of painkiller that it clouds the mind. I’ve cared for many dying of cancer, specifically bone cancer which is one of the most difficult to manage pain. I decrease the dosages slowly until they are uncomfortable and then increase them slightly, trying to find the balancing point.
There is an alternative to the pain killers. That is prayer. With prayer a person can rise above the level of consciousness where the person experiences pain. Prayer works very similar to hypnosis in that it can be an analgesic.
In addition, prayer is the tool for stepping out of the physical body when it’s time to depart. Very often I was praying with people when they died.
The problem with too much pain killer is that it makes it difficult for the person to pray and they just hang on in a drugged up state.
There are two ways to die. One is when the physical body no longer can contain life. The soul just departs, but often hangs around for a while, often days.
The second and better way to die is by your soul consciousness transcending their physical body. This allows the person to straddle the fence and be in both places at the same time. They will often see and hear loved ones who previously passed. One woman I worked with even heard her dogs barking that had passed years earlier.
The second way is far better for soul growth. The last period of life prior to death is very valuable time for soul cleansing work.
Many times I have heard confessions and assisted in forgiveness work in the hours and minutes prior to death. Remember the parable of the vineyard workers. It is of great importance that even work in the last minute prior to death is valuable. (In humor, I call the vineyard worker parable the procrastinator’s parable)
Prayers by other people for the dying person are also very valuable. They assist in guiding the person through the layer of darkness and into Heaven.
I started doing Hospice work after I died myself, crossed over to Heacen, and the returned to my physical body. Heaven is so great that there has not been a day in over thirty five years since my death that I did not want to die again and return to Heaven.
The most difficult and painful deaths I have observed are by those who die holding onto anger. It makes it difficult for the soul to let go and cross over.
Whenever possible, it is better to die at home with family and friends around you.
🙏🙏🙏
I had one woman, just shy of 98 who stopped eating. For three weeks she would not eat.
After two weeks, she stopped drinking liquids. I still used the sponges to moisten her mouth, but she consumed no liquids the last week prior to death.
I had to keep repositioning her body as the blood was coagulating the last few days.
Finally her death was very peaceful.
When a person dies, I feel very cold as they are borrowing my soul energy. When I feel that chilled to the bone cold, I immediately start praying to reconnect and replenish. As soon as they see the Light at the end of the tunnel they have their own connection to guide them home.
My hat is off to you for what you are doing. It’s not easy, but well worth the effort.
You can do in home hospice. That gives you the nursing and Dr. care, and all bills are paid by hospice.
The general rule to qualify for hospice is that life expectancy is less than 6 months. I’ve had people on hospice for almost two years.
Your mother was lucky to have you.
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