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Benefits of dehydration in terminally ill patients
Benefits of Dehydration in Terminally Ill Patients Allowing terminally ill patients to dehydrate is an ethically and legally acceptable therapeutic measure. BY
MELISSA
A.
TAYLOR
n many societies, a link is drawn between food and caring. For example, many people grow up thinking chicken soup can cure just about anything. The giving of food and drink represents love and compassion in the minds of most people. It is not surprising, then, that the issue of permitting dehydration in terminally ill patients is met with great resistance. However, the literature supports the concept that forced nutrition in the terminally ill is of questionable benefit and may indeed worsen a patient's condition. 1 Dehydration in the terminally ill patient can be therapeutic treatment. The benefits and legal and ethical aspects should be considered in every situation, while keeping in mind the individuality of each case. When a health care professional, family member, or significant other is faced with making the decision to discontinue life-sustaining mechanisms, such as hydration measures, the patient's own wishes must always take precedence. The comatose patient obviously presents a more complicated circumstance. To make a more informed decision, people need to be educated about the benefits, as well as the legal and ethical considerations, of dehydration in the terminally ill. The benefits of dehydration are numerous and should be examined in every situation. Perhaps the most important issue concerning the terminally ill patient is controlling pain. The primary goal of palliative care is comfort for the patient. 3 Dehydration is often incorrectly associated with pain: In one study, 8 of 10 hospice nurses agreed that dehydration is not painful. 4 Printz 5 reported that terminally ill patients in end-stage
I
MELISSA A. TAYLOR, BSN, is a staff nurse at the Veterans Affairs Medical Center in Wilkes Barre, Pennsylvania. GERIATRNURS 1995;16:271-2 Copyright 9 1995 by Mosby-Year Book, Inc. 0197-4572/95/$5.00 + 0 34/1/67992
GERIATRIC NURSING Volume 16, Number 6
dehydration experienced less discomfort than did patients receiving medical hydration. One explanation for this is that dehydration causes the production of ketones, which have an anesthetic effect. 6 Another benefit of dehydration is a decreased output of urine, which reduces the need for some invasive measures, such as the use of urinary catheters] Dehydration also decreases gastrointestinal fluids, resulting in decreased incidences of nausea and vomiting. 4 Hydration may actually provide for tumor growth and increase symptoms related to tumor size. 1 Hydrating a terminally ill patient could also increase peripheral edema, thereby increasing the risk for pressure sores. 7 In the pulmonary system dehydration decreases the production of secretions, resulting in diminished congestion and symptoms associated with it. 4 Physicians are realizing the benefits of dehydration in the terminally ill. The Academy of HoSpice Physicians published the following facts regarding dehydration in the terminally ill: 9 Nasogastric or gastrostomy tube feedings are associated with a high incidence of pneumonia. 9 Total parenteral nutrition has been shown to be associated with decreased survival and increased infections. 9 Survival time in cancer patients who did not receive in travenous hydration was significantly longer than that in those who did. 3 The only documented side effect of dehydration in the terminally ill is oral discomfort. 4 To ease this discomfort, a nurse can use saliva substitutes and moisturizes. The nurse can remove buccal debris with a rinse of peroxide and water. Nurses should also offer ice chips and favorite beverages frequently. Chapped lips can be alleviated by applying petroleum jelly. Perhaps the most difficult issues for nurses is the ethical dilemma. Most ethicists weigh burdens and benefits. Taylor 271
Therefore when the patient feels that the burdens of medical hydration and nutrition outweigh the benefits, is it then ethically appropriate to withdraw or withhold intravenous or nasogastric fluids? If the patient or patient decision maker agrees that the benefits of dehydration in the terminally ill outweigh the burdens, it should be considered ethically acceptable. Many people associate the termination of life-supporting mechanisms, such as hydration, with murder. Withholding artificial hydration and nutrition from someone in an irreversible coma does not induce a fatal pathologic condition; rather, it allows an already existing pathologic condition to take its natural course. 8 One basic ethical assumption in nursing and medicine is that life should be prolonged because living enables us to pursue the purpose of life. In the case of the comatose terminally ill patient, however, the ethical obligation to prolong life ceases because that life can no longer contribute to striving for the purpose of life. 8
It is a nurse's responsibility to be educated on the benefits and legalities involved with terminal dehydration. On the legal side of terminal dehydration, the Council on Ethical and Judicial Affairs of the American Medical Association issued the following statement on March 15, 1986: Life-prolonging medical treatment and artificially or t e c h n o l o g i c a l l y s u p p l i e d r e s p i r a t i o n , nutrition, a n d h y d r a t i o n m a y b e w i t h h e l d f r o m a p a t i e n t in a n irrev e r s i b l e c o m a e v e n i f d e a t h is n o t i m m i n e n t , s
Legally, it has been upheld in court that the withdrawal of medical hydration was approved where decision makers chose to have intravenous lines or nasogastric tubes withdrawn from patients suffering an irreversible coma. 5 Myths concerning the law and the terminally ill include the following: 9 Termination of life support is murder or suicide. 9 It is permissible to terminate extraordinary treatments, but not ordinary ones. 9 It is permissible to withhold treatment, but once started, it must be continued. 9 Stopping tube feeding is legally different from stopping other treatments.t1 A nurse has the obligation to first and foremost respect the wishes of the patient. A nurse must also always keep the goal of comfort in mind. It is a nurse's responsibility to be educated on the benefits and legalities involved with terminal dehydration. A nurse should advocate for the patient at all times and educate any person making decisions regarding dehydration. It is a nurse's duty to help alleviate any side effects from dehydration, such as dry mouth. Finally, it is a nurse's obligation not to pass judgment on any decisions made to withhold hydration from or continue the hydration of a terminally ill patient. Nurses who work with terminally ill patients need to take a holistic approach to the situation. The facts presented in this article should help nurses help their patients make informed decisions regarding artificial hydration. Nurses need to be educated on the needs of terminal patients. Dying is the natural closure of a life lived. Although death is a difficult subject for most individuals, those who are in the situation of making life-sustaining decisions need to be aware of, and comfortable with, the realization of their own mortality. Those individuals also need to understand the benefits, as well as the legal and ethical aspects, of dehydration in the terminally ill. 9 REFERENCES
The American Nurses Association published a position paper in 1992 on artificial nutrition and hydration that stated that the refusal of food and fluid by competent patients is morally, as well as legally, permissible for nurses to honor. 9 The American Dietetic Association also published a position paper on terminal hydration issues that declared that discontinuing enteral or parenteral nutrition support may be considered when a competent patient has expressed an informed preference not to receive aggressive nutritional support. 1~ All three professional organiz a t i o n s - t h e American Medical Association, the American Dietetic Association, and the American Nurses Association--agree that it is legally, ethically, and professionally acceptable to discontinue nutritional support of the terminally ill.
272 Taylor
i. Cadthcart SL. Love and chicken soup. Hospice Communique 1990;Winter:i2. 2. Andrews M, Bell ER, Smith SA, Tischler JE Veglia JM. Dehydration in terminally ill patients: Is it appropriate palliative care? Postgrad Med 1993;93:201-6. 3. Storey P. Primer of palliative care. Gainsville, Florida: The Academy of Hospice Physicians, 1994. (Available from The Academy of Hospice Physicians, P.O. Box 14288, Galnsville FL 32604-2288.) 4. Rousseau PC. How fluid deprivation affects the terminally ill. RN 1991;Jan:73-6. 5. Printz LA. Is withholding hydration a valid comfort measure in the terminally ill? Geriatrics 1988;43:84-8. 6. Printz LA. Terminal dehydration, a compassionate treatment. Arch Intern Med 1992;152:697-700. 7. Musgrave CE Terminal dehydration: to give or not to give intravenous fluids. Cancer Nurs 1990;13:62-6. 8. O'Rourke K. The AMA statement on tube feeding: an ethical analysis. America 1986;Nov:321-4. 9. American Nurses Association. Position statement on foregoing artificial nutrition and hydration. Washington: American Nurses Association, 1992. 10. King DG, Malllet JO. Position of the American Dietetic Association: issues in feeding the terminally ill adult. J Am Diet Assoc 1991;92:996-1005. 11. Meisel CJ. Legal myths about terminating life support. Arch Intern Med 1991;151:1497-502.
November/December 1995 GERIATRIC NURSING
MELISSA
A.
TAYLOR
n many societies, a link is drawn between food and caring. For example, many people grow up thinking chicken soup can cure just about anything. The giving of food and drink represents love and compassion in the minds of most people. It is not surprising, then, that the issue of permitting dehydration in terminally ill patients is met with great resistance. However, the literature supports the concept that forced nutrition in the terminally ill is of questionable benefit and may indeed worsen a patient's condition. 1 Dehydration in the terminally ill patient can be therapeutic treatment. The benefits and legal and ethical aspects should be considered in every situation, while keeping in mind the individuality of each case. When a health care professional, family member, or significant other is faced with making the decision to discontinue life-sustaining mechanisms, such as hydration measures, the patient's own wishes must always take precedence. The comatose patient obviously presents a more complicated circumstance. To make a more informed decision, people need to be educated about the benefits, as well as the legal and ethical considerations, of dehydration in the terminally ill. The benefits of dehydration are numerous and should be examined in every situation. Perhaps the most important issue concerning the terminally ill patient is controlling pain. The primary goal of palliative care is comfort for the patient. 3 Dehydration is often incorrectly associated with pain: In one study, 8 of 10 hospice nurses agreed that dehydration is not painful. 4 Printz 5 reported that terminally ill patients in end-stage
I
MELISSA A. TAYLOR, BSN, is a staff nurse at the Veterans Affairs Medical Center in Wilkes Barre, Pennsylvania. GERIATRNURS 1995;16:271-2 Copyright 9 1995 by Mosby-Year Book, Inc. 0197-4572/95/$5.00 + 0 34/1/67992
GERIATRIC NURSING Volume 16, Number 6
dehydration experienced less discomfort than did patients receiving medical hydration. One explanation for this is that dehydration causes the production of ketones, which have an anesthetic effect. 6 Another benefit of dehydration is a decreased output of urine, which reduces the need for some invasive measures, such as the use of urinary catheters] Dehydration also decreases gastrointestinal fluids, resulting in decreased incidences of nausea and vomiting. 4 Hydration may actually provide for tumor growth and increase symptoms related to tumor size. 1 Hydrating a terminally ill patient could also increase peripheral edema, thereby increasing the risk for pressure sores. 7 In the pulmonary system dehydration decreases the production of secretions, resulting in diminished congestion and symptoms associated with it. 4 Physicians are realizing the benefits of dehydration in the terminally ill. The Academy of HoSpice Physicians published the following facts regarding dehydration in the terminally ill: 9 Nasogastric or gastrostomy tube feedings are associated with a high incidence of pneumonia. 9 Total parenteral nutrition has been shown to be associated with decreased survival and increased infections. 9 Survival time in cancer patients who did not receive in travenous hydration was significantly longer than that in those who did. 3 The only documented side effect of dehydration in the terminally ill is oral discomfort. 4 To ease this discomfort, a nurse can use saliva substitutes and moisturizes. The nurse can remove buccal debris with a rinse of peroxide and water. Nurses should also offer ice chips and favorite beverages frequently. Chapped lips can be alleviated by applying petroleum jelly. Perhaps the most difficult issues for nurses is the ethical dilemma. Most ethicists weigh burdens and benefits. Taylor 271
Therefore when the patient feels that the burdens of medical hydration and nutrition outweigh the benefits, is it then ethically appropriate to withdraw or withhold intravenous or nasogastric fluids? If the patient or patient decision maker agrees that the benefits of dehydration in the terminally ill outweigh the burdens, it should be considered ethically acceptable. Many people associate the termination of life-supporting mechanisms, such as hydration, with murder. Withholding artificial hydration and nutrition from someone in an irreversible coma does not induce a fatal pathologic condition; rather, it allows an already existing pathologic condition to take its natural course. 8 One basic ethical assumption in nursing and medicine is that life should be prolonged because living enables us to pursue the purpose of life. In the case of the comatose terminally ill patient, however, the ethical obligation to prolong life ceases because that life can no longer contribute to striving for the purpose of life. 8
It is a nurse's responsibility to be educated on the benefits and legalities involved with terminal dehydration. On the legal side of terminal dehydration, the Council on Ethical and Judicial Affairs of the American Medical Association issued the following statement on March 15, 1986: Life-prolonging medical treatment and artificially or t e c h n o l o g i c a l l y s u p p l i e d r e s p i r a t i o n , nutrition, a n d h y d r a t i o n m a y b e w i t h h e l d f r o m a p a t i e n t in a n irrev e r s i b l e c o m a e v e n i f d e a t h is n o t i m m i n e n t , s
Legally, it has been upheld in court that the withdrawal of medical hydration was approved where decision makers chose to have intravenous lines or nasogastric tubes withdrawn from patients suffering an irreversible coma. 5 Myths concerning the law and the terminally ill include the following: 9 Termination of life support is murder or suicide. 9 It is permissible to terminate extraordinary treatments, but not ordinary ones. 9 It is permissible to withhold treatment, but once started, it must be continued. 9 Stopping tube feeding is legally different from stopping other treatments.t1 A nurse has the obligation to first and foremost respect the wishes of the patient. A nurse must also always keep the goal of comfort in mind. It is a nurse's responsibility to be educated on the benefits and legalities involved with terminal dehydration. A nurse should advocate for the patient at all times and educate any person making decisions regarding dehydration. It is a nurse's duty to help alleviate any side effects from dehydration, such as dry mouth. Finally, it is a nurse's obligation not to pass judgment on any decisions made to withhold hydration from or continue the hydration of a terminally ill patient. Nurses who work with terminally ill patients need to take a holistic approach to the situation. The facts presented in this article should help nurses help their patients make informed decisions regarding artificial hydration. Nurses need to be educated on the needs of terminal patients. Dying is the natural closure of a life lived. Although death is a difficult subject for most individuals, those who are in the situation of making life-sustaining decisions need to be aware of, and comfortable with, the realization of their own mortality. Those individuals also need to understand the benefits, as well as the legal and ethical aspects, of dehydration in the terminally ill. 9 REFERENCES
The American Nurses Association published a position paper in 1992 on artificial nutrition and hydration that stated that the refusal of food and fluid by competent patients is morally, as well as legally, permissible for nurses to honor. 9 The American Dietetic Association also published a position paper on terminal hydration issues that declared that discontinuing enteral or parenteral nutrition support may be considered when a competent patient has expressed an informed preference not to receive aggressive nutritional support. 1~ All three professional organiz a t i o n s - t h e American Medical Association, the American Dietetic Association, and the American Nurses Association--agree that it is legally, ethically, and professionally acceptable to discontinue nutritional support of the terminally ill.
272 Taylor
i. Cadthcart SL. Love and chicken soup. Hospice Communique 1990;Winter:i2. 2. Andrews M, Bell ER, Smith SA, Tischler JE Veglia JM. Dehydration in terminally ill patients: Is it appropriate palliative care? Postgrad Med 1993;93:201-6. 3. Storey P. Primer of palliative care. Gainsville, Florida: The Academy of Hospice Physicians, 1994. (Available from The Academy of Hospice Physicians, P.O. Box 14288, Galnsville FL 32604-2288.) 4. Rousseau PC. How fluid deprivation affects the terminally ill. RN 1991;Jan:73-6. 5. Printz LA. Is withholding hydration a valid comfort measure in the terminally ill? Geriatrics 1988;43:84-8. 6. Printz LA. Terminal dehydration, a compassionate treatment. Arch Intern Med 1992;152:697-700. 7. Musgrave CE Terminal dehydration: to give or not to give intravenous fluids. Cancer Nurs 1990;13:62-6. 8. O'Rourke K. The AMA statement on tube feeding: an ethical analysis. America 1986;Nov:321-4. 9. American Nurses Association. Position statement on foregoing artificial nutrition and hydration. Washington: American Nurses Association, 1992. 10. King DG, Malllet JO. Position of the American Dietetic Association: issues in feeding the terminally ill adult. J Am Diet Assoc 1991;92:996-1005. 11. Meisel CJ. Legal myths about terminating life support. Arch Intern Med 1991;151:1497-502.
November/December 1995 GERIATRIC NURSING