Benefits and Risks of Artificial Nutrition or Hydration

It's common and completely normal for patients facing a terminal illness to experience loss of appetite, a decreased interest in food or drink, and weight loss. As the illness progresses, patients will either be unable to take in food or fluid by mouth or they will refuse to eat or drink.

It may be that the patient has been ill for some time or has been receiving artificial nutrition but not getting any better. In either case, the question of whether to withhold or withdraw artificial nutrition may arise. This can be a cause of great unease and distress if you're the patient’s loved one and caregiver.

Artificial nutrition is the delivery of a patient’s nutritional support without requiring the patient to chew and swallow. This can be achieved with total parenteral nutrition (TPN) or through a nasogastric tube (NG tube) or gastrostomy tube (G-tube or PEG tube).

There are many factors that can cause loss of appetite and reduced eating and drinking near the end of life. Some causes are reversible, such as constipation, nausea, and pain. Other causes are not able to be treated effectively, such as certain cancers, altered states of consciousness, and weakness of the muscles necessary to eat.

Reversible causes should be identified by the patient’s physician and addressed. If the cause is unknown or not treatable, the decision whether to withhold or withdraw support may need to be made.

Making the decision to withhold or withdraw artificial nutrition and hydration raises intellectual, philosophical, and emotional conflicts for many people. It is often helpful for people faced with that difficult decision to understand what science and medicine have found regarding artificial nutrition and hydration at the end of life.

Benefits and Risks

In our society and culture, food and fluids are viewed to be essential to sustain life and to speed healing and recovery from illness. It goes against most people's values to withhold food and fluids from a critically ill or dying patient.

Yet we all know that knowledge is power. As with any medical decision you are faced with, it is important to understand the benefits and risks. Is artificial nutrition beneficial for a terminally ill patient? Let’s take a look at what medical research can tell us:

• Total parenteral nutrition: TPN is an imperfect form of nutrition that is only used short term. It is delivered through a central line that's usually inserted in the neck or armpit and threaded through a vein, where it ends up near the heart. It was once thought that patients with cancer could benefit from TPN. The hope was that it could reverse the loss of appetite and severe weight loss that cancer patients experience and improve their prognosis. However, several studies have found that it neither helps cancer patients gain weight nor improves their quality of life. On the contrary, it actually increases the risk of infections and problems with the central line and is dangerous to patients.
• Nasogastric (NG) tubes: For patients who are unable to swallow, whether it’s due to invasive tumors, weakness, or neurological disorders, feeding through a tube has been the standard way to deliver nutrition. The nasogastric tube is the easiest way to achieve this. A tube is inserted through the nose and down the throat into the stomach. A liquid food formula is given through the tube continuously at a slow rate or several times a day with a larger dose. Like TPN, however, multiple medical studies have shown that survival rates for terminally ill patients are no different if they are artificially fed or not, and the risks are dangerous. Patients with NG tubes have a higher risk of pneumonia, which can significantly lower their survival rate. NG tubes also can be easily pulled out, causing distress to both the patient and their loved ones. Also, the irritation caused by these tubes can cause patients to become restless and agitated, which is sometimes the opposite effect of what a terminal patient needs.
• Gastrostomy (G) tubes: A gastrostomy tube is inserted directly into the stomach by a surgeon. A percutaneous endoscopic gastrostomy, or PEG tube, is inserted endoscopically (using a long, hollow tube with a light and camera attached) and is less invasive. With either of these tubes, there is less risk of the patient pulling the tube out. There is still the risk of pneumonia, however. Just like the nasogastric tube, there is little evidence that feeding through a gastrostomy tube will increase the health or life expectancy of terminally ill patients.
• Intravenous (IV) hydration: If a patient can no longer drink fluids or isn’t drinking enough, the caregiver may be tempted to ask for IV fluids. Fluids can be delivered through a small needle that is inserted in a vein and hooked up to tubing. Studies have shown that administering fluids to a terminally ill patient at the end of life offers little, if any, benefit. Risks include infection at the insertion site or in the blood, and fluid overload, resulting in swelling or even breathing problems in more severe cases.