To What Extent Does Clinically Assisted Nutrition and Hydration Have a Role in the Care of Dying People?

Abstract

The question over whether to administer clinically assisted nutrition and hydration (CANH) to a dying patient is controversial, with much debate concerning this sensitive issue. The administration of CANH poses clinical and ethical dilemmas, with supporting and opposing views. Proposed positive effects of CANH include preventing thirst, delirium, hypercalcemia, and opioid toxicity. However, CANH has been shown to increase the risk of aspiration, pressure ulcers, infections, and hospital admissions as well as potentially causing discomfort to the patient. Guidance from several national bodies generally advises that the risks and burdens of CANH outweigh the benefits in the dying patient. However, an individualized approach is needed, and the patient’s wishes regarding CANH need consideration if they have capacity and can communicate. Otherwise, sensitive discussions are required with the family, enquiring about the patient’s prior wishes if there is no advanced care plan and acting in the patient’s best interests. The ethical principles of autonomy, beneficence, non-maleficence, and justice need to be applied being mindful of any cultural and religious beliefs and potential misperceptions.

Fonoaudiología en cuidados paliativos para adultos y adultos mayores: fundamentos, roles, abordajes y desafíos

“…En el caso de aquellas personas que inician con cuidados de final de vida, existen algunas consideraciones adicionales. Así, se establece que en etapas más cercanas al final de la vida -en el contexto de una persona con cáncer, por ejemplo-un indicador pronóstico de que la expectativa de vida ha disminuido a semanas o días es la pérdida de interés por los alimentos o líquidos (NICE, 2004; Royal College of Physicians and British Society of Gastroenterology, 2010), condición que se replica para otras condiciones terminales (Carter, 2020;Rochford, 2021). En este contexto, la aplicación de estrategias que favorecen un buen cuidado e higiene oral resultan más apropiadas que cualquier otra intervención orientada a intentar algún tipo de ingesta oral.…”

“…En este contexto, la aplicación de estrategias que favorecen un buen cuidado e higiene oral resultan más apropiadas que cualquier otra intervención orientada a intentar algún tipo de ingesta oral. Esta condición supone, además, evaluar si continúa siendo apropiada la nutrición e hidratación por una vía alternativa, si esta ya fue implementada (Carter, 2020;Rochford, 2021; Royal College of Physicians and British Society of Gastroenterology, 2010). Al respecto, el descontinuar fluidos por vía parenteral debe ser considerado, tomando en cuenta que en estados avanzados de la enfermedad su mantención favorece la exacerbación del edema pulmonar y periférico; incrementando la producción de secreciones, las cuales una PeCP con bajo nivel de conciencia no es capaz de manejar (Rochford, 2021; Royal College of Physicians and British Society of Gastroenterology, 2010).…”

Nutrition at the End of Life: Basic Care or Treatment?

“…Therefore, given this controversy about the usefulness of nutrition and hydration at the end of life, each case should be studied individually taking into account the patient's circumstances and the benefits and risks of the interventions. However, reduced nutrition can give rise to a conflict among patient and family since it can be associated with a feeling of abandonment due to the fact that the patient is not being fed [15][16][17][18][19][20].…”

“…Quality studies report on a series of recommendations of practical utility, which can lead to inconsistencies in the results and a limitation in the recommendations for or against the use of hydration and nutrition at the end of life. In fact, individual studies show an improvement in certain symptoms, but benefits are shortlived and must be weighed against patient preferences and the risks that malnutrition can pose [24].…”

“…With regard to hydration, numerous studies have raised controversy as to the benefits and drawbacks. Arguments in favor of parenteral hydration include emotional well-being, alleviation of symptoms of dehydration (hallucinations, myoclonic, fatigue and sedation), not prolonging agony, prevention of delirium and increased renal perfusion [24][25][26]. However, certain studies have shown certain issues related to parenteral hydration such as worsening of both overall and lung oedema, increased bronchial secretions, pain, erythema, pleural effusion, ascites and dyspnoea, hypotension, nausea, and constipation [25,27].…”