End of life care: Clinically assisted nutrition and hydration
112. Clinically assisted nutrition includes intravenous feeding, and feeding by nasogastric tube and by percutaneous endoscopic gastrostomy (PEG) and radiologically inserted gastrostomy (RIG) feeding tubes through the abdominal wall. All these means of providing nutrition also provide fluids necessary to keep patients hydrated. Clinically assisted hydration can also be provided by intravenous or subcutaneous infusion of fluids through a ‘drip’. The terms ‘clinically assisted nutrition’ and ‘clinically assisted hydration’ do not refer to help given to patients to eat or drink, for example by spoon feeding.
113. Providing nutrition and hydration by tube or drip may provide symptom relief, or prolong or improve the quality of the patient’s life; but they may also present problems.xxvii The current evidence about the benefits, burdens and risks of these techniques as patients approach the end of life is not clear-cut.xxviii This can lead to concerns that patients who are unconscious or semi-conscious may be experiencing distressing symptoms and complications, or otherwise be suffering either because their needs for nutrition or hydration are not being met or because attempts to meet their perceived needs for nutrition or hydration may be causing them avoidable suffering.
114. Nutrition and hydration provided by tube or drip are regarded in law as medical treatment32, and should be treated in the same way as other medical interventions. Nonetheless, some people see nutrition and hydration, whether taken orally or by tube or drip, as part of basic nurture for the patient that should almost always be provided. For this reason it is especially important that you listen to and consider the views of the patient and of those close to them (including their cultural and religious views) and explain the issues to be considered, including the benefits, burdens and risks of providing clinically assisted nutrition and hydration. You should make sure that patients, those close to them and the healthcare team understand that, when clinically assisted nutrition or hydration would be of overall benefit, it will always be offered; and that if a decision is taken not to provide clinically assisted nutrition or hydration, the patient will continue to receive high-quality care, with any symptoms addressed.
115. If disagreement arises between you and the patient (or those close to a patient who lacks capacity), or you and other members of the healthcare team, or between the team and those close to the patient, about whether clinically assisted nutrition or hydration should be provided, you should seek resolution following the guidance in paragraphs 47-49. You should make sure that the patient, or someone acting on their behalf, is informed and given advice on the patient’s rights and how to access their own legal advice or representation.
32 Airedale NHS Trust v Bland  1 All ER 821.
xxvii An explanation of the different techniques for providing nutrition and hydration by tube or drip can be found in the NICE guideline Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. (Feb 2006). Artificial Nutrition and Hydration: guidance in end of life care for adults. National Council for Palliative Care (2007).
xxviii For a detailed discussion of evidence on the benefits, burdens and risks when nutrition or hydration is provided by drip or tube, refer to Improving Nutritional Care. A joint action plan from the Department of Health and Nutrition Summit stakeholders (October 2007).