End of life care: Clinically assisted nutrition and hydration

1. 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.
2. 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.
3. 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.
4. 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.

Subsections:

• Patients who have capacity (paragraphs 116-117)
• Adult patients who lack capacity (paragraphs 118)
• Adult patients who lack capacity and are not expected to die within hours or days (paragraphs 119-122)
• Adult patients who lack capacity and are expected to die within hours or days (paragraphs 123-125)
• Patients in a persistent vegetative state (PVS) or similar condition (paragraph 126)
• Conscientious objection (CPR) (paragraph 127)