Comfort at the End of Life Part 3 of 3

The role of nutrition and hydration at the end of life can be a controversial issue for many people.  When an individual is near the end of life, families may feel concerned about the effects of decreased or absent food and fluid intake.  As healthy people, we experience sensations related to hunger and thirst as signals from our bodies that nutrients and fluids are needed to maintain energy levels and promote normal functioning of our cells, tissues, and organs.  Some people automatically assume that these sensations continue to be experienced at the end of life, and that the lack of food and fluids causes pain and discomfort.  “Starvation” and dehydration are viewed as cruel ways to die, and questions about intravenous fluids and tube feedings can lead to mixed emotions and disagreements among individuals, families, and medical professionals. 

Most people would agree that they want to be comfortable at the end of life, and physical comfort is usually a primary concern.  Physical comfort or discomfort can be related to food intake. During the dying process, a loss of appetite is a normal occurrence as the body naturally begins to slow down. As our body systems (such as the digestive, circulatory, respiratory, and muscular systems) utilize fewer nutrients, sensations of hunger are lessened.  The ability to swallow food may become difficult or impaired, leading to discomfort when attempting to eat, and increased risk of aspiration (food particles getting into the lungs instead of the digestive system).  Aspiration places people at risk for pneumonia.  Other symptoms, such as nausea, vomiting, and constipation, may occur. Food intake may serve only to aggravate these symptoms.  As saliva production decreases, the sensation of taste may be altered, which can reduce an individual’s desire to eat.  Nutrition provided via a feeding tube may not improve symptom control or even lengthen life as the body may not be capable of absorbing or using the nutrients.  At the end of life, the focus of food intake should be for the enjoyment of the individual, and not for the purpose of nutrition.  Small portions of favorite foods as requested by the individual are the most effective method of giving comfort at this time. 

Another misperception at the end of life is that the lack of sufficient fluid intake can cause discomfort.  While thirst is an indicator of the body’s need for fluids, at the end of life, the sensation of thirst is more often associated with a dry mouth.  Frequent mouth care can help alleviate this symptom.  Avoid using flavored swabs as they may be irritating to sensitive tissues in the mouth, and if the individual is on oxygen, be sure to use lip balm that isn’t petroleum based.  Artificial saliva also may be used to reduce dry mouth.  Individuals who are conscious and not at risk of aspiration may enjoy ice chips.  As the body begins to naturally dry out, watch for dryness of the eyes.  Artificial tears, eye lubricant, and moist washcloths over the eyes can help promote comfort. 

When oral intake is poor or not recommended, the use of intravenous fluids may be thought of as a method of preventing dehydration.  In a dying individual, intravenous fluids may cause more harm than good.  First is the discomfort and potential for infection related to maintaining an access to administer the fluids.  The body may be unable to effectively process the fluids, leading to swelling in various areas of the body.  Intravenous fluids will increase the amount of secretions an individual has, resulting in coughing spells and/or shortness of breath.  Lastly, fluid that goes in will also cause the bladder to fill.  Fatigue and physical pain may make toileting difficult, or the individual may be incontinent and experience discomfort with the frequent skin care needed to prevent breakdown.  A catheter may take care of the incontinence issue, but is another potential source of infection, in addition to the discomfort experienced with its insertion.  When allowed to dry out naturally, normal chemical changes in the body and brain may produce a mild euphoria and improve an individual’s comfort level.  This euphoria may allow for lower doses of narcotics or other medications to be used, thus reducing the side effect of increased sedation and allowing for more quality time with loved ones. Does dehydration still sound cruel?

When considering the physical and psychosocial issues associated with food and fluid intake, bear in mind that the body’s inability to process food and fluids at the end of life is the result of advanced age, a disease process, or a traumatic injury.  One or a combination of these three conditions becomes the cause of death, not the lack of food or fluids.  The use of tube feedings and intravenous fluids may give an individual a little more time on this earth, but at what price?  Individuals, families, and health care providers can benefit from open and honest discussions about personal preferences for care prior to the nearing of the end of life.  Not all situations are black or white, however, and sometimes the end of life is unpredictable.  Education about the potential risks and benefits associated with the issues of food and fluid intake can help you be better prepared in case you need to make difficult decisions for yourself or a loved one.

Karen Kaslow, RN
Care Coordinator, Keystone Elder Law

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