The decision to stop providing food and water in hospice care is often emotionally challenging for families. Hospice focuses on providing comfort, dignity, and quality of life for individuals with a terminal illness, rather than attempting to cure the disease. Reducing or stopping nutritional and fluid intake is a medically informed approach rooted in the physiological understanding of the natural dying process. This shift acknowledges that the body can no longer safely process food and fluids, and forcing them can introduce unnecessary suffering.
The Natural Decline in Nutritional Needs
As a person approaches the final stages of life, the body’s metabolism slows significantly due to the progressive failure of organ systems. The body conserves energy, and the process of digesting, absorbing, and utilizing nutrients becomes inefficient. This metabolic shutdown means the body does not need the same level of calories or hydration.
The digestive system slows, leading to reduced gut motility and difficulty processing complex nutrients. Forcing food can cause uncomfortable symptoms such as nausea, vomiting, bloating, and abdominal cramping. Signals for hunger and thirst also diminish naturally, meaning the patient often does not experience the painful sensations of starvation or dehydration that a healthy person would.
The body shifts to using fat reserves for fuel (ketosis), which can have a mild anesthetic effect that promotes comfort. Attempting to force nutrition or hydration can be physically distressing, as the patient may be too weak to swallow safely. This biological reality justifies shifting the focus from nutritional maintenance to comfort care.
Defining Artificial Hydration and Nutrition as Medical Treatment
A distinction in hospice care is made between comfort measures and medical treatments. Artificial nutrition and hydration (ANH) includes interventions like intravenous (IV) fluids or tube feeding (NGT or PEG). In hospice, these methods are classified as medical treatments, not basic, routine care.
Since hospice prioritizes comfort and stops curative measures, medical interventions that no longer offer a clear benefit are discontinued. Palliative care professionals agree that ANH is unlikely to prolong life or alleviate suffering for a patient nearing the end of life. Withholding or withdrawing ANH is an ethical and legal choice to stop a non-beneficial medical treatment, aligning with the goal of a peaceful death.
Basic comfort measures are never stopped. These include offering ice chips, moistening the lips with swabs, or providing small sips of fluid for pleasure. These measures address dry mouth, the primary source of discomfort, without introducing the complications of artificial medical interventions.
How Reduced Intake Promotes Patient Comfort
Reducing fluid and food intake prevents several uncomfortable symptoms in a dying person. As the kidneys and circulatory system fail, the body loses its ability to process and eliminate excess fluid. Introducing large volumes of fluid via IVs or feeding tubes can cause fluid overload and distressing symptoms.
Fluid overload can manifest as peripheral edema (swelling in the hands and feet) or pulmonary edema, where fluid accumulates in the lungs, causing congestion and severe shortness of breath. Avoiding artificial hydration reduces the risk of these complications, prioritizing the patient’s ability to breathe easily.
Avoiding forced food intake also prevents aspiration pneumonia, which occurs when food is inhaled into the lungs due to impaired swallowing reflexes. Reduced intake lessens the volume of waste produced, minimizing the need for frequent repositioning for toileting and decreasing the risk of nausea, vomiting, and diarrhea. Hospice teams focus heavily on excellent oral care, using moist sponges and lip balm to manage the sensation of thirst without systemic hydration.
The Role of Patient and Family Decision-Making
The decision to forgo artificial hydration and nutrition is rarely made unilaterally. This choice is guided by the patient’s previously expressed wishes, often documented in an advanced directive, such as a Living Will. These legal documents specify preferences regarding medical interventions, including ANH, when the individual cannot communicate.
If the patient is unable to participate, the healthcare proxy or Power of Attorney makes the decision based on substituted judgment, honoring what the patient would have chosen. Hospice teams provide comprehensive education to the patient and family, explaining the medical rationale and the comfort benefits of reducing intake. Open communication ensures the decision aligns with the overall goals of comfort and dignity. The hospice team supports the patient’s autonomy, ensuring the end-of-life care plan reflects their personal values and preferences.