National Council for Palliative CareGuidelines-V1.00-0267 ...



National Council for Palliative Care Artificial Nutrition and Hydration – Summary GuidanceIn May 2007 The National Council for Palliative Care (NCPC) and the Association for Palliative Medicine published Artificial Nutrition & Hydration: Guidance in End of Life Care for Adults. This is a summary of that Guidance. It identifies some of the practical, legal and ethical issues that may arise when artificial nutrition and hydration is being considered.Artificial nutrition and hydration (ANH) has the potential to prolong life, and improve general well being. For some patients with life threatening illnesses this may be advantageous even if the underlying disease process continues to deteriorate. However, in some circumstances, giving ANH will only prolong the period of suffering. As ANH is regarded legally as a medical treatment, a clinician should only offer it if he/she thinks it is in the patient’s best interest. In addition, a clinician cannot be compelled to prescribe ANH if he/she does not believe it to be in the patient’s best interests.A blanket policy of artificial nutrition or hydration, or of no artificial nutrition or hydration, is ethically indefensible and, in the case of patients lacking capacity, prohibited under the Mental Capacity Act 92005).Artificial nutrition may prolong survival in cancer patients who have difficulty in swallowing due to a local cause e.g. obstructing tumours such as throat cancers. However, for patients with cancer cachexia or those with other conditions near to death, there is no evidence that artificial nutrition lengthens survival or improves quality of life.Artificial hydration is unlikely to influence survival for patients with advanced cancer and those with other conditions who are near to death. However, it may have a limited place on a trial basis, in treating those who have thirst who are near to death but still conscious or semi-conscious. It is important to note, however, that dry mouth for such patients is often caused by mouth breathing and medication, and this will not be helped by artificial hydration. Good mouth care is more appropriate in this situation. Also for these patients, parenteral (given via a drip) fluids have the potential to exacerbate oedema (swelling) and increase transudates (leakage) in other body spaces.Some advanced neurological conditions may compromise the ability to swallow, for example motor neurone disease. Patients with these conditions should be helped to discuss whether they wish ANH before they become unable to swallow, by being given the full information regarding risks and benefits. This should be a part of the advance care planning process for all such patients.Where swallowing is unlikely to be compromised even towards the end of life, for example for people with heart failure or advanced respiratory disease, then decisions about ANH may not arise. However the ability to swallow can be reduced for patients with any other conditions such as advanced dementia or stroke. As with cancer, the potential benefits and burdens of ANH for such patients need to be carefully assessed on an individual basis.In assessing whether to give ANH, each case needs to be individually assessed to determine what is in that person’s best interests. This applies to all forms of ANH however it is administered. Best interests decisions will include an assessment of the benefits and burdens of ANH to the patient.Is there a difference between the fitting of a feeding tube and passing of food and fluids down it?No distinction should be made, ethically or legally, between withholding feeding tube insertion in the first place, and withdrawal of feeding through the feeding tube 1,4 in other words flood and fluid passed through a feeding tube is considered medical treatment along with the insertion of the tube itself.For a patient who is already established on PEG (percutaneous endoscopic gastronomy – a feeding tube passed through the abdominal wall into the stomach) feeding it is usually appropriate to have a frank discussion with the patient if he/she has capacity as to if, or in what circumstances, feeding will be withdrawn. If the patient lacks capacity, it is necessary to try to determine what is in the patient’s best interests. This should take into account the views of those “interested” in the welfare of the patient’ (under the Mental Capacity Act) as to where the patient’s best interests lie. Thus, an appropriate agreement might be to continue feeding though the tube until death is thought to imminent in the following few days. In practice, it might prove to be in the patient’s best interests to reduce the volume of nutritional fluid being passed through the feeding tube as patients who are near to death often become unable to tolerate the same volume.It might also be agreed that fluids will be continued until the patient loses consciousness prior to death. Again, this would have to be in the patient’s best interests as there are associated risks including swelling and leakage.Do imminently dying patients suffer hunger and thirst without ANH?* High quality evidence in this area is limited and chiefly focuses on people with cancer but it is important to note that experience in palliative care suggests that most imminently dying patients due peacefully and comfortably without artificial fluids. In particular, thirst or dry mouth in people who are terminally ill may frequently be caused by medication, when artificial hydration is unlikely to help. Good mouth care and sensible prescribing is more important. However, for patients who are conscious or semi-conscious and complaining of thirst, it may be beneficial to give a trial of parenteral fluids to see if this helps. Some patients may suffer confusion and agitation as part of the dying process. Associated agitation can be treated pharmacologically as appropriate.* Appropriate palliative care includes artificial hydration where dehydration results from a potentially correctable cause (e.g. over-treatment with diuretics and sedation, recurrent vomiting, diarrhoea, hypercalcaemia, and infection).* Patients with advanced cancer often have diminished hunger as part of the cancer cachexia syndrome. Moreover, as a patient with cancer nears death, the desire for food and drink lessens. It is generally accepted that hunger is not a significant factor in patients who are imminently dying.How should mental capacity be assessed?The Mental Capacity Act contains a prescriptive test to determine whether a patient has the capacity to make a particular decision. The person must have impaired function of the mind or brain, as a result of which he must be unable to do at least one of the following:* understand the information about ANH (which must be explained in a manner which can realistically be understood, such as via an interpreter).* retain that information (even if only for a short period)* use or weigh that information* communicate the decision (by any means)It is important to note that people have the right to make decisions which may seem eccentric or unwise to other people and that this in itself is not evidence that they lack capacity. We are all entitled to make our own choices without our capacity being called into question.There may be instances in certain complex cases when determining capacity is difficult. In this situation it would be appropriate to seek a second opinion and/or refer for a psychiatric or psychological opinion. Where there is a serious dispute over whether a patient has capacity legal advice should be sought over the need to consult the court of protection.Reproduced with the kind permission of the National Council for Hospices and Specialist Palliative Care ................
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