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  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Site Index
    Back to Module 11: Withholding/Withdrawing Treatment
    Three Applications

    Example 1: Artificial Feeding and Hydration Example 2: Ventilator Withdrawal
    Example 3: Cardiopulmonary Resuscitation (CPR)

    Example 1: Artificial Feeding and Hydration

    A Brief Overview

    • Difficult to discuss
    • Food and water are symbols of caring

    Physicians frequently perceive the discussion about whether or not to use or continue artificial feeding and/or hydration to be difficult. Successful approaches are not customarily demonstrated during medical training. Food and water are widely held symbols of caring, so withholding of artificial nutrition and hydration may be easily misperceived as neglect by the patient, family, or other caregivers (professional and volunteer). The following are key points, in addition to the general approaches described above:


    Review Goals of Care

    • Establish overall goals of care
      • Talk about the general medical condition

      • Evaluate the ability of artificial hydration and nutrition to help achieve those goals, before discussing specifics

      • For example, if the patient has advanced cancer, establish an understanding of the overall situation

        • What is the expected course of the cancer?
        • Is anything reversible?
        • How will artificial hydration and nutrition contribute to the overall goals of care, or improve the situation?
    • Will artificial feeding and hydration help achieve these goals
    • If patient and family hope to see improved energy, weight, and strength, then artificial fluid and nutrition may not help accomplish those goals
    • Help the patient and family to understand the goals for which artificial nutrition and hydration would be appropriate


    Address Misperceptions

    During the discussion, listen for misperceptions expressed by patients and families. They may believe that lack of appetite and diminished oral intake of fluids is causing the patient’s level of disability. Most then make the assumption that, "If only the patient got more fluids and nutrition, he or she would be stronger." Use clear, simple language to help them focus on the true causes of the situation: e.g., "The cancer is taking all of your strength" or, "The fact that your heart is so weak is what is causing you to lose your appetite and feel so fatigued."

    • Cause of poor appetite and fatigue
    • Relief of dry mouth
      • If the patient is close to dying, make sure the family knows that a dry mouth may not improve with intravenous fluids

      • Relief is much more likely with attention to mouth care and oral lubricants
    • Delirium
      • Delirium may be related to dehydration, so a clinical trial of intravenous fluids may be warranted

      • However, before starting, ensure that everyone is aware that there are other causes of delirium that may not respond to fluids

      • Also, there is a risk that fluids will only increase other physical symptoms (e.g., edema, breathlessness) without relieving the delirium
    • Urine output
      • Urine output normally declines in the patient who is dying; it is not just an indicator of hydration

      • Urine output in the range of 300 to 500 mL/day is adequate

      • The large volumes (2 to 3 liters/day) in hospitalized patients are usually the result of intravenous infusions and do not reflect normal output with oral hydration

      • Both high-volume infusions and excessive urination may be a source of discomfort to the patient


    Help Family with Their Need to Give Care

    • Identify their feelings and emotional needs
      • Identify the emotional need that providing food and water meets

      • Don’t just address issues of artificial hydration and nutrition
    • Identify other ways to demonstrate caring
      • Teach the skills they need


    A Part of Normal Dying

    • Loss of appetite
      • Loss of appetite and diminished fluid intake are a part of normal dying

      • Trying to counteract natural trends may lead to more discomfort for the family without affecting outcome.
    • Decreased oral fluid intake
    • Artificial food/fluids may make situation worse
      • Breathlessness
      • Edema
      • Ascites
      • Nausea/vomiting


    Concerns of Patients and Families

    • Suffering from thirst or hunger if the patient is not taking any fluids or nutrition?
    • Help the patient and caregiving family to understand that dehydration is a natural part of the dying process
    • It does not affect the dying patient in the same way as a healthy person who feels thirsty on a hot day or becomes dizzy on standing
    • Let family members know that if the patient is not hungry, artificial fluids and hydration will not help him or her feel better
    • Badgering the patient to eat or drink more will only increase tensions and may cause the patient to become angry, depressed, or withdrawn, if he or she cannot comply
    • Make sure that family members and caregivers know that artificial fluids and nutrition may make edema, ascites, pulmonary and other secretions, and dyspnea worse, particularly if there is significant hypoalbuminemia
    • Ensure that family and caregivers know that a state of dehydration in a patient who is bed-bound and imminently dying may have some benefits
      • Pulmonary secretions, vomiting, and urinary incontinence may be less

      • Dehydration may actually stimulate the production of endorphins and other anaesthetic compounds that help to contribute to a peaceful, comfortable death for many patients
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