Refusal of artificial feeding as a natural part of dying

Judith Ahronheim, MD

Adapted extract from an article entitled ‘Artificial feeding: what’s involved?’ by Judith Ahronheim, MD, Associate Professor of Geriatrics and Medicine at Mt. Sinai Medical School, New York City. This article appeared in the Choice in Dying newsletter for Summer 1984. Choice in Dying is an American not-for-profit organisation which issues Advance Directives for each state, and various other publications such as DDying at Home (US$5) which looks at the legal and medical implications for the family of a person preferring to die at home rather than in hospital.

Although potentially valuable and life saving in many situations, artificial nutrition and hydration do not provide comfort care for dying patients. Experience and available scientific evidence have shown that death without artificial nutrition or hydration is natural and pain free. Most dying patients feel little hunger; some stop eating completely and drink less and less. When patients experience severe symptoms, such as pain or nausea, these are due to the disease itself, not the avoidance of food and water. If a patient experiences thirst, it is usually controlled by sips of water, ice chips, or lubricants for the mouth. Patients with brain disease who avoid nutrition and hydration quickly slip into a coma, a sleep-like state that is inherently free of pain.

In contrast, tube feeding prolongs and often worsens the dying process. Terminally ill patients can sometimes benefit temporarily from artificial feeding. But to assume that it must always be provided fails to consider the patients’ needs. Because we ourselves tend to see the provision of food and water as intrinsic to caring, we sometimes feel uncomfortable about withholding artificial nutrition and hydration. When we are entrusted with making decisions for the dying, we need to broaden our understanding of caring so that we address the patient’s ccomfort, not our own.

The possible side effects of tube feeding

Tube feeding differs from ordinary feeding in important ways. Technical skill is required to insert the tube and make decisions about what type of feed is given and how much, but even with skilled care, there can be side effects.

Implantation through the abdominal wall can cause surgical complications and skin infection. Feeding tubes can traumatise and erode the lining of the nasal passage, oesophagus, stomach or intestine. Most patients fed by tube have brain disease and are unable to report that they feel full or unwell, so abdominal bloating, cramps, or diarrhoea may occur. Regurgitation is common, and the feed may be inhaled into the lungs. Confused patients can also become anxious over the tube’s presence and try to pull it out. This can lead to the imposition of mechanical restraints – tying the arms down – which heightens their distress. Intravenous lines can be uncomfortable, especially if fluid leaks into the skin or the skin becomes inflamed or infected. Intravenous fluids must be given with extra care to frail patients in order to avoid fluid overload and serious breathing difficulties.

Choice In Dying, Inc., 200 Varick Street, New York, NY 10014-4810 (tel 212 366 5540; fax 212 366 5337).