Hospice of Washington's Philosophy and Policy Regarding Medical Intervention to Supply Fluids and Nutrition

Hospice of Washington is dedicated to the service of dying persons, their families, and friends. Our principal mission is to enhance the lives of those patients admitted to hospice care. Although most of our patients will die in our care, the majority within a few weeks, we will not undertake to hasten that death. In ameliorating suffering, however, some plans of care must be adopted that make it likely that the patient's death will come earlier than it would with some alternative plan of care. This is warranted if the plan chosen is expected to provide a more comfortable and appropriate dying than would the alternative, and if this assessment reflects the views of the responsible caregivers and patient, or those family and friends who can appropriately speak as surrogates for the patient who is unable to speak on his or her behalf.

Other than the refusal to deliberately end a patient's life, and our commitment to enhance life whenever possible, we have no policy which requires or bars any particular interventions. The care plan for each patient is developed and adjusted in collaboration with the patient, the patient's family and friends, and the hospice staff, and is expected to reflect the individual patient's goals, values, and capabilities, and the professional expertise and personal commitment of the hospice staff.

Like every other potential treatment, the artificial provision of fluids and nutrition is pursued whenever doing so is expected to benefit the patient (or, at least, to benefit the patient's loved ones and not to harm the patient) and is in accord with the patient's wishes or those of the appropriate surrogate(s) for the patient. In judging this, the likely benefits and burdens of available modalities must be assessed and weighed. A decision to institute or continue artificial procedures for supplying fluids and nutrition does not create an obligation to continue them if later assessment indicates that withdrawing them has become beneficial.

In making these decisions, it is worthwhile to bear in mind the following observations from our experience with dying persons.

1. 1. Persons near death ordinarily do not tolerate substantial volumes of enteral feedings.

2. 2. Dying persons given the volumes of fluid ordinarily given in texts as normal replacement requirements commonly get clinical signs of overload, including pulmonary edema, which is particularly distressing.

3. 3. Despite substantial physiological deficits, hospice patients almost never report feeling hunger or thirst, though they may well have dry mouth and lips that are easily remedied with lubricants and ice chips.

4. 4. Hospice patients and their loved ones often have an especially harsh distaste for the presence of, and the minor annoyances attendant upon, the tubes and associated equipment needed for the artificial provision of fluids and nutrition.

5. 5. Patients who fear aspiration, hunger, or thirst may be relieved to have an alternative method of ingestion. Further benefits to the patient and his or her loved ones can sometimes be achieved by giving them control of the content, amount, and timing of feedings.

6. 6. Apart from the correction of physiological abnormalities, providing food and drink is often of symbolic importance to the patient, loved ones, and caregivers, as a sign of compassion, loyalty, steadfastness, and concern. Even when it has been decided that the intervention necessary to correct physiological deficits should be forgone, it may be important to institute or to continue to offer sips of juice, spoon feedings, low-volume tube-feedings, or some alternative, so as to honor and protect these sensitivities.