Nutrition And Hydration

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Nutrition And Hydration Essay

Development in clinical medicine has made it possible for medical practitioners and care givers to supply nutrition and hydration to patients whose medical conditions do not allow normal eating processes.1 In most cases, these life-supporting substances are given through a host of methods, including but not limited to intravenous tubes, nasogastric tubes, hyperalimentation and surgical gastrostomy tubes.Nutrition And Hydration Essay


This procedural provision of food to patients has, however, been viewed by others as a form of treatment, being compared to a respirator, used to allow breathing in patients. On the other hand, this form of feeding is perceived as a form of basic care, which should not be denied patients in need of it.2

Numerous cases have been decided, involving this matter with no consensus being reached, regarding the implication of tube-feeding in the health of a patient. 3

This essay discusses the question of whether nutrition and hydration should be withheld or withdrawn from patients or not. Even though the discussion is two-sided, this analysis supports the fact that nutrition and hydration should be withheld or withdrawn under medical and ethical circumstances. In particular, the arguments presented in this essay will focus on laws and ethical issues in Australia.Nutrition And Hydration Essay

Reluctance to withhold food
In cases where a person cannot eat because of his or her medical condition, a decision is usually made about providing food through the available feeding methods for such patients. However, emphasis for this decision is based on medical needs of the patient, challenges and benefits of carrying out the process.4

While physicians find no difficulty in initiating this mode of feeding, it is evident that the main challenge arises when they are supposed to withhold or withdraw nutrition and hydration towards the end of life. Although most physicians are qualified in making other medical-ethical decisions of terminating treatment or life, forgoing feeding is still a problematic issue.

Whilst most decisions concerning medical issues are supposed to be weighed thoroughly, there is a notion that decisions to withdraw or withheld nutrition and hydration in patients are never based on advantages and disadvantages of the process. In some cases, physicians are usually reluctant to terminate feeding even when the demerits of the process evidently outweigh the benefits.Nutrition And Hydration Essay
Additionally, it has been observed that some medical practitioners become biased on the kind of treatment to be forgone when a patient is in a critical situation and is not willing to withdraw or withhold feeding. It is essential to note that this reluctance persists although medical organizations do recognize withdrawing or withholding nutrition and hydration from patients under proper ethical and medical conditions.

By considering this kind of feeding as a form of life-prolonging treatment, similar principles of terminating treatment have to be observed within the confines of ethical and medical implications.6 In fact, there are several professional organizations around the world, which have gone ahead to list nutrition and hydration under life-sustaining treatment, while others do criminalize the withdrawing or withholding of feeding.

Moreover, medically provided food and water is viewed a basic human need, which patients in all situations are entitled to. As a result, physicians may develop the fear of subjecting patients to unfair pain or denying them their right to feed and live.Nutrition And Hydration Essay

While addressing this issue, it is extremely important to appreciate the fact that it can be viewed from a legal, ethical and religious point of view. This further implies that different countries or societies may hold varying views concerning the issue, due to the diverse nature of human ideologies.8

The following segment narrows down to Australia and how it ethically and legally views the issue of withdrawing or withholding nutrition and hydration from patients.

Nutrition and Hydration in Australia
The question of withdrawing or withholding feeding in certain circumstances has drawn international attention, from the United Kingdom, U.S., Canada and Australia among other countries around the world.

For instance, Australia has witnessed court rulings revolving around the issue of terminating feeding in incompetent patients and its implications. The most mentioned case is Gardner; re BWV in which the Victorian Supreme Court issued a landmark verdict that was to influence the society’s perception towards assisted-feeding in hospitals.9

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Legal provisions in Australia
Currently, any life-supporting systems in Australia are partly covered under the country’s common law and statutes from various territories. For example, the first law was the Natural Death Act of 1983, in South Australia, Natural Death Act (NT) 1989, Natural Death Regulations (NT) 1989 and the Medical Treatment Act (Vic) 1988. Nutrition And Hydration Essay

Unlike these territorial acts, it is worth noting that the common law addresses the issue of withdrawing or withholding treatment in all states, including the Australian Capital Territory.

Australian Statutory Provisions
The Natural Death Act was enacted by the Australian authorities in 1983. This act gives incompetent patients the freedom to withdraw life-supporting systems under certain circumstances. Notably, it applies to patients suffering from terminal health complications; the illness is incurable, irreversible and any support system would simply prolong the patient’s dying process.10

In essence, NDA gives power to terminal patients who possess soundness of the mind to direct physicians not to expose them to extraordinary measures, which could be aimed at prolonging life. In this context, extraordinary measures are intended to prolong a patient’s life by supporting certain body operations that cannot operate independently.Nutrition And Hydration Essay

It is worth noting that patients exposed to this act have to be sound in mind when the direction is being made but incompetent when it is being executed. Additionally, this act does not recognize the withdrawal of extraordinary measures as a cause of death, especially when there is a direction to be acted upon.

The implication of this is that physicians who comply with the direction issued by patients are not held responsible for causing the death, by acting accordingly, even when the patient lacked soundness of the mind during the execution time. The Northern Territory of Australia also has similar provisions as those recognized by the South Australian Natural Death Act of 1983.

On the other hand, the Victorian statute holds a different stance, regarding the issue of withdrawing or withholding medical treatment from patients. The Medical Treatment Act was enacted in the year 1988 and has undergone a series of amendments to address the changing dynamics of ethical and professional issues in medicine, which present dilemmas for physicians.

Unlike NDA which applies only to terminally-ill patients who are incompetent, the MTA applies to terminally-ill patients together with all adult Australians under medical care.11

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Additionally, the decision by a competent patient to be denied treatment is applicable depending on the status of the patient at the time of such a refusal. This means that the decision to withdraw or withhold life-supporting systems cannot be based on the patient’s anticipation of incompetency, but the current medical status.

Under the MTA, it is essential to note that a patient is allowed to have medical agents during treatment to ensure that he or she has control over medical decisions made by physicians.Nutrition And Hydration Essay

These agents are legally permitted to request for termination of extraordinary measures as directed by the patient, while she, or he was competent, based on the health status.

As stated under common law, a person is allowed to appoint a medical agent while he or she is in a sound mode, even though the attorney’s powers are withdrawn once the donor is legally out of mind.12 Of great significance is the fact that the statutory does not give the agent or a competent patient the power to refuse palliative care.

The MTA defines palliative care as any form of treatment given by physicians for the well-being of the patient through relieve of pain without curing the illness.Nutrition And Hydration Essay

Provision of reasonable food and water is also included under this act, and it encompasses life-supporting measures like induced nutrition and hydration. In essence, MTA does not allow patients and their agents to direct physicians to withdraw or withhold artificial feeding like tube-feeding and intravenous feeding.

From an analytical point of view, it can be argued that the Medical Treatment Act protects physicians who may consider discontinuing support-treatment from being guilty of causing death of incompetent patients.

However, the same immunity is not applied to medical practitioners who may choose to withdraw or withhold “reasonable provision of food and water.” Withdrawal of life-supporting systems from incompetent patients can be supported on the basis that the result would be unreasonably disturbing and that such procedures were not meant to save life but to sustain or prolong the dying process.Nutrition And Hydration Essay


Despite the course taken by this debate, it is essential to note that the issue of withdrawing or withholding nutrition and hydration is a weighty matter that deserves serious attention and caution in debating it. Importantly, the MTA is not an exception across the globe.

In twenty American states, the law favours living wills of patients and further detaches termination of one’s life from denial of reasonable supply of food and water.

In summary, the South Australian and Northern Territory laws allow patients to direct the termination of extraordinary measures, which are usually aimed at supporting the biological functioning of the body.14 On the other hand, the Victorian law gives adult patients the right to appoint a medical agent, to give consent to the withdrawal of life-support measures from a patient who is out of his or her sound mind.

In analyzing the concept of forgoing life-support, it is paramount to consider the implication of certain words and phrases, which are commonly used by medical practitioners. For instance, ordinary and extraordinary measures are used to prolong the life of a person regardless of their status.15

However, the difference arises in their application and perceived impact in the society. Generally, ordinary measures must be applied by physicians to ensure that a healthy status of the patient is restored. On the other hand, extraordinary measures are commonly applied when handling patients with terminal-illnesses.Nutrition And Hydration Essay

As a result, extraordinary measures can be withdrawn based on the fact that their continued application would only increase the treatment burden and prolong the dying process of the patient. Based on this argument, there is confusion in deciding whether assisted nutrition and hydration is ordinary or extraordinary.

Moreover, some procedures, which are recommended by physicians, may be a composition of medical support and comfort. For instance, Pope John Paul II is historically remembered for having considered assisted nutrition as a normal care, contrary to the view that the practice is a medical act.16

Although this can be argued from various view points, it suffices to mention that assisted nutrition and hydration procedures involve a lot of medical and professional skills, including surgery. This is commonly used by those who argue against assisted-feeding being considered as a normal act.

Nevertheless, the material or food which, is usually given to the patients is natural, thus coupling with idea that the process is a normal act that promotes life. In fact, it would be better to argue that assisted nutrition and hydration encompass natural and medical aspects of supporting life.Nutrition And Hydration Essay

When one talks about withdrawing or withholding nutrition and hydration, the emotional impact is what dominates the mind of most people. This is highly anticipated since one is expected to die shortly after these life-support measures are withdrawn.

The main purpose of maintaining or withdrawing nutrition and hydration depends on the benefits are likely to be witnessed against the burden of prolonging the life of such a patient.17 In general, the goal of medical care is to restore or preserve one’s health by minimizing the pain.

In other words, medical procedures like assisted-feeding are supposed to promote the optimum functioning of the body, so that a meaningful state of health is achieved. Therefore, medical processes do not necessarily cure infections or prolong life.

Unlike other medical approaches applied in prolonging life, nutrition and hydration are principally aimed at promoting physiological and psychological aspects of life. In other words, it is capable of offering spiritual and social nourishment to the body.Nutrition And Hydration Essay

This kind of care is essential in ensuring that a sick person enjoys his or her life to the fullest. They also help a person in ordering his relationship with the maker and are often bestowed in the mind of the patient, through the evaluation of living a better life.

Should burdens be considered when deciding whether to withdraw or withhold nutrition and hydration? This is a question, which has drawn a host of controversies in the society. According to religious approaches, medical burdens have the potential of affecting that which is supposed to be enjoyed in life by both the sick and those who are healthy. As such, nobody would prefer being exposed to any form of burdens in life.

However, for one to forgo life based on medical and other forms of burdens, it is essential for several factors to be considered.18 The commonest is the degree and impact of the burden. How excess is the burden?

There is no doubt that the determination of the excessive nature of a burden is the greatest challenge encountered in justifying burdens as a reason to withdraw or withhold nutrition and hydration from patients. Needless to say that any form of medical care is a burden and has the potential of making it difficult for one to enjoy life.

Theologians, therefore, support the need for one to acquire fortitude, which is a virtue in handling some of the burdens experienced in life. When discussing medical burdens, it is equally important to note that burdens can occur during medication and even in the future.Nutrition And Hydration Essay

For instance, maintaining a person’s health on assisted nutrition and hydration may be seen as a future problem, on the ability of family members and other caregivers to enjoy their lives normally. Under this, a decision may be considered to withdraw or withhold a life-supporting program like assisted-feeding as a way of averting future burdens.

Another aspect of human life that is essential in determining whether or not assisted feeding should be terminated is the quality of life. Even though “quality of life” is medically viewed as a measure of human functioning, it is imperative to note that human life is sacred.Nutrition And Hydration Essay

In this case, the right to live or die is commonly seen to be beyond human power but rather within the powers of the Supreme Being.19 It is on this basis that Pope John Paul II argued that assisted-feeding ought not to be terminated.

Based on the arguments presented in this discussion, it suffices to mention that withdrawing or withholding of nutrition and hydration remains a controversial issue. Nevertheless, the decision to discontinue assisted–feeding should be based on medical and ethical issues surrounding the patient.

With regard to medical factors, physicians are better placed to make this decision even though all parties involved like family members and other caregivers have to be consulted.20 Generally, medical decisions can also be guided by professional provisions. Legal statues defined by countries’ constitutions equally play a major role in helping family members and physicians to achieve a credible consensus.Nutrition And Hydration Essay

The issue of withdrawing or withholding nutrition and hydration remains contentious around the world. Nevertheless, a concise decision can only be achieved if ethical and medical aspects of the situation are considered. This is important to ensure that all parties involved are treated fairly with dignity while handling incompetent patients.

The purpose of this position statement is twofold. The first is to clarify nurses’ roles in the care of patients at the end of life, for whom decisions regarding artificial nutrition and hydration are being considered. The second is to ex plain how nurses can work with other health care professionals, patients and surrogate decision -makers who are representing the patients’ preferences. Discussions should include the risks, benefits and alternatives to various forms of nutrition and hydrati on for people who are dying. Dimensions to be discussed include comfort feedings, as well as decisions to forgo food and fluids, dietary supplements, and artificially administered nutrition and hydration.Nutrition And Hydration Essay

Nutrition and Hydration
Providing food and fluids has great meaning to many people as they often relate the provision of food and fluids to comfort and nourishment, and to the giving and preserving of life. A person’s cultural background can have great impact on their values and beliefs regarding this topic and should never be underestimated.

Providing food and fluids for as long as someone wants them and can safely take them is important. It is when the person can no longer take them that the complexities of ethical decision making arise. This can be an emotive issue for nurses as well as for families.

Some family members insist on trying to continue to feed their loved one even when it is no longer safe to do so. They may consider not doing this as a failure to care. They may also insist on parenteral fluids or a feeding tube once someone can no longer eat or drink. In these circumstances it is important to talk to them about comfort measures, such as regular mouth care, wetting the patient’s lips and using lip balms. If the family are so distressed at the thought of dehydration, a small amount of subcutaneous fluid may be an acceptable compromise.Nutrition And Hydration Essay

Other health professionals are a good resource. For example, if unsure whether someone can still safely swallow food and fluids, referral to a speech therapist would be helpful.

Some patients themselves choose to specifically request not to receive artificial nutrition or hydration at the end of their life, such as in an advance directive. Some may make this choice at the time, with or without the agreement of their relatives.

Artificial nutrition and hydration are seen by some as interventions in what should be a natural process. They may be easy to initiate but there can be difficulties when the time comes to consider their withdrawal. All discussions should take place early with families, ensuring they are aware of burdens and benefits of continuing this therapy.Nutrition And Hydration Essay

Evidence of poor practice

Many examples of poor hydration practice can be found. To cite just one, the Francis Inquiry Report into failings at Mid Staffordshire Foundation Trust concluded that: “some patients were left food and drink and offered inadequate or no assistance in consuming it, even water or the means to drink it could be hard to come by.”4

The issues raised in the Francis Inquiry Report are also fairly typical and the basic principles it proposes for improving hydration are equally telling: ensuring drinks are within reach; recording fluid balance accurately; delivering drinks in appropriate containers; and using systems to highlight patients who need assistance with hydration.Nutrition And Hydration Essay

Causes of dehydration in older adults

Dehydration in older adults can occur for a number of reasons including both physiological and environmental factors.

As ageing occurs the water content of our bodies’ and our thirst decreases. People usually rely on thirst as a signal for needing to drink, for older people this may not be an accurate indicator of the body’s fluid needs. Equally, difficulties with swallowing, mobility and sensory impairment can create barriers to maintaining adequate hydration.

However there are a number of key risk factors that are not associated with the physical ability to drink. If older people have to rely on others to supply drinks then they will probably not be drinking enough. Understanding the patient and seeing the person behind the illness will help to maintain hydration. For example recognising that:Nutrition And Hydration Essay

· Being admitted to hospital can increase disorientation and confusion particularly if there is impaired sensory perception and glasses or other aids are not to hand.

· Changes in functional mobility or poor oral health may cause difficulties in drinking.

· People who have dementia or cognitive impairment may not recognise thirst and need regular prompts that they can understand to remind them.

· Older people will often self-limit fluid intake for fear of incontinence or being a nuisance if they need help to use the lavatory bedpan or commode.

· Being lonely, afraid, or not understanding what is happening in a ward or care home can have a devastating effect on wellbeing and maintaining health.

· Knowing and offering what people like to drink will help to increase fluid intake.

Risks of dehydration

If mild dehydration is not recognised or is left uncorrected, the effects can be serious and rapid.5 Common consequences of dehydration include confusion, falls, pressure ulcers and UTIs. Dehydration can deteriorate rapidly and lead to unnecessary invasive clinical interventions and long-term outcomes that can result in the loss of independence, dignity and death.Nutrition And Hydration Essay

Chronic dehydration also develops over time, which is why detailed, structured, standardised and regular assessments are needed.

Bridging the theory to practice gap

Achieving and maintaining good hydration in healthcare is complex and can often be complicated by pre-existing long term conditions.6 Bridging the theory to practice gap remains a constant challenge, and identifying and addressing why staff do not recognise dehydration is fundamental to improving practice.Nutrition And Hydration Essay

There is clearly a role for improving training. Health and care assistants make up a significant proportion of the hands-on workforce and are often relied upon to observe and report subtle changes or concerns in patients and residents conditions. Yet clinical leads often wrongly make the assumption that training has equipped staff with an adequate theoretical and practical understanding of the importance of hydration.


It is reasonable to suggest that preventable dehydration can be regarded as a quality indictor of potential neglect and clinical leaders must do all they can to eliminate it.Nutrition And Hydration Essay

The key to raising the profile of this and making hydration a priority, is strong consistent clinical leadership underpinned with policy’s processes and guidelines to tackle preventable dehydration. With that, nurses and care staff must be supported to develop the skills to identify people who are at risk of dehydration and have the skills to then document that risk in care plans.

But we must also recognise the need for a whole systems approach to raising awareness. It is vital that more information about preventing, recognising and tackling dehydration is made available to older people, families and carers as well as healthcare professional.

Drinking water is like washing out your insides. The water will cleanse the system, fill you up, decrease your caloric load and improve the function of all your tissues.” – Kevin R. Stone –Nutrition And Hydration Essay

Lately, the trend is that nearly everyone carries a water bottle with them and sips all day long. But what does water really do for the body? Is it essential that people gulp down the prescribed “eight glasses of water a day” for optimal health and performance? A growing body of information now points to evidence that water is beneficial to your health.

Hydration with water and other water-based liquids is critical for survival and functioning of the body’s organs. Water is 60% of the total human body composition. Water is involved in the…show more content…
Many differing claims are being made about the effects of water by varying groups to use for their own purposes. Despite the strong claims being made by many parties, some individuals are still not drinking water. The excuses for not drinking water vary in such ways as; forgetting and water being inaccessible. Much of the American public, however, is uninformed about the benefits and the consequences on health of not drinking water. Also, many Americans think that any liquid qualifies as hydration. Confusion exists about what is the best liquid to drink and whether purified or higher quality is better. With the misunderstandings and unconcerned public, America is often dehydrated. Nutrition And Hydration Essay Dehydration is a problem that can be fixed easily through self-awareness and a conscious effort to drink. Many techniques exist to help facilitate and encourage water consumption: making drinking water a habit; keeping a liquid journal; and making water more appealing. Although the topic of water consumption and drinking eight glasses of water appears to be such a simple element of health, it is key to effective body function, and optimal health. Part One: Liquid Effects Liquid is continually present and functioning in our bodies. The process is like a heart beating: we do not think about the water in our bodies unless we have an insufficient amount and we feel thirsty. “According to health professionals, most people live at a level of mild dehydration,Nutrition And Hydration Essay


This assignment has been structured to demonstrate the management of nutrition and hydration in end of life care. In this learning utilising the reflective frame work of Driscoll, 2007, I will critically explore and analyse the management of end of life care in relation to management of a patient’s nutrition and hydration, identifying potential elements and their impacts upon care delivery. As a health care practitioner, my role towards end of life care involves communicating with patients and their family members on a need to know the basis of the treatment plan. Also this would include adequate handover to professionals to maintain a seamless service; as outlined in the Individual Plan of Care (Support for the Dying Person in the Last Days and Hours of Life, NHS, Wigan & Leigh Hospice 2014) which, is currently in used in my area of practice. Each outcome would be supported with current literature including local and national government documents.
I will identify and explore current and local initiatives e.g.” Individual Plan of Care”, Local Hospice, which have influenced care delivery of nutrition and hydration within the end of life and critically analysing its impact on future care delivery Nutrition And Hydration Essay

Adults with decision -ma king capacity, and surrogate decision -makers for patients who lack capacity, are in the best position to weigh the risks, benefits and burdens of nutrition and hydration at the end of life, in collaboration with the health care team. The acceptance or refu sal of clinically appropriate food and fluids, whether delivered by oral or artificial means, must be respected, provided the decision is based on accurate information and represents patient preferences. If a patient chooses food, even if that intake may c ause harm (e.g., oral feedings in people who are at risk of aspirating), the nurse is responsible for minimizing risk (i.e., using both positional changes and slow, assisted feedings). This is consistent with ANA’s values and goals of respect for autonomy, relief of suffering and expert care at the end of life (ANA, 2015; ANA, 2016).Nutrition And Hydration Essay

The decision to voluntarily stop eating and drinking, referred to here as VSED, with the intention of hastening death can be made only by those patients with decision -making c apacity, not by surrogates. Apatient’s decision regarding VSED remains binding, even if the patient subsequently loses capacity.


ANA Recommends that:

Nurses recognize those situations when nutrition and hydration can no longer benefit a patient, and adhere to clinical standards that include providing nutrition and hydration only to patients for whom it is indicated.
Patients with decision -making capacity — or their surrogates, who are relying on the patients’ preference or have knowledge of the person’s values and beliefs — will be supported in decision -making about accepting or refusing clinically appropriate nutrition and hydration at the end of life.
Nurses will have adequate and accurate information to understand patients’ cultural, ethnic, and religious beliefs and values regarding nutrition and hydration at the end of life. Patients’ views and beliefs should be respected.Nutrition And Hydration Essay
Nurses will support patients and surrogates in the decision -making process by providing accurate, precise and understandable information about risks, benefits and alternatives.
Decisions about accepting or forgoing nutrition and hydration will be honored, including those decisions about artificially delivered nutrition as well as VSED.
People with decision -making capacity have the right to stop eating and drinking as a means of hasten ing death.
Supporting Material

The fundamental principle that underlies all nursing practice is respect for the inherent dignity of all individuals. That respect is operational ized through the principles of respect for autonomy and self -determination, and manifested in dimensions of culture, values, religious or spiritual beliefs, lifestyle, social support system, sexual orientation or gender expression, and primary language. “P atients have the moral and legal right to determine what will be done with and to their own person” (ANA, 2015, p. 2).Nutrition And Hydration Essay

They have the right to accurate, complete and understandable information, and to be supported as they weigh the benefits, burdens and opt ions for their treatments, including the choice to refuse a particular treatment through the informed consent process (ANA, 2015). When the patient lacks decisional capacity, the surrogate makes decisions as the patient would, based on the patient’s previo usly expressed wishes and known values. Nurses and other caregivers should assist patients and their surrogates with decisions about accepting or forgoing nutrition and hydration through promotion of advance care planning conversations (ANA, 2015).

The pat ient’s or surrogate’s right to forgo nutrition and hydration is well -established (Nelson, 1986; Cruzan v. Director, Missouri Department of Health, 1990; In re Schiavo, 2000). Advance directives allow adults with decisional capacity to appoint surrogate dec ision -makers who can accept or refuse treatments on the patient’s behalf, should the patient lose capacity, or if the patient chooses not to participate in decision -making.Nutrition And Hydration Essay

Food and fluids are universally understood as necessary to sustain life and promot e healing. A key component of nursing care is the assessment and management of the nutritional needs of patients throughout the life span. Caring is central to the nursing profession. The rich symbolism of feeding is intimately linked to caring, compassion , nurturing and commitment. Social encounters, developmental memories and human interactions often center on events that involve food and drink.

The acts of feeding and providing fluids are closely tied to humankind’s basic beliefs regarding care (van de V athorst, 2014). As patients become sicker and approach the end of life, physiological indications change, including routes and amounts of nutrition and hydration (van de Vathorst, 2014). As people approach the end of life, their appetite, their desire for food and fluids, and their abilities to utilize them efficiently decrease (Danis, 2016).

Patients and their surrogates often look to nurses to explain diagnosis, prognosis and treatment options, including those related to nutrition. Options for nutrition a nd hydration should first consider what is physiologically possible. Based on options developed with an accurate understanding of the patient’s disease processes, the patient’s (or surrogate’s) values can be elicited. Decisions to provide food and fluid at the end of life reflect personal desires, cultural and religious beliefs, lifestyle, and support systems.Nutrition And Hydration Essay

Beliefs and attitudes about nutrition and hydration at the end of life may be rooted in religion, ethnicity and culture. A basic understanding of pat ients’ cultural, ethnic, and religious and/or spiritual beliefs and values may help support patients and families. Chaplains and other resources to assist with the understanding of pertinent cultural values should be consulted, enabling the nurse to ensure that patients’ spiritual needs are addressed by those qualified to do so (Druml et al., 2016).

In some cases, the continued provision of calories and fluid can no longer benefit a patient, and in fact, can cause harm. For example, patients nearing the en d of life have decreased caloric needs. Continuing fluid and calories based on prior intake can lead to edema, heart failure and pulmonary congestion (Groher & Groher, 2012). While the use of nasogastric or percutaneously inserted gastrostomy tubes were pr eviously considered the norm for people who lost the ability to swallow and who were at risk for aspiration; it is now known that the provision of PEG tubes and other artificial nutrition and hydration is contraindicated in patients with dementia and other diseases at the end of life (Groher & Groher, 2012; Ribera -Casado, 2015).Nutrition And Hydration Essay

The Academy of Nutrition and Dietetics (2013) has adopted the position that individuals have the right to request or refuse nutrition and hydration as medical treatment. Their posi tion asserts that when nutrition and hydration are no longer likely to benefit the patient, or when the burdens outweigh the benefits received, it is ethically appropriate to withhold or withdraw nutrition and hydration.

Certain conditions are recognized a s appropriate for cessation of artificial nutrition and hydration. These conditions include severe neurological conditions, proximate death from any pathology and irreversible total intestinal failure (Academy of Nutrition and Dietetics, 2013). Dementia, r ecognized as a terminal illness, is also associated with anorexia and cachexia. Individuals with end -stage dementia lose interest in food and often become too confused to eat, or even to be fed, or they refuse to eat.Nutrition And Hydration Essay

There is no evidence that enteral tube feeding provides any benefit for individuals with dementia in terms of survival, mortality, quality of life, physical function, skin integrity or nutritional parameters (Academy of Nutrition and Dietetics, 2013). Feeding tubes have been associated with po or outcomes for patients residing in nursing facilities (Academy of Nutrition and Dietetics, 2013).

Individuals at the end of life typically do not experience hunger or thirst; therefore, a decline in intake with associated weight loss is a natural progres sion of end -stage disease (Academy of Nutrition and Dietetics, 2013). The absence of food and fluid results in ketosis and releases opioids in the brain, which may produce a sense of euphoria (Academy of Nutrition and Dietetics, 2013). If a person wants to eat or drink, that should be accommodated if possible.Nutrition And Hydration Essay

Voluntary Stopping Eating and Drinking

People consider forgoing nutrition and hydration for a number of reasons. The decision to voluntarily and deliberately stop eating and drinking with the primary intention of hastening death is known as VSED (Ivanović, Büche, & Fringer, 2014; Lachman, 2015). Nurses may encounter individuals who choose to forgo food and fluid. It is beyond the scope of this position statement to address all situations of refusal to eat and drink; for example, hunger strikes.Nutrition And Hydration Essay

There is some consensus (though not universal agreement) that VSED can be an ethical and legal decision (Lachman, 2015; Pope & West, 2014). For VSED to be an informed decision, the patient must not be encumbered by depression or other factors that impede decision -making. The decision to stop eating and drinking with the intention of hastening death must be made by the patient. This decision can never be made by a surrogate; the “voluntary” dimension of this term m ust be the patient’s decision. A patient’s decision regarding VSED is binding, even if the patient subsequently loses capacity.Nutrition And Hydration Essay

Patients who are at the end of life likely have reasons for stopping nutrition and hydration, such as physiologic causes that l ead to loss of appetite and/or the inability to eat. Some people who choose VSED may not be imminently dying. Psychological, spiritual or existential suffering, as well as physical suffering, can lead to patient requests for hastened death. There is an ext ensive knowledge base to help manage the burden of most physical symptoms. Symptom control is imperative. For many patients, maintaining control is also important in their dying. Terminally ill patients who are no longer able to eat do not suffer, as long as adequate palliation of symptoms such as dry mouth is provided (Clarke et al., 2013 ). VSED at the end of life is used to hasten death, and is a reflection of autonomy and the patient’s desire for control.Nutrition And Hydration Essay


When a patient at the end of life or the patient’s surrogate has made the decision to forgo nutrition and/or hydration, the nurse continues to ensure the provision of high quality care, minimizing discomfort and promoting dignity. Meticulous oral care should be provided in addition to comfort ca re, human touch and palliative care.

Nurses are responsible for understanding the physiologic factors that frame clinical options. They should also have the knowledge and skills to address changing nutritional needs in the face of terminal illness.Nutrition And Hydration Essay

Nurses who have an informed moral objection to either the initiation or withdrawal of nutrition or hydration should communicate their objections whenever possible, to provide safe alternative nursing care for patients and avoid concerns of patient abandonment (A NA, 2015).

History/Previous Position Statements

In 1992, the ANA board of directors approved the position statement “Forgoing Nutrition and Hydration.” The statement was developed by members of the Task Force on the Nurses’ Role in End of Life Decisions. The position statement was revised in 1995 and last revised by the Congress on Nursing Practice and Economics, and approved by the ANA board of directors on March 11, 2011. Related documents include the Code of Ethics for Nurses with Interpretive Statement s (2015) and the ANA End of Life Position Statement (ANA, 2016). This position statement supersedes ANA Position Statement Forgoing Nutrition and Hydration, March 11, 2012.Nutrition And Hydration Essay

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