Special challenges of withholding artificial nutrition and hydration

Despite society's increasing understanding of and comfort with end-of-life decision-making, questions about the appropriate use of artificial hydration and nutrition remain particularly challenging to both professional and family members. These decisions are complicated by misunderstandings about likely benefits and burdens, concern about patient suffering, and ambivalence regarding the moral status of feeding. Data regarding the effectiveness of tube feedings in terms of prolonging survival, improving wound healing, or preventing aspiration do not support the widespread use of this intervention in states of severe dementia or end-stage disease. Further, there is evidence that withholding feeding is not associated with suffering, so long as adequate mouth care and desired sips of water are provided. Nonetheless, surveys of both long-term care residents and family members of persons with dementia indicate that at least 30% to 50% of those queried expresses a preference for artificial feeding if they (or their relative) could not eat. Given the absence of conclusive data about the efficacy of feeding and the apparent plurality of values surrounding the provision of this intervention, health professional must focus efforts on using a careful, deliberate approach to decision-making that involves all interested parties and make use of valid empirical data.