Artificial hydration refers to the medical practice of introducing nutritional fluids and water into a patient’s body by means of tubes, catheters or needles. The issue of artificial hydration in the context of patients who are terminally ill is an emotional one for many patients and families because giving or withdrawing fluids plays can mean the difference between life or death (Ferrell and Coyle, 2006). Caregivers get worried when patients are unable to take fluids on their own and know they are on the route to dying. The decision to give artificial fluids in such cases is easy to take, but the decision to stop is generally a hard one as it involves the emotions of various parties concerned. Ethical, moral and religious viewpoints do not distinguish between withholding and withdrawing a treatment such as artificial hydration (Ferrell and Coyle, 2006). Most patients and families are aware that without artificial hydration in the case of terminally ill patients, death may happen quickly. The decision to give to stop artificial hydration should be based on careful individual assessment.
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Thesis: The uniqueness of the individual situation, the goals of care and the comfort of the patient must be considered while deciding on the issue of artificial hydration.
According to Zerwekh (1983), the following factors may be considered while evaluating the decision to initiate or continue artificial hydration: the probable increase in the patient’s well being as a result of hydration, identification of symptoms that would be relieved, side effects, effect on consciousness of the patient, the patient’s goals and personal wishes in the context of end of life care, probability of prolonging the patient’s life and effect of artificial hydration on the family members and caregivers (Ferrell and Coyle, 2006). Regarding hydration, some researchers argue that patients may sometimes benefit from dehydration because dehydration allows an individual to slip into a coma (Lacey, 2006), whereas artificial hydration may prolong the dying process, cause painful swelling, and worsen other symptoms associated with hydration (Huang & Ahronheim, 2000). Dunlop and Ellershaw have found that intravenous fluids in the terminally ill patients can cause pulmonary edema, acites and peripheral edema and moreover, there is evidence that patients who die without hydration die more peacefully than patients who are hydrated (Finegan et al, 2007). Thus from the patient’s point of view, artificial hydration may mean endless suffering.
Religion also plays a role in the decision for or against artificial hydration. Studies show that Christian patients and families often demand aggressive treatment and fluids at the end of life as they are positive that they would receive help from God in the form of miracles (Brett and Jersild, 2003). Relatives of Jewish patients demand that life is maintained as long as possible and they find that artificial hydration is required even in the case of patients in coma. Islam regards life as sacred and hence anything that is seen to hasten death will be resisted.
In 2004, the General Medical Council stated that “life has a natural end” and this should be allowed. Kevin D. O’Rourke (2000) says that artificial provision of hydration and nutrition is a medical treatment rather than a nursing procedure and good medical practice entails intiating hydration and nutrition when the patient’s prognosis is uncertain but allows for termination if the patient’s condition is hopeless and the patient’s family has consented to withdrawal. O’Rourke suggests that decisions regarding artificial hydration may be taken as per principles governing other forms of medical treatment and taken on the basis of “the patient’s diagnosis and prognosis, the prospective benefits and burdens of the treatment and the stated preferences of the patient and family” (O’Rourke, 2000, p. 118). He further strongly concludes that when medical treatment is futile and does not contribute to a patient’s well being, there is no ethical obligation to provide it and this includes artificial hydration.
Thus there are different perspectives on the issue of artificial hydration and the decision needs to be taken in consideration of viewpoints of the patient, his close family and caregivers and the medical fraternity.
Brett, Allan and Jersild, P. Inappropriate treatment near the end of life: conflict between religious convictions and clinical judgment. Arch Intern Med. 2003. Vol. 163, p. 1645-9.
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Dunlop R. J. and Ellershaw, J. E. On withholding nutrition and hydration in the terminally ill: has palliative medicine gone too far? J. Med. Ethics. 1995. Volume 21. p. 141
Ferrell, Betty and Coyle, Nessa (2006). Textbook of Palliative Nursing. Oxford University Press.
Finegan, C. Wesley; Rogernson, Elizabeth and McGurk, Angela (2007). Care of the Cancer Patient. Radcliffe Publishing.
Huang, Z. B., & Ahronheim, J. C. (2000). Nutrition and hydration in terminally ill patients: An update. Clinics in Geriatric Medicine, Vol. 16, p. 313-325.
Lacey, Debra. End-of-Life Decision Making for Nursing Home Residents with Dementia: A Survey of Nursing Home Social Services Staff. Health and Social Work, 2006. Vol. 31.
O’Rourke, D. Kevin. A Primer for Health Care Ethics: Essays for a Pluralistic Society. Georgetown University Press. 2000.
Zerwekh, C. Joyce. The Dehydration Question. Nursing, Jan. 1983, p. 47-51