Nutrients and fluids at the end of life: Physiological and ethical guideposts over uncertain terrain (pp. 265-282)
Authors: Lee A Bricker, Barry M Kinzbrunner, Kevin J Kavanaugh, and Donald E Greydanus
Abstract: Controversy over how and whether to provide nutrition and fluid support to patients at the end of life has raged across medical, legal, ethical and religious disciplines for years, largely unaided by agreed-upon scientifically established guidelines. Many terminally ill patients are anorexic and may wish to be spared food and liquid beyond their own limited preferences, raising questions, particularly on the part of family members, as to whether, when, and how to initiate artificial feeding and administration of fluids. This paper outlines common techniques and consequences of such support. It reviews some unique biochemical features of terminal illness, including the role of inflammatory cytokines in anorexia and cachexia, and proposes tentative physiological mechanisms as to how those processes in terminal phases of diseases, cancer-associated and others, may lead to adverse effects when artificial nutrition and fluids are employed. In managing a patient nearing death, the ethical physician, acting within the constraints of known physiology, should provide the patient, caregivers, and surrogate decision makers with the best available information regarding the benefits and burdens of such artificial support. The properly informed patientís decisions should be held as first priority when possible.