Terminal Dehydration: A Solution for Caregivers

Death is inevitable. Does suffering have to be? Given the plethora of ways that death may come, it is reasonable to assume that most, until they are faced with it, have not given much thought to their options when it comes to end-of-life care. As health care providers in a not-for-profit hospital based hospice setting, it is imperative that you understand the options available to patients in these situations so that you can help them integrate their experiences and make their final decisions about how they want to spend the rest of their lives. When the patient has made the decision to forgo curative treatments and only accept palliative, end-of-life comfort measures, they should be able to make the decision with the full support of their care team. Terminal dehydration is one option open to patients who are not able to handle the suffering that they are experiencing as a result of their illness or the natural aging process. When a patient chooses this course of action, the health care team should follow current recommendations, supporting the patient thoroughly.

What is Terminal Dehydration?

Terminal dehydration is the voluntary refusal of fluids and food for the purpose of hastening death. This includes the refusal of artificial nutrition and hydration. According to Franklin G. Miller and Diane E. Meier, “evidence indicates that death by terminal hydration is not painful and that attendant physical discomfort can be adequately alleviated (1998).” Pursuing this course of action may be preferable to some patients with terminal illnesses whose pain and suffering cannot be alleviated by palliative cares and therapies. It is different from physician-assisted suicide because it is under the control of the patient, and physician intervention is not necessary. It has the advantage of taking anywhere from a few days to weeks, so that the patient has an opportunity to change their mind (Miller, 1998). Those who are determined will succeed, and it is not a “quick fix” like physician-assisted suicide. Remember that healthcare providers are morally obligated to honor the patient’s refusal of all and any medical treatments, including food and water, orally or otherwise.

When a patient requests more information about or help with terminal dehydration.

Involved health care professionals should not

Initiate conversation about terminal dehydration with the patient or their family.

Make assumptions about the patient’s mental health without the involvement of the interdisciplinary team, including a clinical and licensed psychiatrist.

Force upon the competent patient cares and therapies which they refuse.

Under any circumstance knowingly hasten the patient’s death by artificial means.

Involved health care professionals should

Maintain decorum and professionalism.

Comply with requests to discontinue any therapies they refuse.

Make every effort to make the patient comfortable.

Involve an interdisciplinary team in all cases and evaluate therapies.

Set up psychiatric, informed consent, and family counseling (Quill 2000).

Comply with requests for food and fluids and reevaluate the plan of care if such requests continue (Miller, 1998).

Admit the patient into the hospice program as they grow weaker, whether or not they are otherwise near death.

Involve an interdisciplinary team in all cases and evaluate therapies.

A team of representatives from different disciplines should be consulted and kept involved in the patient’s cares. The therapies available to the patient from disciplines such as “pharmacology, psychology, interpersonal, spiritual, and pain management” should be evaluated for their effectiveness in relieving suffering and symptoms. The extent to which these alternative therapies have been tried should also be evaluated (Kirk 2010). Any therapy that is prolonging life without improving quality of life should be discontinued. This team will also evaluate the competency of understanding the patient has so that true informed consent can take place.

Counseling

All areas of counseling should be conducted by a trained and licensed psychiatrist who has experience and training in end-of-life and hospice situations. This should include counseling to screen for depression, informed consent counseling, and family counseling (Quill 2000) (Berger 2010).

Admittance into the hospice program

If the patient is not already admitted into the hospice organization, then the interdisciplinary team will assess whither this needs to happen now or in the near future. This decision might depend on the patient’s prognosis and tolerance to suffering, as well as family willingness to help with end of life cares. These decisions should be made on a case to case basis, though generally patients should have a prognosis of 6 months or less. If a patient who is not otherwise near death, they should be admitted into the hospice program as they grow weaker.

Cares for those undergoing terminal dehydration

Every care must be evaluated for its effectiveness in relieving symptoms and suffering, and whether or not it will extend life. Cares such as talk therapy and palliative sedation, for example, could go a long way in relieving physical and existential or psychological suffering. Therapies such as “…artificial nutrition, hydration , antibiotics, mechanical ventilation, and other life-prolonging interventions are not instituted, and arc usually withdrawn if they are already in place (Quill 2000).” Doing otherwise would be counterproductive and generally a waste of time and resources if the patient is serious about terminal dehydration as a course of action.

Ethical Considerations

Terminal dehydration is controversial because it blurs the lines between end-of-life cares and physician-assisted suicide. Although terminal dehydration is a measure that does not necessarily require the involvement of a physician, palliative sedation is a measure which can greatly enhance a patient’s comfort and relieve suffering. Many caregivers are morally opposed to any course of action that could hasten death and claim that support of this course of action violates the purpose of health care providers to not cause harm to the patient. In response, we affirm that there is

“A stronger moral basis exists for voluntary death by terminal dehydration than by physician-assisted suicide. The right to forgo food and water, whether by mouth or by artificial means, derives from the fundamental right of competent patients to refuse medical treatment and to be free of unwanted bodily intrusion (Miller 1998).”

With this in mind, terminal dehydration is not to be supported by the heath care team in cases where the patient is not terminally ill and is only going through existential suffering. Such suffering is dynamic and may increase or decrease from day to day. These patients whose suffering is non-physical in origin should have their primary care turned over to a licensed psychiatrist.

Continuing Education

Each member of the team involved in palliative care must stay current with education on the subject, as instructed by their supervisor or team educator. According to the National Hospice and Palliative Care Organization, “this education should address symptom assessment and management as well as the ethical considerations related to the use of palliative sedation. Education must also address family-centered care (Kirk 2010).” In response to this education and emerging information, the process to handle terminal dehydration cases will change and be improved upon.

References

Berger, J. T. (2010) Rethinking guidelines for the use of palliative sedation. Hastings Center Report, 40(3), 32-38.

Kirk, T. W., & Mahon, M. M., (2010). National hospice and palliative care organization (NHPCO) position statement and commentary on the use of palliative sedation in imminently dying terminally ill patients. Journal of Pain and Symptom Management, 39(5), 914.

Miller, F. G., & Meier, D. E. (1998). Voluntary death: A comparison of terminal dehydration and physician-assisted suicide. Annal of Internal Medicine, 128(7). 559-562.

Quill, T. E., & Byrock, I. R. (2000). Responding to intractable terminal suffering: The role of terminal sedation and voluntary refusal of food and fluids. Annal of Internal Medicine, 132(5) 408-414.