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Subject:  Re: Unexpected windfall Date:  6/24/2007  12:10 PM
Author:  xraymd Number:  95015 of 127642

Greetings, Wendy and Phil, this is how I regularly witness the end of life once someone has become unable to eat or drink - either they are largely somnolent and sleeping for great stretches of time or to take in nutrition and fluids actually makes them feel worse (nausea in a kidney failure patient because the kidneys can no longer filter the toxins that the body creates as byproducts of processing nutrients).

In a patient who is awake and able to eat and drink, by all means is this continued and NOT withheld! When nutrition and fluids are withheld is when a patient has ALREADY become unable to take them in independently (someone who has become dependent on tube feeds, for instance, who has been rendered unable to swallow due to stroke, esophageal stricture or bowel obstruction likely from cancer, unremitting nausea from numerous processes) and who is clearly made less comfortable by being given such nutrition. Why near the end it becomes adverse to continue trying to feed and hydrate is that when the organs begin to shut down, the body struggles to metabolize the intake with much lower reserves and this puts a strain on the processes that are already diminished. The patients refusal of food and water is instinctive.

In Hospice, nutrition and hydration are offered but not foisted. The patient guides the staff by ceasing to seek food over time. Mouth swabs and ice chips are always available to moisten but the sensation of raging hunger or thirst appears to just dissipate. Unlike in health! So one of the major misconceptions about standing guard when someone is dying is that somehow they must be hungry or thirsty and must be fed and hydrated at all costs. I have seen patients whose families insisted on this literally yank out their IV or their feeding tube with some of their last remaining strength. So I have learned to respect that, when the time comes, the patient will choose not to continue with nutrition or hydration because they simply feel better without it. Sometimes that choice is made alertly and sometimes it is when the patient has begun to sleep for longer and longer stretches (dehydration particularly confers somnolence as the kidneys invariably shut down) and this ends up being among the more calm and tranquil ways to pass.

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