The difficult subject of artificial hydration for patients at the end of life is addressed by Drs Lunny and Tiernan, in an editorial in the latest Irish Medical Journal.
The authors say that communication with family and consideration of existing patient care orders should be reflected in providing end of life care, including the giving or withholding of hydration.
While the question of assisted nutrition has been well documented, “the question of artificial hydration is more controversial and has received increased attention in recent years, both from an ethical and clinical perspective,” the authors say.
They discuss the ethical debate, which centres on whether providing fluids by an artificial route constitutes basic care, to which the patient would be automatically entitled, or a medical intervention, which according to the circumstances may or may not be justified.
In 2011 the Irish Association for Palliative Care (IAPC) published a Position Paper on Artificial Hydration in Terminally Ill patients. In this, artificial hydration is considered to be a medical intervention and not part of normal comfort care. Its withdrawal or non -commencement may therefore be justified if it is “excessively burdensome or futile”. It states that consideration much be given to the unique circumstances of each patient. The UK National Council for Palliative Care provides similar guidelines.
The Law Reform Commission of Ireland, it is also noted, has published on advanced care directives and distinguishes between life-sustaining and basic treatment for the patient. Under those terms, for the patient who is clearly dying, artificial hydration qualifies as life sustaining treatment rather than basic care.
The editorial reflects on the legal, scientific and ethical circumstances, along with preferential familial and medical consensus that must be considered in making the decision on whether to give or withhold fluids at the end of life.