Facing a Hard Choice: Saying Yes or No to Artificial Nutrition & Hydration (ANH)

It can be difficult to have a conversation with your family about whether or not an elderly family member should be put on artificial nutrition and hydration (ANH) when he or she is nearing the end of life. However, it’s usually much easier to make that decision while the elderly person can still give informed consent and include their wishes in an advanced health directive. Providers need to be aware of the goals of all concerned and families must be informed as to whether ANH can realistically achieve these goals.
Have the Conversation
A few months before my 97-year-old father died, he and I sat down with a kind doctor who explained the risks and benefits of ANH. Dad was able to state unequivocally that he did not want ANH or any other extreme measures, including hospitalization, if he developed a life-threatening illness. We made contact with a hospice service that sprang into action immediately when he developed aspirational pneumonia. Within three days, he died peacefully in his own bed.
For some families the choice is not so easy. Each situation is different. Some people consider it an ethical matter and feel they must prolong life as long as possible. Others worry that their loved one will suffer needlessly without nourishment or fluids. Your spiritual advisor and doctor can help you make the decision that is right for the patient and family, including informing you of the risks and benefits of ANH and alternative treatments and interventions.
Possible Side-Effects of ANH
When a person has a curable illness and can’t swallow, ANH can help him or her recover. For a patient who has a life-threatening illness and is dying, ANH may not be beneficial. These patients may live a little longer with ANH, but not always. In either case, there are side-effects to consider.

  • Requires the patient to undergo uncomfortable, and at times painful, procedures when the treatment is started
  • Serious infections,
  • Nausea, vomiting and diarrhea
  • Skin breakdown due to constant moisture from urine and/or feces on the skin
  • Electrolyte and mineral imbalance

Dehydration and Poor Nutrition Common in the Elderly
According to the Journal of the American Geriatrics Society, the elderly are at a high risk for dehydration due to a decreased sense of thirst, fear of being incontinent, swallowing difficulties and gastrointestinal disorders, etc. See our blog on Strategies to Prevent Dehydration in the Elderly. They also often suffer from a loss of appetite or for other reasons don’t want to eat, putting them at risk for nutritional deficiencies. See our blog on Why Seniors Don’t Want to Eat and What you Can Do About it.
 Alternatives to ANH
ANH does not prevents aspiration pneumonia in a person who has difficulty swallowing; it may actually increase episodes. There also is evidence that ANH actually causes more harm than good in people with advanced Alzheimer’s disease. In both cases, careful feeding by hand is a better alternative.
Dehydration in dying patients is not painful. Increased sleepiness and less mental alertness occur without other signs of distress. The majority don’t experience thirst, and any initial thirst that occurs can be alleviated by small amounts of fluids or ice chips given by mouth, and by lubricating the lips.
When a person with advanced age or a terminal illness stops eating, usually it is because they are no longer able to process food and fluids. Forcing this person to eat, or starting artificial nutrition and hydration usually does not help the person to live longer or feel better. For those who experience hunger, small amounts of food and fluids, offered whenever the person wants, will relieve the hunger.
We often think of giving food and water as a form of comforting or nurturing. For a dying person, more helpful forms of nurturing can be expressed by gentle presence, touch, talking with the person (regardless of his/her ability to respond), keeping the person’s lips and mouth moist, gently massaging the skin using lubricants, praying with the person, or playing favorite music.
Call Dakota Home Care for assistance in managing the care of a loved one who is facing this difficult choice: 701.663.5373.
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