Nutrition and fluids in the final phase of life: what makes sense?

When eating and drinking decrease

One of the most common concerns voiced by relatives is: "My father is barely eating anything — is he starving?" Or: "My mother hardly drinks anything anymore — is she dying of thirst?" These questions are understandable, because eating and drinking stand for care, comfort and life itself in everyday experience. In the final phase of life, however, the body changes profoundly, and with it its need for food and fluids.

Modern palliative medicine assumes that a marked reduction in hunger and thirst is part of the natural dying process. The body gradually shuts down metabolic processes, and the need for energy and fluids declines. What is vital in healthy life can even become a burden at the end of life.

Nutrition in the dying phase: what happens in the body?

In the final days or weeks of life, metabolism changes fundamentally:

• Energy requirements decrease significantly.
• Digestion and absorption of nutrients work only to a limited extent.
• The sensation of hunger and thirst diminishes or disappears entirely.
• Weakness, tiredness and increased sleeping are typical.

These changes are not a sign that "something is being done wrong", but rather an expression of a physical process that cannot be halted by supplying calories. Studies in palliative medicine show that artificial nutrition in this phase generally does not prolong life or improve quality of life.

Artificial nutrition in palliative care: when is it appropriate?

Artificial nutrition refers to the provision of nutrients via tubes (such as a nasogastric tube or PEG) or via infusions (parenteral nutrition). Whether such measures are appropriate cannot be answered in a blanket way — it depends on the stage of the illness, the goals of treatment and the wishes of the patient.

Possible benefits

• In earlier stages of an illness, artificial nutrition can help to preserve strength, for example when swallowing difficulties are present but the underlying condition is still treatable.
• In temporary situations (e.g. after operations) it can serve as an important bridge.

Possible burdens at the end of life

• Nausea, vomiting and a feeling of fullness when the body can no longer process food.
• Increased fluid retention and breathlessness due to pulmonary oedema.
• Pressure sores, infections or complications caused by tubes and access devices.
• Restricted mobility and reduced closeness to relatives.

International specialist societies — including palliative care guidelines in German-speaking countries — therefore recommend using artificial nutrition cautiously in the dying phase and weighing it up on an individual basis. The focus is on the relief of symptoms and quality of life, not on reaching a specific calorie intake.

Fluids at the end of life: more is not always better

The situation is similar with fluid intake. For a long time the principle was: "Drinking plenty is healthy." In the last days of life, however, excessive fluid administration — for example via infusions — can lead to burdens:

• Increased airway secretions and so-called "death rattle".
• Oedema in the arms, legs or abdomen.
• Increased urge to urinate in bedridden patients.
• Worsening breathlessness.

On the other hand, a lack of fluids can contribute to a dry mouth, confusion or an unpleasant sensation of thirst. The individual situation is decisive. Often it is enough to offer small amounts of fluid and, above all, to provide intensive mouth care, because the subjective feeling of thirst usually arises from dry oral mucosa — not from a lack of fluid in the body as a whole.

What relatives can do in practice

• Moisten the lips regularly with lip-care sticks or damp cloths.
• Moisten the mouth with small amounts of water, tea or frozen pieces of fruit (if swallowing is still possible).
• Offer favourite drinks in small sips, without pressure.
• Use cotton swabs or special oral-care sponges.

These small gestures often relieve discomfort more effectively than an infusion — and at the same time provide closeness.

An individual decision: will, dialogue, support

The question of nutrition and fluids in the dying phase is always also an ethical one. In Austria — as in many other countries — the principle applies that medical measures must be of benefit to the person concerned and should correspond to their will. An advance directive or a healthcare power of attorney can provide valuable guidance here.

Important building blocks of a good decision are:

• Clarifying the goal of treatment: Is it about prolonging life, stabilisation or the best possible quality of life in the time remaining?
• The patient's will: What has the person expressed in the past? Is there an advance directive?
• Medical assessment: Which measures are realistically helpful in this phase — and which are more likely to be a burden?
• Involving relatives: Open conversations within the family can reduce feelings of guilt.
• Palliative support: Hospice services, mobile palliative care teams and general practitioners offer support with medical and emotional questions.

Myths and concerns of relatives

Many relatives fear that by forgoing artificial nutrition they are "doing nothing" or hastening death. Current findings in palliative medicine show, however, that it is not the omission of artificial nutrition that triggers the dying process, but the underlying illness itself.

Common misunderstandings:

• "Without food my relative will starve." In the dying phase, the sensation of hunger is usually no longer present.
• "Without an infusion my relative will die of thirst." A dry mouth is usually the real problem — and can be relieved well through mouth care.
• "More calories give more strength." In this phase, the body can no longer utilise the energy supplied.

Conclusion: care instead of coercion

Nutrition and fluid administration at the end of life are sensitive topics that cannot be decided in a schematic way. Today's palliative medicine is guided by individual needs, the wishes of those affected and quality of life — not by rigid specifications. Often it is loving gestures such as mouth care, a moist sponge or the offer of small favourite dishes that achieve more than any infusion.

Those who seek conversations with doctors and palliative care professionals early on create reassurance — for themselves and for the people closest to them.

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This article does not replace medical advice.