Balancing Ethics and Evidence In End-Of-Life Nutrition And Hydration

The initiation, continuation, or withdrawal of clinically assisted hydration (CAH) and nutrition (CAN) remains one of the most complex and sensitive areas in end-of-life care. A recent article published in Clinical Medicine provides a detailed overview of current evidence, guidance, and best practices for managing these interventions in terminally ill patients.1

Clinically assisted hydration involves delivering fluids through intravenous, subcutaneous, or enteral routes when oral intake is insufficient or impossible. Similarly, clinically assisted nutrition refers to the delivery of nutrients via parenteral or enteral means. While these treatments are widely perceived as beneficial, the actual clinical evidence supporting their use in palliative care settings is limited and inconclusive.

A Cochrane review on CAH found no definitive proof that hydration improves quality of life or survival in patients receiving palliative care. Only four small randomized controlled trials involving 422 patients were included, and many of these studies utilized suboptimal fluid administration. Likewise, a review on CAN reported an insufficient number of high-quality studies to form strong clinical recommendations, with no randomized controlled trials available and only a few small observational studies.

Recognizing the ethical complexity and emotional weight of these decisions, the Multinational Association of Supportive Care in Cancer (MASCC) has issued detailed clinical guidance. This includes regular assessment of hydration and nutritional status, patient and family involvement in decision-making, and individualizing care based on prognosis and clinical context. 

For CAH, fluids may be considered for patients at risk of dehydration-related complications, primarily when the prognosis extends beyond a few days. Conversely, it may be withheld in cases where fluid overload or other contraindications exist. Notably, the so-called "death rattle" is not linked to hydration status, despite common concerns about it.

CAN, on the other hand, is generally not recommended for patients experiencing cancer cachexia or appetite loss without reversible causes. It may be considered when patients are unable to ingest or absorb nutrients and have a prognosis of at least one month.

Importantly, ethical and legal frameworks emphasize that patients can refuse CAH or CAN if competent, but cannot demand them if not clinically indicated. Advance directives must be honored, and multidisciplinary discussions are crucial to align care with a patient's goals and values.

(Source: Davies A. Clinically assisted nutrition and hydration at the end of life. Clin Med (Lond). 2025;25:100323. doi:10.1016/j.clinme.2025.100323. Available from: https://www.sciencedirect.com/science/article/pii/S1470211825000417 )