In the Midst of Life

may prolong life, such as chemotherapy or radiation therapy, and includes investigations needed to better understand and manage distressing clinical complications. (World Health Organization, 2004)
    Other principles of palliative care promote:
     
Quality of life: palliative care tries to enhance this as much as is realistically possible
Patient choices: patient autonomy is respected and encouraged as much as possible
Open communication
Looking after the whole person which includes physical, emotional,psychological, spiritual and intellectual issues
Looking after the whole family because the patient is not an isolated unit but part of a whole social unit. Their disease, and its effects may have catastrophic influences on this social unit and its dynamics.
Involving support from the whole multi-disciplinary team (MDT): this includes professionals in the hospital and community such doctors, nurses, palliative care specialists, hospice services, dieticians, physiotherapists, occupational therapists, and chaplaincy. (Regnard and Kindlen, 2002)
    Hydration, nutrition, sedation and pain relief in end-of-life care
    Adapted from
Palliative Care Resuscitation
by Madeline Bass, published in 2006 by John Wiley and Sons: pp. 8 , 13-14 and 113-115.
    The subject of whether to use artificial hydration and nutrition in terminally ill patients, which could be included under the cloak of ‘active treatment’, has brought about different points of views. Rousseau (2000) states that many doctors and nurses feel food and fluid is always a basic need for human existence. However, although this is true, tube-feeding terminally ill patients (either via nasogastric, nasojejunostomy, gastrostomy or via parenteral routes, such as total parenteral nutrition - TPN) has not been found to enhance or prolong life. Remember, tube-feeding in no way resembles normal eating since it is a passive process that totally bypasses the sensory part gained from oral feeding: there is no smell, taste or texture of feeling food in the mouth. Tube-feeding can also have serious complications such as aspiration, nasal cartilage erosion, and tube displacement, which may require an uncomfortable, perhaps even painful, replacement.
    It is important for healthcare professionals, patients and their family carers, to realise that weight loss and anorexia are part of the dying process and that the absence of tube-feeding does not lead to death caused by starvation or dehydration; tube-feeding does not lengthen life. In fact it may encourage tumour growth (Rousseau, 2000).
    It maybe felt by some that artificial hydration is not required for various reasons, a feeling echoed by the National Council for Palliative Care (NCPC, 2002). Their reasons include that, towards death, the person’s need for nutrition and fluid is lessened, and evidence suggests that artificial hydration in terminal illness neither prolongs life nor helps symptom control (see list of references for more details). Artificial hydration is not usually needed if good mouth care is given – think how quickly thirst is quenched when a few mouthfuls of drink are taken: it is some time before the fluid is actually absorbed by the body’s system, yet almost immediately there is some relief from the thirst. Hence, it is felt that good mouth care can achieve the same results.
    The NCPC (2002) continue that certain medications the terminally ill patient may be receiving can cause a dry mouth, such as morphine. Simply adding artificial hydration will not lessen this. They state that artificial hydration being used to correct the correctable is appropriate, such as in hypercalcemia, diarrhoea and delirium caused by electrolyte imbalance. Rousseau (2000) also argues that artificial hydration may cause a complication known as ‘third spacing’, which can cause peripheral and pulmonary oedema from low oncotic pressures, secondary to low blood albumen [protein] levels and poor nutritional status. It can also increase gastro-intestinal and pulmonary secretions, increase urinary output, and in the end probably cause more patient discomfort then less (Printz, 1992; Kinzbrunner, 1995). It helps, if needing to stop fluids for these reasons, that the family carers are supported during this decision. If they feel they would prefer artificial fluids or nutrition to continue, sensitive explanation why they need to be stopped (because they are causing more side effects than benefits) would need to be given. However, if