BMJ 2002;325:1326 ( 7 December )

Papers

Withholding the artificial administration of fluids and food from elderly patients with dementia: ethnographic study

Anne-Mei The, anthropologist, ^a Roeline Pasman, sociologist, ^a Bregje Onwuteaka-Philipsen, health scientist, ^a Miel Ribbe, professor, ^b Gerrit van der Wal, professor. ^a

^a Department of Social Medicine, Institute for Research in Extramural Medicine, Vrije University Medical Centre, 1081 BT, Amsterdam, Netherlands, ^b Department of Nursing Home Medicine, Institute for Research in Extramural Medicine

Correspondence to: A-M The am.the.emgo{at}med.vu.nl

Objective: To clarify the practice of withholding the artificial administration of fluids and food from elderly patients with dementia in nursing homes.
Design: Qualitative, ethnographic study in two phases.
Setting: 10 wards in two nursing homes in the Netherlands.
Participants: 35 patients with dementia, eight doctors, 43 nurses, and 32 families.
Results: The clinical course of dementia was considered normal and was rarely reason to begin the artificial administration of fluids and food in advanced disease. Fluids and food seemed to be given mainly when there was an acute illness or a condition that needed medical treatment and which required hydration to be effective. The medical condition of the patient, the wishes of the family, and the interpretations of the patients' quality of life by their care providers were considered more important than living wills and policy agreements.
Conclusions: Doctors' decisions about withholding the artificial administration of fluids and food from elderly patients with dementia are influenced more by the clinical course of the illness, the presumed quality of life of the patient, and the patient's medical condition than they are by advanced planning of care. In an attempt to understand the wishes of the patient doctors try to create the broadest possible basis for the decision making process and its outcome, mainly by involving the family.

What is already known on this topic Debate has focused on whether it is beneficial to withhold the artificial administration of fluids and food from patients with advanced dementia What this study adds The course of dementia, the patient's quality of life, and the patient's current medical condition influence doctors' decision making more than advanced planning of care Doctors try to create the broadest possible basis for the decision making process and its outcome, mainly by involving the family

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