Letters

Artificially giving nutrition and fluids is not one action

EDITORThe and colleagues' description of decision making for patients with severe dementia who have difficulties in eating and drinking, raises several troubling issues.¹

Firstly, they implicitly consider tube feeding to be life sustaining. In fact, no credible data show that tube feeding prolongs life in advanced dementia.^2-5 An honest summary of the data is, "We have no good evidence that tube feeding will prolong life, and chances are good your loved one will die soon if we put in a tube." To offer, "We could put in a tube or you can let your loved one starve" is inaccurate and often hurtful.

Secondly, administering nutrition and fluids is treated as a single intervention, one all or nothing decision. Acute, self limited illnesses can stop fluid intake, causing death in days. Providing fluids can prolong life. Unlike dehydration, poor intake of nutrients rarely threatens life acutely, usually occurring in chronic illness. Furthermore, fluids may be replaced orally, subcutaneously, intravenously, or enterally, whereas long term parenteral and enteral nutrition may impose substantial burdens. Nutrition and hydration are very different decisions.

Finally, The et al refer twice to prolonging life "unnecessarily" and twice say that to prolong life would not be beneficial. If an incapacitated patient is allowed to die without life sustaining treatment, something serious and extremely complex has occurred. To say "unnecessary" or "not beneficial" conceals volumes. The true purport is to say the patient would be better off dead. Perhaps The et al used these terms as shorthand, or perhaps doctors and family members are the ones using this shorthand.

Patients nearing death or their carers must often choose between a future that offers longer survival with intensified suffering, or an alternative where comfort and dignity are emphasised instead. Tube feeding in advanced dementia is not such a decision; it neither prolongs survival nor enhances comfort and dignity.

Thomas Finucane, professor of medicine. 
tfinucan{at}jhmi.edu

Colleen Christmas, assistant professor of medicine. 
Johns Hopkins Geriatric Center, 5505 Hopkins Bayview Circle, Baltimore, MD 21224, USA

Competing interests: None declared.