Moral dilemmas associated with the withdrawal of artificial hydration

Gillian Blakely, Jennifer Millward

with personal ethical principles, has produced an exceptionally convoluted area of healthcare practice.

Abstract
Withholding artificial hydration from unconscious terminally ill patients is a complex phenomenon identified as terminal dehydration. Towards the end of a terminal illness it is acknowledged that a patient's desire for fluid and food diminishes, followed by a period of unconsciousness (McAulay, 2001). Inconsistent care philosophies produce divergent opinions and often diametrically conflicting treatments (Craig, 1994). Additionally, literature disputes the detrimental effects of dehydration, therefore, decisions pivot on legal and ethical considerations. Consequently, the vie^vpoints of the medical and nursing staff can vary; furthermore, recognition must be made to the psychological impact of the relatives. As terminal illness is boundless, all areas of healthcare can be affected. Further investigation into this dilemma is required to identify the most appropriate care management plan. Key words: Artificial hiydration Terminai dehydration Care pathways Ethical and legal issues

Literature review
An electronic search of specialist databases including MEDLINE, PubMed and the British Nursing Index was undertaken. Search terms included: 'terminally iU', 'dehydration', 'legal issues' and 'ethics'. The search was further supplemented through hand searching ofthe chosen articles' reference lists and by an internet search using generic search engines. From the search, 286 potential articles were found between 1974 and 2006. Articles examining dehydration or the non-provision of hydration in terminal iUness were chosen. The majority of articles identified ^vere over 10 years old; however, they were not discarded due to the specific nature of their content. Additionally, contemporary literature make reference to some of these sources, implying their credibility. Eventually, due to accessibility restrictions, 30 articles were chosen for reference. Despite acquiring dated literature, generic themes arose alongside the contemporary articles, with particular reference to the complexities of decision-making regarding withdrawing AH from terminally ill patients. This alone highlighted the stasis within the topic and the continuing unresolved issues surrounding such circumstances.

7his article discusses the importance ofthe ethical and legal debate associated with the decision of withholding artificial hydration (AH) from unconscious terminally ill patients, a complex phenomenon identified as terminal dehydration. Towards the terminal stages of illness a patient's desire for fluid and food diminishes, followed by a period of unconsciousness (McAulay, 2001). The decision to give fluids involves the physician, the nurse, the family and, when possible, the patient (Musgrave et al, 1996). The care management plan for such a circumstance, has lead to much controversy (SutclifFe and Holmes, 1994; Vaz, 1999; McAulay, 2001), and Craig (1994) recognized that these inconsistent care plans had lead to widely divergent opinions and often conflicting treatments, such as administering AH therapy under the belief that it alleviates uncomfortable symptoms caused by dehydration (Hamdy

Gillian Blakely is Adult Nursing Research Assistant and Jennifer Millward is Senior Lecturer, Faculty of Health and Social Work, University of Plymouth
Accepted for publication: July 2007

and Braverman, 1980), or in contrast, the withdrawal of fluids is conducted to promote comfort (Printz, 1988). This could result in erroneous implementation of policies for either hydrating or not hydrating terminally iU patients, thus potentially creating patient harm and stress to the family (Maxwell, 2005). Further investigation into this multifaceted dilemma is imperative to ensure the most appropriate patient care pathway is identified and implemented. The managerial intricacies of terminal dehydration are recognized to include legal, ethical, physiological and psychological components (Craig, 1994; Fox, 1996). The variability of physiological appreciation, and issues of legal and ethical implications underpinning decisions, will also be reviewed, with reference to medical and nursing staff. Clearly, there is an overlap between these healthcare professionals' legal and ethical decision-making skills. However, they will be considered as separate entities so that the definitive roles can be estabhshed. Additionally, the psychological implications for the family will be discussed. Overall, inconclusive evidence and the varying knowledge of terminal dehydration among healthcare professionals, combined

Baci(grounci
Terminal dehydration is a complex phenomenon affecting patients in all areas of healthcare. Clearly, legal factors and ethical principles will underpin medical and nursing decision-making and subsequent patient management. However, Sutcliffe and Holmes (1994) argued that the perception of AH therapy differs between healthcare workers in hospitals arid hospices. The majority of terminally ill patients with an insufficient oral intake in secondary care receive parental fiuids (Dalai and Bruera, 2004; Musgrave et al, 1996), yet House (1992) remarked that hospice staff tend to accept a patient's

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imminent death and do not feel the necessity to prolonging it. Bruera and MacDonald (2000) believe that the absence of randomized controlled trials focusing on the possible advantages and disadvantages of parental hydration has consequendy led to further complications in decision-making. This emphasizes a need for essential physiological education regarding benefits and disadvantages of terminal dehydration, thus promoting best clinical practice.

Legal aspects The medical staff perspective

Currently, no statutory law regarding terminal dehydration is available for guidance. Consequently, uncertainty and discrepancy in the management ofdehydration is evident in literature. Case law identifies some circumstances where withholding or withdrawing lifeprolonging treatment would be lawful. For instance, when consideration has been given to the doctor's primary intention or to the patient's competence level (General medical Council [GMC], 2002). Hence, without a legal precedent, researchers fi^equendy cite a common fear of litigation among the medical professionals due to potential accusations of negligence (Musgrave, 1990; Vaz, 1999). However, in this circumstance, the legal profession contribute a two-fold argument in support of their medical colleagues. They argue patients die of multi-system failure due to their underlying disease and not dehydration (Stone, 1993; Montgomery, 2003; Slomka, 2003). This is related in literature to the principle of 'double effect', whereby a good initial motive prevails over a known undesirable outcome (Montomgery, 2003).To expand this doctrine, Craig (1996) explains that in the case of withholding AH, the aim is to provide palliative care and if this influences the timing of death then this is of lesser concern. Stone (1993) confirms this point, stressing in terminal illness, when withdrawing or not prescribing hydration, health professionals are acting legally if the intention is not to hasten death but to administer palliative treatment. Furthermore, the American College of Physicians and the American Society of Internal Medicine challenge the belief that it is illegal to relinquish nutrition and hydration at the end of life (Meisel et al, 2000). In 2002 the GMC pubhshed Withholding

Physiological effects
Musgrave (1990) utilized Maslow's hierarchy of needs to identify fluids as the most basic of human need. Musgrave provided a balanced argument discussing the beneficial and detrimental effects of dehydration, and briefly evaluated the advantages of hydration. This physiological analysis is independently replicated in further journal articles. Using previous research, SutclifFe and Holmes (1994) provided an unambiguous, tabulated summary of suggested advantages and disadvantages of terminal dehydration. Common benefits ofdehydration documented by these two studies included a reduction in urine output, leading to reduced incontinence and need for catheterization; and a reduction in gastrointestinal and pulmonary secretions, hence diminishing vomiting and congestion, respectively. Sutcliffe and Holmes (1994) refer further to the analgesic and anaesthetic effects of dehydration with reference to appropriate physiological evidence. Fox (1996) agrees, commenting on these pain-relieving effects. Musgrave (1990) instead relates to the palliative effect attributed to the collapse of oedema surrounding tumours. The clinical features of dehydration are well documented in research articles, detailing nausea, vomiting, headaches, dry mouth, thirst and lethargy (Sutcliffe and Holmes, 1994; McAulay, 2001). Sutcliffe and Holmes (1994) expanded their research by including evidence produced by expert terminal care clinicians (thereby implying their credibility), remarking that the only distressing symptoms are dry mouth and sporadic thirst. From a different viewpoint, Lamerton (1991) argued that patients who are fully hydrated before they die have increased incontinence and dyspnoea due to waterlogged lungs. Therefore, it is clear that literature disputes the detrimental effects of terminal dehydration. Consequently, the underpinning components of such decisions pivot on legal and ethical matters.

(/!(a,registered nurses are accountable for their practice and must act in a manner to promote and safeguard the wellbeing of patients. Thus, the dilemma over the dehydration/hydration question has prompted some authors to seek further understanding of the situation to gain confidence in clinical decisions. Fox (1996) and McAulay (2001) researched such literature and provided a concise record of implications for practice. Clear themes of patient advocacy and evidence-based practice were recognized. In order to perform competently, section 6.2 of the NMC Code of Conduct (NMC, 2004) instructs nurses that they must possess sufficient knowledge, skills and abilities required to produce legal, safe and effective practice. Vaz (1999) agrees, remarking that a nurse must have substantial understanding of all areas of dehydration management for the implementation of accurate nursing interventions, and for advocacy of the terminally ill patient. In concurrence with Vaz (1999), McAulay (2001) reinforces this point by suggesting that if awareness is raised concerning the effects ofdehydration this would lead to a fuller appreciation of the circumstances and enable further promotion of comfort for dying patients. Consequently, McAulay (2001) advises this additional knowledge would be extremely beneficial in comforting relatives, to be able to fully answer questions related to patients' care. In particular, the highly emotive concern of witnessing suffering from apparent starvation and dehydration then could be acknowledged and discussed (Dalai and Bruera, 2004).

Ethical and psychologicai diiemma The medical staff perspective

The issue of withholding or withdrawing AH is recognized by Vaz (1999) as an ethical and Withdrawing Life-Prolonging Treatments: minefield for all healthcare staff. Ignorance Cood Practice in Decision-Making, designed of the law or of ethical knowledge is no to provide doctors with a legal and ethical defence for poor decision-making (Fox, framework to formulate their decisions. It 1996). Summarily, House (1992) identified clearly stipulates that doctors must act in that a medical professional's decision over this the patient's best interests, assessing their convoluted dilemma must be based on the individual needs. Ultimately this concurs ethical issues involved but with an appreciation with articles 2 and 3 of the Human Rights ofthe scientific evidence available. Fox (1996) Act (1998), denoting a patient's right to life stressed such complex decision-making should and protection from inhuman and degrading not be founded on the routine application of treatment respectively. a small set of principles, but requires balancing of relevant factors. The nursing staff perspective One ethical theory used in this dilemma According to the Nursing and Midwifery is consequentialism. This is based on the Council's (NMC, 2004 p4) Code of Professional concept that what determines an act as Conduct: Standards for Conduct, Performance and either bad or good is the desired or achieved

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end, i.e. 'the end justifies the means' (Fox, 1996). However, arguably, clinical decisions must not solely be based on the principle of one theory. Curtin and Flaherty (1982) constructed an ethical decision-making framework in order to provide a systematic approach to ethical problems. This incorporates an analysis of the background information to determine the nature of the problem and to identify its ethical elements. Those involved in the decision are also acknowledged and together this allows the potential choices available and possible outcomes to be considered. Altogether Curtin and Flaherty's (1982) steps conclude with reviewing the ethical theories and ultimately arriving at a resolution. However, a report by Lynn and Childress (1983) detailed that physicians often feel they are obliged to continue treatment in terminally ill patients. Oberele and Hughes (2001) comment that end-of-life decision-making leads to much deliberation and reflection regarding what is considered to be the correct approach. A research study by Micetich et al (1983) supports this. The authors conducted a survey of 93 doctors to determine attitudes towards hydration of terminally ill patients. Findings showed that 73% would support administration of therapeutic intravenous (IV) fluids, 27% were prepared to subscribe fluids at a sub-therapeutic rate and 50% regarded IV fluids as standard care for terminal illness. Stone (1993) believes this action to be an expression of 'doing something' rather than standing by. Lynn and Childress (1983) identified this provision of symbolic treatment as an obligation physicians felt compelled to submit. The ethical viability of such a decision has to be questioned. Such a ritualized act would promote a false sense of security among the healthcare team and the family (Fox, 1996), and possibly could be considered as a procedure undertaken by the doctor to avoid unambiguous cause of death (Lynn and Childress, 1983). In addition to ethical considerations surrounding the withdrawal of AH, food and drink has immense social connections (Slomka, 2003). Therefore, due to the symbolic nature and psychological hopes that are pinned on the provision of fluids, ceasing fluids once they are already started is considered to be more poignant, particularly for the family (Fox, 1996). Printz (1989) concurs, believing the withdrawal of unbeneficial treatment has the same ethical

significance as not starting it. Nevertheless, the British Medical Association (1993) state where medical treatment fails to provide for a patient's welfare there is no ethical obligation to provide it.

The nursing staflf's perspective

Nurses also are faced with ethical dilemmas surrounding terminal dehydration.Tingle and Cribb (1996) believe a nurse must assess the potential harm and benefit of particular actions for that individual patient at that specific time. This applies the ethical codes of beneficence and non-maleficence, defined by Martin (2003) as the duty of doing good and the duty of avoiding harm, respectively. Clearly these two principles are interconnected and Fox (1996) believes they may be violated in some approaches to hydration/dehydration of terminally ill patients. One of the greatest challenges for the nursing profession is considered by Blasszaur and Palfi (2005) to be caring for dying people and representing their interests. Davidson et al (1990) researched such a dilemma of ethical decision-making of registered nurses via an international study. They concluded that decisions were influenced by cultural differences, which implies a nurse's background and personal experiences could affect care given (Fox, 1996; Jenkin and Millward, 2006). Fawcett (1993) agrees, commenting prejudices gained from previous experiences may cause some nurses to take a moral stance. Therefore, depending on the attitude of the staff member in question, this could produce conflicting views regarding individual application of ethical principles. Furthermore, in this instance, consideration must also be given to the ethical code of autonomy, which is reflected in respecting the patient's wishes (Davidson et al, 1990). The NMC (2004) infer that a nurse must value a patient's autonomy, acknowledging their right to decide; therefore, when possible, terminally ill patients should have the right to choose their treatment (Stone, 1993). Nevertheless, staff must respect any decisions made and the patient must receive the best quality of care from health professionals who are committed to professional clinical and ethical obligations (Fox, 1996).

relatives and the psychological impact of deciding to \vithdraw AH. Bruera and Lawlor (1998) recommend early discussions regarding treatment choices should be held with the patient and family. Thus, by providing the best evidence for the benefits and burdens surrounding the withdrawal of AH, will allow an informed choice. Unfortunately, in some instances, when this decision has been made, the family have felt instrumental in their relative's death (Vaz, 1999). This could occur if they were not fully informed of the principles of dehydration. Thus, the nurse's own knowledge of evidence-based practice (NMC, 2004 plO) is a pivotal point in the psychological care of the family, allowing misconceptions to be dispelled (McAulay, 2001). Hence, the nurse's competency can be proportional to their understanding of dehydration management (Vaz, 1999). The equipment used in AH can also cause relatives undue stress due to its dominant appearance (Fawcett, 1993). Baerg (1991), remarked the removal of such a barrier would allow relatives the opportunity to have cherished contact. Lamerton (1991) agreed believing that this equipment made a cuddle almost impossible. For both the nursing staff and relatives, the decision to withdraw fluids can produce a mixture of emotions. Often a strong association is formed between the provision of fluids and care giving (Sutchffe, 1994). Psychologically, fluids therefore symbolize security and life, hence their removal can cause distress due to the recognition that death is imminent (Chadfield-Mohr and Byatt, 1997). Brown and Chekryn (1989) believe it is felt that the offering of compassionate care is replaced with the sensation of helplessness. Potentially, some nursing staff may also be uncomfortable with this decision, and will need to examine their own feelings (Jenkin and Millward, 2006). However, abiding to
the Code of Professional Conduct ( N M C , 2004,

section 2), nurses have a duty to respect the individual beliefs and to overlook personal subjectivity.

Discussion
McAulay (2001) remarks that positive contributions to the palliative management of a patient can occur via collaborative team work. Sutcliffe (1994) agrees, identifying that any decisions made will not only impact on patient care but, will have specific consequences for the family. The interlinking principles of beneficence and non-maleficence, therefore, will have

The relatives' perspective

Davidson et al (1990) described the ethical principle of justice as the distribution of care in a reasonable way. Tingle and Cribb (1996) believe it to be the fair consideration of all those affected. Therefore, this includes

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an impact on the patient's care and will be facilitated via palliative care management (Fawcett, 1993). Literature critically analyses benefits and detrimental effects of terminal dehydration, (Stone, 1993; Sutcliffe and Holmes, 1994). Therefore, to provide the most appropriate nursing interventions and counteract any suggested potential problems, nurses would have to maintain their own professional knowledge and competence (NMC, 2004, section 6). Thirst and dry mouth are reported to be the main distressing factors of terminal dehydration (SutclifFe and Holmes, 1994). To counteract this, literature identifies simple comforting measures such as regular oral care, lubrication of lips and the offering of sips of fluid or ice to suck (Stone, 1993; Malone, 1994). A further criticism of dehydration is the increased risk of pressure sores and deep vein thrombosis due to reduced tissue perfusion and subsequent fragile skin (Stone, 1993; Sutcliffe and Holmes, 1994). However, through appropriate tissue viability assessments, prophylactic treatment should have already been implemented (Alexander et al, 2003).Together these basic interventions promote patient comfort and ^A^ill underpin the ethical principles of nursing.
particular interest would be a comparable analysis of those working in a hospital environment with those in a hospice. Additionally, the religious and faith positions o f t h e patients' relatives could also impact on decisions made. This is an additional area of consideration to an already convoluted subject, but is one of great importance that deserves its own debate. ISHil
Hamdy RC, Braverman AM (1980) Ethical conflicts in the long-term care ofthe aged. Br MedJ 280(6215): 717 Human Rights Act (1998) The Human Rights Act 1998. HMSO, London. Available at: http://\vww.opsi.gov.uk/ acts/actsl998/80042d.htm#schl (last accessed 26 July 2007) House N (1992) The hydration question: Hydration or dehydration of terminally ill patients. Prof Nurse 8(1): 44-8 Jenkin A, Millward J (2006) A moral dilemma in the emergency room: confidentiality and domestic violence. Accid Emerg Nurs 14: 38^2 Lamerton R (1991) Dehydration in the dying patient. Lancet 337(8747): 981-2 Lynn J, Childress J (1983) Must patients always be given food and water? Tlie Hastings Centre Report 13(5): 17-21 Malone N (1994) Hydration in the terminally ill patient. Nurs Stand 8(43): 29-32 Martin EA (ed) (2003) A Dictionary of Nursing. 4th edn. Alexander MF, Fawcett JN, Runciman PJ (2003) Nursing Oxford University Press, Oxford Practice: Hospital and Home TlieAdult. 2nd edn. Churchill Maxwell L-A (2005) Purposeful dehydration in a terminally Livingstone, Edinburgh ill cancer patient. BrJ Nurs 14(21): 1117-19 Baerg KL (1991) Effects of dehydration on the dying McAulay D (2001) Dehydration in the terminally iU patient. patient. Rehabil Nnrs 16(3): 155-6 Ni/r.'jStonrf 10(16): 33-7 Blasszaur B, Palfi I (2005) Moral dilemmas of nursing in Meisel A, Snyder L, Quill T (2000) Seven legal barriers to end-of-life care in Hungary; a personal perspective. Nurs end-of-life care: myths, realities, and grains of truth._//4i Ethics 12(1): 92-105 British Medical Association (1993) Medical EthicsToday.BM], MedAssoc 284(19): 2495-501 Micetich KC, Steinecker PH, Thomasma DC (1983) Are London intravenous fluids morally required for a dying patient? Brown P, Chekryn J (1989) The dying patient and Arch Intern Med 143(55): 975-8 dehydration. Cancer Nurs 85(5): 1416 Montgomery J (2003) Health Care Law. 2nd edn. Oxford Bruera E, Lawlor P (1998) Defining palliative care University Press, New York interventions.J Palliat Care 14(2): 2 3 ^ Musgrave CF (1990) Terminal dehydration. To give or not Bruera E, MacDonald N (2000) To hydrate or to not to give intravenous fluids? Cancer Nurs 13(1): 62-6 hydrate. How should it he? J Clin Omol 18(5): 1156-8 Musgrave CF, Bartal N, Opstad J (1996) Intravenous Chadfield-Mohr SM, Byatt CM (1997) Dehydration in hydration for terminal patients: what wre the attitudes the terminally ill iatrogenic insult or natural process? of israeli terminal patients, their families, and their health Postgrad MedJ 73(862): 476-80 professionals? J Paiti Symptom Manage 12(1): 4751 Craig GM (1994) On withholding nutrition and hydration Nursing and Midwifery Council (2004) Code of Professional in the terminally ill: has palliative medicine gone too far? Conduct: Standards for Conduct, Performance atid Ethics. J Med Ethics 20(3): 139-43 NMC, London Craig GM (1996) On withholding artificial hydration and Oberele K, Hughes D (2001) Doctors' and nurses' nutrition from terminally ill sedated patients. The debate perceptions of ethical problems in end-of-life decisions. continues.J Med Ethics 22(3): 147-53 Curtin L, Flaherty MJ (1982) Nursing Ethics: Tlteories and _//)(ifNiiri 33(6): 707-15 Printz LA (1988) Is witholding hydration a valid comfort Pragmatics. Prentice Hall, USA measure in the terminally ill? Ceriatrics 43(11): 848 Dalai S, Bruera E (2004) Dehydration in cancer patients: to Slomka J (2003) Withholding nutrition at the end of treat or not to treat. J Support Oncol 2(6): 46787 life: Clinical and ethical issues. Cleve Clin J Med 70(6): Davidson B.Vander Laan R, Davis A et al (1990) Ethical 548-52 reasoning associated with the feeding of terminally ill Stone C (1993) Prescribed hydration in palliative care. BrJ elderly cancer patients: an international perspective. Nurs 2(7): 53-7 Cmifcr Nurs 13(5): 286-92 Sutcliffe J (1994) Terminal dehydration. Nnrs Times 90(6): Fawcett H (1993) Interpreting a moral right, ethical 60-3 dilemmas in nutritional support for terminally ill patients. Sutcliffe J, Holmes S (1994) Dehydration: burden or benefit Prof Nurse 8(6): 380-3 to the dying patient?_//4rfi' Nurs 19(1): 71-6 Fox E (1996) IV hydration in the terminally ill: ritual or Tingle J, Cribb C (1996) Nursitig Law and Ethics. BlackweU therapy? BrJ Nurs 5(1): 41-5 General Medical Council (2002) Withholding and Withdrawing Science, Oxford Life-Prolonging Treatmettts: Cood Practice in Decision-Makitig. Vaz H (1999) The management if dehydration in terminally ill patients. CIAP,Australia.Available http://www.clininfo. GMC, London. Available at: http://www.gnic-uk.org/ health.nsw.gov.au/hospolic/stvincents/stvin99/Helen. guidance/current/library/witholding_lifeprolonging_ htm. (last accessed 26 July 2007) guidance.asp (last accessed 26 July 2007)

Conclusion
The decision to withhold AH is a highly emotive and multifaceted dilemma. Despite many studies investigating the benefits and detrimental effects of terminal dehydration, no conclusive arguments have been established. The potential benefits of terminal dehydration are increasingly being acknowledged but again are not conclusive. Healthcare professionals face an ethical and legal dilemma. No statutory law is available; therefore, appropriate decision-making requires a review of all factors. Thus, as each case is individual, all decisions need to be based on the ethical issues involved with a clear appreciation of evidence based practice, while liaising with staff and relatives. The possession of sufficient knowledge, skills and abilities are required to produce legal, safe and effective practice. Therefore, continual education of all staff is paramount, not only to ensure the patient will receive the optimal quality of care, but that the staff receive the support they need in making such complex decisions.

KEY POINTS
IThe potential withdrawal of artificial hydration has iead to continuing debates in the nursing and medical communities. I Despite many studies investigating the benefits and detrimentai effects of terminal dehydration, no conclusive arguments have been established. I Each case requires the balancing of legal and ethicai issues in conjunction with latest evidence-based practice. IThe psychological impact of any decision made needs to be recognized.

Suggested research
T h e background of the health professionals in question could influence their beliefs. O f

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