Dietitian Blog | Jan 30 2025
Nutrition interventions for patients at end of life

Nutrition interventions at end of life depend heavily on the goals of care determined by your patient. Whether curative, palliative, or hospice care, these different philosophies will dictate how intensive your patient’s nutrition plan of care may be.
Important terminology
- End of life (EOL): The support and medical care given during the time surrounding death. It includes the days, weeks, and months leading up to death.
- Goals of care philosophies: Curative, palliative, and hospice. In the care continuum, curative can include palliative, and hospice can include palliative.
- Curative care: To cure a disease or boost recovery from a disease.
- Palliative care: To provide relief from discomforts, symptoms, and stress of a serious condition. Acute therapies can continue. Relief of pain and suffering is the focus.
- Hospice care: A caring, holistic and person-centered approach to end of life. The focus is on the best quality of life for the patient and families for whatever time is left. Generally, the patient must have a life expectancy of 6 months or less. An interdisciplinary team provides holistic services to manage symptoms and provide pain control. Palliative chemotherapy can continue if desired by the patient and consistent with their goals. Support is offered for the family for several months after the patient passes.
- ANH: Abbreviation for artificial nutrition and hydration.
Role of nutrition in end-of-life care
The level of care being provided in your nutrition interventions should align with your patient’s preferred philosophy of care. If your patient is unable to make decisions for themselves, you may refer to legal documents such as the Advanced Directive or the Medical Order for Life-Sustaining Treatment (MOLST).
If in place, these documents provide guidance on the type of care a patient wants to receive when they are unable to make their own decisions. These documents typically have a section that specifically addresses a patient’s wishes regarding artificially administered nutrition and hydration (ANH).
Considerations with artificial nutrition and hydration
Artificially administered nutrition and hydration, which is abbreviated ANH, encompasses enteral and parenteral nutrition and IV fluids.
The topic of ANH may come up when discussing nutrition options with your patient and/or interdisciplinary team. ANH may offer benefits during curative therapy to assist with short-term issues or manage chronic symptoms. However, it is important to educate both the patient and family that ANH is not curative care and can potentially lead to medical complications and increased suffering in patients nearing the end of life.
Patients with advanced, life-limiting illnesses often lose the ability to eat and drink and/or lose interest in the intake of food and fluids. Appetite and tolerance of food may be altered due to pain, medication, and/or other related symptoms from their end-stage illness. In some cases, oral intake may be solely for comfort or pleasure purposes in lieu of sustenance.
Ethical issues may arise when patients, families, or caregivers request ANH even if there is no prospect of recovery from the underlying illness or any added benefits from this therapy. Benefits and risks must be weighed to determine the appropriate and individualized nutrition therapy plan. In some cases, your health system may have an ethics committee, comprised of various medical professionals. The committee members together will review each case and determine the most ethical plan of care for each respective situation. When patients or family members are conflicted in their choice to pursue ANH (or not), the dietitian can help to provide information while staying neutral in the decision-making process.
Making the most of oral nutrition intake
It’s common for patients, family members, or clinicians to choose not to pursue ANH in end-of-life situations. There are some strategies dietitians can try to maximize a patient’s oral nutrition intake, which may help to maintain a patient’s energy level, strength, or comfort family members.
- Small, frequent meals and snacks: Choose nutrient-dense foods when possible. Oral nutrition supplements can serve as a meal replacement if better tolerated than a meal.
- Strategic fluid intake: Avoid fluids with meals to reduce feelings of fullness. Offer ice chips or popsicles for relief of dry mouth symptoms. Even lip balm or sour candy can help relieve the feeling of a dry mouth.
- Slower-paced eating: Patients can eat at their own pace, stopping and restarting whenever they need. Don’t force food/liquids at any time.
- Tailored food choices: Offer foods that are easy to eat and digest. Cold foods may be more appealing than hot foods. Avoid spicy, greasy, or salty foods. Opt for “comfort” foods that are bland, soft and moist.
- Avoid over-eating or over-drinking: Doing so may cause bloating, uncomfortable fullness, nausea, vomiting, diarrhea, constipation, gastric reflux, or aspiration.
- Honor patient food/drink requests: Hospice patients may have a craving for a specific food or drink. Try to honor these requests and avoid restrictive diets.
Summary
- ANH is a form of medical therapy and should be weighed by its benefits and burdens, aligning with the patient’s quality of life, goals of care, and achievable treatment goals.
- ANH can be ethically withheld or withdrawn, as consistent with the patient’s wishes and their clinical situation.
- Open communication with active listening between patient/families/caregivers to validate choices and feelings. Clarify and define the natural progression of advanced disease or clinical conditions.
- Respect patient/family preference for treatment, once the prognosis and anticipated progression of the condition with or without ANH has been explained.
The interdisciplinary team is the glue to support the patient and family in all areas and to assist them with determining realistic goals of care that align with their quality of life. Dietitians play a vital role on this team. Our knowledge of ethics, risks, and benefits of ANH and the overall EOL process allows us to be steadfast advocates for our patients.
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References
“Hospice Nutrition & Care Guidance: End-of-Life Nutrition.” Crossroads Hospice: End of Life and Palliative Care Services. Available at https://www.crossroadshospice.com/hospice-resources/nutrition-hydration. Accessed September 7, 2024.
Pasha, Amirala, et al. “Healing or Harming: Approaches to Ethical Dilemmas in Nutrition.” ASPEN website. Published Mar. 2024. Available at https://aspen.digitellinc.com/p/s/healing-or-harming-approaches-to-ethical-dilemmas-in-nutrition-m22-30279.
Medicine, American Academy of Hospice and Palliative. “Artificial Nutrition and Hydration Near the End of Life | AAHPM.” American Academy of Hospice and Palliative Medicine. Available at https://aahpm.org/positions/anh. Accessed September 7, 2024.
Dodd, Katie. “End-Of-Life, Understanding the RD’s Role.” Today’s Dietitian website. Published Mar. 2017. Available at https://www.todaysdietitian.com/newarchives/0317p36.shtml#:~:text=RDs%20are%20responsible%20for%20providing,they’d%20make%20for%20themselves.
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