Nutrition and hydration

Meeting the basic needs for food and drink is an important part of caring for someone coping with a life limiting illness. To do this successfully requires sensitivity and clarity.

It is essential that the person and those close to them, are at the centre of any care planning and decisions about nutrition and hydration. It is important to understand and convey the reduced need for food and drink as the person approaches their final days. This communication is pivotal in supporting those close to the individual in understanding the dying process.

A greater understanding of the importance of adequate food, drink and nutritional care is needed as this is an integral part of care, particularly as the person approaches their final days.

What are the fundamentals?

The NMC describe fundamentals of care as:

The fundamentals of care include, but are not limited to, nutrition, hydration, bladder and bowel care, physical handling and making sure that those receiving care are kept in clean and hygienic conditions…making sure you provide help to those who are not able to feed themselves or drink fluid unaided (NMC, 2015).

Key points

When you are providing nutrition and hydration support at at the end of life, it is important to remember:

If you are concerned that a patient is not receiving adequate nutrition or hydration by mouth, even with support, you must carry out an assessment of their condition and their individual requirements.

You must assess their needs for nutrition and hydration separately and consider what forms of clinically assisted nutrition or hydration may be required to meet their needs.

Sensitive communication may be required about why a drip may or may not be needed in the last few days of life.

Eating is an important social activity to many, where friends and family use meal times for interaction. However, our need and desire to eat and drink reduces when we have a life limiting illness, greatly impacting our quality of life, both physically and psychologically, not only on the person, but also those around them.

For more information around cultural and spiritual meaning please see the Culture and Spirituality module.

The person’s appetite and thirst may decrease, and they may have little desire to eat or drink. This concerns relatives and those close to the patient, but is a natural process and is not painful for the person. Sips of water, or a moist mouth swab will help them, however, attempting to feed someone who is unable to swallow may make them distressed.
Preparing people with a gentle explanation for this loss of appetite can help them to understand the dying process.
It is recognised that the oral intake of both food and drink can diminish significantly at end of life, combined with weight loss and muscular weakness. Patients may require additional support to ensure they receive adequate nutrition and hydration. You can learn more in the section “Strategies for Nutrition and Hydration care”.
The psychological impact of losing the ability to eat and drink, can have a profound effect on the patient’s quality of life, including their relationship with partners and relatives. You need to recognise this when dealing with patients and those close to them.
Explain sensitively why the need for food and drink diminishes as the body goes through each of the stage of the dying process.  Our bodies are less active and systems are shutting down, so the body needs less calories and fluids. And the body may be satisfied with just liquid received via frequent oral care, in the last few days and hours of life.

Providing support to a patient for as long as they need it is very important, however it’s also important to understand when this support is to be withdrawn, as doing so can be distressing and painful for the person.
Relatives can often become distressed when death approaches and don’t always understand the rationale around some of the decisions being made around nutrition and hydration, for instance why a drip is not being set-up or a water jug is removed. To them the withdrawal of these can seem like a neglect in care. It’s important to be sensitive and explain why nutrition and hydration is no longer required. They may be upset and may not understand at first, so it is important to persevere and remain calm. If you feel overwhelmed then seek support from a colleague.