Synopsis
Decide separately about assisted nutrition and hydration using clinical goals, swallowing and refeeding assessment, capacity, lawful authority and monitored benefit-versus-burden trials.
- Food and drink by mouth, including careful assistance, is distinct from nutrition or fluid delivered through a tube, vein or subcutaneous route.
- Clinically assisted nutrition and hydration are medical treatments, so consent, capacity, clinical appropriateness and review apply as with other interventions.
- Assess nutrition and hydration separately because their goals, routes, benefits and harms may differ.
- Start with safe oral support, preferred tastes, positioning, adaptive equipment, mouth care and speech-and-language assessment when these can meet goals.
- Tube feeding does not eliminate aspiration risk and may add dislodgement, infection, diarrhoea, restraint and treatment burden.
- Do not routinely use enteral feeding in severe dementia unless a potentially reversible comorbidity provides a clear time-limited indication.
- In the last days, evidence is uncertain that assisted hydration prolongs life or that withholding it hastens death; a monitored trial may relieve selected symptoms.
- Any trial needs an explicit goal, duration, measures of benefit and stopping rules for overload, distress or failure.
Key red flags
Coughing, wet voice, recurrent chest infection or oxygen desaturation during intake suggests clinically significant swallowing impairment.
A nasogastric tube is used before position confirmation or after displacement, creating a risk of pulmonary feeding.
Feeding is started at full requirement after prolonged little or no intake without phosphate, potassium, magnesium and thiamine planning.
New oedema, crackles, increased secretions or breathlessness during hydration suggests fluid overload, particularly in heart or kidney failure.
Restraint or repeated traumatic tube replacement is occurring without a documented capacity and benefit-versus-burden decision.
Relatives are told they alone must choose, or are excluded despite providing important evidence about a patient who lacks capacity.
Oral care and comfortable hand feeding are withdrawn merely because tube feeding is not being provided.
Investigation priorities
Define safe oral options and aspiration risk.
Management branches
Eating or drinking is reduced but the person can still participate in oral intake.
- Treat mouth pain, constipation, nausea, delirium and medicine effects, and optimise alertness, seating, hearing and meal assistance.
- Offer preferred energy-dense food, small portions, adapted utensils and texture or fluid changes based on skilled assessment.
- Discuss aspiration, enjoyment, independence and nutritional goals with the person, avoiding risk language that removes all choice.
- Monitor intake, comfort, respiratory events, weight trajectory and carer workload, escalating to dietetics and speech-and-language therapy.