Synopsis
Separate mouth care and supported oral intake from medical hydration and nutrition, identify reversible swallowing or metabolic problems, set a measurable goal for any assisted treatment and make lawful shared decisions to start, continue, withhold or stop it.
- Offer safe sips, preferred tastes, eating assistance and frequent mouth care whenever wanted; reduced intake in dying is not corrected reliably by pressure to eat or automatic fluid.
- Clinically assisted hydration includes intravenous, subcutaneous and enteral fluid; clinically assisted nutrition includes tube and parenteral feeding. Both are medical treatments requiring indication, consent and review.
- First-line assessment identifies thirst, delirium, dysphagia, aspiration, nausea, obstruction, fluid losses, medicine effects, prognosis and the outcome the person wants treatment to achieve.
- Use swallow assessment before unsafe oral intake. A functioning accessible gut generally favours enteral feeding; parenteral nutrition is reserved for selected patients whose gut cannot be used and who have time to benefit.
- In the last days, evidence is uncertain that clinically assisted hydration prolongs life or extends dying; it may relieve dehydration-related symptoms or worsen oedema, ascites, secretions and repeated procedures.
- Offer an individual therapeutic trial when benefit is plausible: state the route, volume, target symptom or function, review time and stop criteria before treatment begins.
- Artificial nutrition cannot reverse inflammatory cachexia by itself. Explain this to reduce blame and food-related conflict while continuing enjoyable intake if safe.
- Screen for refeeding risk before nutrition after prolonged little or no intake; give thiamine, introduce energy cautiously and monitor phosphate, potassium, magnesium, glucose and fluid.
- A capacitous adult may refuse assisted hydration or nutrition. When capacity is absent, check any valid advance decision or attorney authority and use a documented best-interests process under the applicable UK law.
- The gold-standard plan is goal based and reversible: continue only while the person experiences the agreed benefit without disproportionate aspiration, infection, overload, restraint or monitoring burden.
Key red flags
Cough, desaturation, wet voice or respiratory distress during feeding suggests aspiration and requires immediate cessation and assessment.
A displaced nasogastric tube must never be used until position is confirmed by the approved safety method.
Rapid breathlessness, crackles, oedema or rising oxygen need during hydration suggests fluid overload.
Fever, rigors, hypotension or inflamed central access during parenteral nutrition raises line sepsis.
Low phosphate, potassium or magnesium, arrhythmia, oedema or weakness after feeding starts suggests refeeding syndrome.
Physical restraint solely to maintain a feeding tube can create disproportionate harm and requires urgent best-interests review.
Serious family-team disagreement about starting or stopping life-sustaining nutrition needs senior mediation, second opinion and sometimes legal advice.
New oedema, tachycardia, weakness, confusion, arrhythmia or respiratory failure after restarting nutrition may reflect dangerous phosphate and electrolyte shifts.
Investigation priorities
Clarify desired outcome, appetite, actual intake, assistance, symptoms, cultural meaning, prognosis and burdens acceptable to the person.
Management branches
The person wants oral intake and can swallow some food, fluid or tastes with acceptable risk.
- Treat mouth pain, candidiasis, nausea and constipation, provide upright assistance and offer small preferred textures and fluids without pressure.
- Discuss aspiration and enjoyment openly, including a documented risk-feeding plan when the person chooses oral intake despite known risk.
- Review comfort, coughing, fatigue, family anxiety and intake and adapt the plan as alertness and swallowing change.