End of life - withdrawing and withholding artificial nutrition and hydration
April 2007
The BMA’s guidance on withholding and withdrawing artificial nutrition and hydration provides advice for health professionals about the range of factors that should be taken into account in making these difficult decisions. The guidance is very clear that oral nutrition and/or hydration should continue to be offered to all patients who are able to swallow.
Where there is a problem with the swallowing mechanism which makes oral feeding very difficult or impossible, it advises that careful thought should be given to whether artificial feeding should be provided or continued. The guidance is based on the premise that the primary goal of medicine is to benefit the patient by restoring or maintaining the patient's health as far as possible. If treatment, including artificial nutrition and/or hydration, fails or ceases to give a net benefit to the patient, or if the patient has refused it - either contemporaneously or in advance - that goal cannot be realised and the justification for providing the treatment is removed.
The decision to withhold or withdraw artificial nutrition and/or hydration is a profound one. Where patients make that choice for themselves, it should be respected. It may also be considered in very severe cases where an incompetent patient has no prospect of recovery to a level he or she would find acceptable. The majority of people, with even very severe physical and mental disability are able to experience and gain some pleasure from their lives – and would not fall into that category. Some people, however, have no or very minimal awareness of their own existence or surroundings, no ability to interact at any level and no chance of regaining any awareness.
For some of these people, a decision to withhold or withdraw artificial nutrition and/or hydration may, in the BMA’s view be appropriate. This decision must be reached carefully and thoughtfully, in consultation with relatives, in close discussion with the whole team of people involved in the care of the patient and, in the BMA's view, with independent advice from another doctor. Making these decisions, although difficult, is an important part of good medical practice.
- The third edition of the BMA's guidance, published March 2007, included guidance on the Mental Capacity Act 2005 which, from 2007, allows competent adults to appoint a welfare attorney to make healthcare decisions once capacity is lost.
- Copies of the BMA's guidance have been placed in the Houses of Commons and Lords Libraries or can be purchased from Hammicks BMA bookshops at http://www.bmjbookshop.com/shop/default.asp , priced £17.99.
For further information, please email the parliamentaryunit@bma.org.uk.