special subjects
Symptom Relief for the Dying Patient
Anorexia
Anorexia and marked weight loss are common among dying patients. For family members, accepting the patient’s poor oral intake is often difficult because it means accepting that the patient is dying. Patients should be offered their favorite foods whenever possible. Conditions that may cause poor intake and that can be easily treated—gastritis, constipation, toothache, oral candidiasis, pain, and nausea—should be treated. Some patients benefit from appetite stimulants such as oral corticosteroids (dexamethasone2 to 8 mg 2 times a day orprednisone10 to 30 mg once a day) ormegestrol160 to 480 mg orally once a day. However, if a patient is close to death, family members should be helped to understand that neither food nor hydration is necessary to maintain the patient’s comfort. IV fluids, total parenteral nutrition, and tube feedings do not prolong the life of dying patients, may increase discomfort, and even hasten death. Adverse effects of artificial nutrition in dying patients can include pulmonary congestion, pneumonia, edema, and pain associated with inflammation. Conversely, dehydration and ketosis due to caloric restriction correlate with analgesic effects and absence of discomfort. The only reported discomfort due to dehydration near death is xerostomia, which can be prevented and relieved with oral swabs or ice chips. Even debilitated and cachectic patients may live for several weeks with no food and minimal hydration. Family members should understand that stopping medically supplied fluids does not result in the patient’s immediate death and ordinarily does not hasten death. Supportive care, including good oral hygiene, is imperative for patient comfort during this time. 