What is the recommended volume for comfort feeding in end-of-life care?

Comfort Feeding Volume in End-of-Life Care

When the end of life is very close, most patients require only minimal amounts of food and little water to reduce thirst and hunger, with symptoms adequately controlled by small amounts of foods and fluids rather than specific volumes. 1

Fluid Volume Recommendations

For Subcutaneous Hydration

• Approximately 1000 ml per day of subcutaneous fluids is adequate for most terminal cancer patients when hydration is deemed appropriate 1
• For patients with bowel obstruction symptoms specifically, 0.5-1.0 liters of 0.9% saline solution per 24 hours administered subcutaneously can control symptoms 1
• Subcutaneous infusions can be safely administered at home and provide a vehicle for drug administration 1

For Oral Comfort Feeding

• No specific volume targets are recommended - the focus is on patient-desired amounts only 1
• In a study of 32 terminally ill mentally aware patients, 20 experienced no hunger and either no thirst or only initial thirst, with all symptoms relieved by small amounts 1
• Small amounts of fluid help avoid dehydration-induced confusion 1

Key Clinical Decision Points

When to Use Minimal Comfort Feeding Only

• Life expectancy less than 3 months 1
• Karnofsky index ≤50% or ECOG performance status ≥3 1
• The dying phase has clearly started 1
• Rapidly progressive disease despite oncologic therapy 1

When Artificial Nutrition May Still Be Considered

• Expected survival exceeds 2-3 months (the survival time of complete starvation) 1
• Patient has not yet entered the dying phase 1
• Patient consents and weight loss minimization remains a goal 1

Practical Management Approach

Symptom-Based Rather Than Volume-Based

• Hunger is rare in imminently dying patients 1
• Thirst and dry mouth do not correlate with hydration status or fluid volume given 1
• Ice chips and lip lubrication are more effective for dry mouth than increased fluid volume 1

Short Trial of Hydration for Confusion

• In acute confusional states at end of life, consider a short and limited hydration trial to rule out dehydration as a precipitating cause 1, 2
• This is a diagnostic and therapeutic trial, not routine practice 1, 2

Critical Pitfalls to Avoid

Do Not Use Standard Nutritional Goals

• Covering nutritional requirements is entirely irrelevant in the palliative situation 1
• Routine parenteral hydration and nutrition are unlikely to provide benefit for most dying patients 1
• During terminal hypometabolism, normal amounts of energy and substrates may be excessive and induce metabolic distress 1

Communication Is Essential

• Relatives and caregivers frequently demand medical nutrition or hydration for terminally ill patients 1
• It is mandatory to explain that the goal is comfort and communicate pros and cons with patients, family, and care team 1
• A patient classified as imminently dying who is awake and hungry may have been misdiagnosed and requires reassessment 1

Dehydration in Terminal Phase

• Dehydration in the terminal phase is often neither painful nor uncomfortable 1
• Routine hydration showed no improvement or only limited effects on symptoms and quality of life in imminently dying cancer patients 1

Multidisciplinary Decision-Making

Patients should be evaluated jointly by the oncologist, nutritionist, and palliative care specialist to design treatment on a personalized basis, as it may be difficult to judge expected survival time 1