Anorexia and marked weight loss are common in dying patients. The family often has difficulty accepting the patient's poor oral intake, because to accept a loved one's refusal to eat is to accept his dying.

Easily treatable conditions that might be a cause of poor intake--gastritis, constipation, oral candidiasis, pain and nausea--should be addressed. Some patients benefit from appetite stimulants such as corticosteroids (dexamethasone 2 mg or prednisone 10 mg tid) or megestrol.

However, if a patient is close to death, the family should be counseled that neither food nor hydration is necessary to maintain the patient's comfort.

IV fluids, TPN, and tube feedings have not been shown to prolong the lives of dying patients. All are associated with increased discomfort and may decrease survival. Dying patients fed artificially have increased incidence of pulmonary congestion and pneumonia. Artificial hydration may worsen edema and pain associated with inflammation.

Conversely, starvation and dehydration are associated with analgesic effects and absence of discomfort. The only reported discomfort associated with dehydration near death is xerostomia, which is easily relieved with oral swabs or ice chips.

The family should be told gently that the patient is dying and that food will not help the patient's strength or substantially delay death.

Families should be given concrete recommendations, such as use of favorite foods, small portions, and foods that are easy to swallow. The family should also be helped to use other ways to show their caring and love and should be reassured that the patient will not suffer from having little or no intake.

Even debilitated and cachectic patients may live for several weeks after the discontinuation of all food and hydration.

Families should be counseled that the discontinuation of fluids will not result in the patient's immediate death. Supportive care is imperative for patient comfort during this time.

Such care includes good oral hygiene (brushing the teeth, swabbing the oral cavity, applying lip salve, and providing ice chips for dry mouth).

Providing oral hygiene can also give family members a valuable role in caring for the dying patient.