Medically Administered Nutrition and Hydration

Journal of Hospice and Palliative Nursing. 2020;22(3):E13-E16. 

In This Article

Position Statement

It is the position of the Hospice and Palliative Nurses Association (HPNA) that it is medically, ethically, and legally acceptable for patients with serious illness or their surrogate decision-makers to choose to initiate, withhold, or withdraw medically administered nutrition and hydration (MANH).[1–6]

Clinical Practice

• Hospice and palliative nurses caring for patients and families deliberating whether to initiate, to withhold, or to withdraw MANH are responsible to ensure

   • Patient autonomy;

   • Education regarding benefits and burdens of interventions; and

   • Informed decision-making based on the patient's clinical condition, goals, values, beliefs, culture, ethnicity, and religion.[6–8]

• Hospice and palliative nurses must ensure that discussions and decisions regarding initiating, withholding, or withdrawing MANH in advanced illness and end of life are guided by ethical and cultural considerations; patient goals of care, preferences, and beliefs; and evaluation of the benefits and burdens of MANH.[9,10]

• Hospice and palliative nurses must ensure that patient and surrogate decision-maker wishes regarding MANH are congruent with advance care planning documents, such as advance directives, living wills, in-hospital and out-of-hospital orders for life sustaining treatments, or nursing documentation.[4,11–13]

• Hospice and palliative nurses must ensure interdisciplinary team support for patients' and families' decision-making related to MANH.


• Hospice and palliative nurses must have education about MANH in the health care setting, specifically that MANH is considered a medical intervention.[9,14]

• Hospice and palliative nurses must affirm that different cultures and religions view MANH as a necessary treatment because administration of food and water is a basic human right.[15,16]

• Hospice and palliative nurses, patients, families, and other caregivers must be educated about the natural and expected trajectory of advanced illness and the dying process, as well as their effects on nutrition and fluid status.[17]

Policy and Advocacy

• Hospice and palliative nurses must understand MANH as an established medical intervention in which common themes include the following:[1–3,6,10]

   • Decisions about MANH need to reflect the patient's and family's values, preferences, beliefs, religion, ethnicity, and culture.[6]

   • Medically administered nutrition and hydration is a medical intervention that requires consideration of its benefits and burdens for the patient, family, and care team.

   • Medically administered nutrition and hydration may be declined, withheld, or withdrawn based on the patient's clinical condition and goals of care.[6,18,19]

• Hospice and palliative nurses must ensure the development of policies to guide a decision-making process for resolving disagreements about MANH among patients, families, surrogates, and health care team members.[5,8]

• Hospice and palliative nurses must ensure that patients employ surrogate decision-makers, the legal assignment of a surrogate decision-maker for health care, advance directives, or living wills to document choices and values that guide care, such as MANH, at the end of life in the event decision-making capacity is absent.[13,20]


• Hospice and palliative nurses must promote more research about MANH, along with the benefits and burdens, because the current literature is limited and equivocal in that some patients receive no benefit, whereas others receive benefit from MANH.[6,17]