Problems raised by discontinuing nutrition and hydration in children receiving palliative care

Withdrawal of nutrition/hydration is a legal and ethical decision in adults. It is very rarely practiced in children in France, due to the fear of letting a child die from hunger and thirst. Several pediatric issues make this decision a complex one. The root of the decision should be the best interest of the child, knowing that the subjective feelings of the family should also be addressed. The physiologic dependence of the infant on environment for food and water is indistinctly superimposed on the means involved for sustaining nutrition during a disease. Nutrition/hydration is synonymous to life and the oral character is linked to pleasure. Thus, the wish to withdraw nutrition/hydration can be considered as a decision to deliberately provoke death. Given the child's lack of autonomy and the fact that the child can be harmed with a chronic disease at birth, make the ethical approach to the decision more complex. Death is the unavoidable result of the decision of withdrawal of nutrition/hydration, but the patient may not suffer from hunger and thirst during the remaining days. Particular attention should be devoted to the prevention of pressure ulcers and use of analgesic drugs in the setting of renal failure. The presumption of an important moral suffering of the family and/or the treating team should balance the choice of this option among other end-of-life decisions in children. (C) 2009 Elsevier Masson SAS. All rights reserved.