Withdrawing clinically assisted nutrition and hydration (CANH)

Guidance on making the difficult and emotive decision to withdraw life sustaining treatment from patients in a vegetative or minimally conscious state.

Clinically assisted nutrition and hydration (CANH) is defined as all forms of tube feeding. It does not cover oral feeding. In law, nutrition and hydration provided by tube or drip are regarded as medical treatment.

Considering end of life care

The withdrawal of CANH is one of a range of ethical concerns arising from the provision of end-of life care, alongside mental capacity assessments, DNACPR decisions and organ donation. Doctors involved with the care of a dying patient are advised to familiarise themselves with local policies and procedures.

If the patient lacks capacity, it may help to consider the following MDU advice.

  • Find out whether the patient has previously made a valid advance decision to refuse treatment or if a representative has specific legal authority to make decisions on their behalf; for example, a lasting power of attorney.
  • Try to establish an open and honest dialogue with family members from the outset. Encourage them to ask questions, discuss their concerns and tell you what they know about the patient.
  • When considering what course of action will be of overall benefit to the patient, take into account anything you have been told about their wishes, feelings, beliefs and values, the views of those close to the patient, and others in the healthcare team.
  • Plan ahead as much as possible to minimise delays and help family members come to terms with the situation. However, you should be prepared to reassess the benefits, burdens and risks of treatment if their condition changes, and to seek a second opinion if necessary.
  • Ensure the patient is kept comfortable throughout and try to address any distressing symptoms. Make sure their palliative and terminal care needs are clearly noted in the medical records and communicated with colleagues, particularly during handovers.
  • Remember, there may be a need to get an independent second opinion.

If you believe it might not be possible to reach an agreement on the patient's best interests, consider getting further advice - for example, from the trust legal services team and your medical defence union. Also, be ready to consider the possibility of mediation.

More resources for decision making

The Royal College of Physicians and BMA has published guidance for England and Wales on CANH and adults who lack the capacity to consent, with input from the GMC, MDU and other organisations. It has been endorsed by the GMC and should be read alongside the GMC's own guidance on end of life care.

While recognising that every case requires "careful consideration of the individual circumstances of the patient," the guidance is intended to support informed decision-making where the patient's death is not imminent and where CANH is the primary life-sustaining treatment.

Additional resources include a quick reference guide, decision-making flow-chart, training materials and an information leaflet for families.

This page was correct at publication on 19/01/2021. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.