**Abstract**

Background: Death is preceded by several medical decisions that impact the dying process. One of the challenges faced by the multidisciplinary team regarding the care for patients at the end of life process is the indication or interruption of enteral feeding. The aim of this study was to describe the decision experience of the indication of artificial nutrition for seriously ill patients at the end of life by physicians working in a private oncology clinic in Manaus-Amazonas (AM), and their perceptions about end-of-life process. Material and Methods: A cross-sectional and observational study based on a qualitative approach. A clinical case involving a hypothetical patient with advanced dementia, not a candidate for disease-modifying therapy, evolving with signs of end of life was applied. The doctors answered in a discursive manner a question about which nutritional option would be the most adequate. Content analysis was used to analyze the data. Results: A total number of 15 specialists physicians acting in a private oncologic clinic in Manaus-AMwere included. Approximately 42.84% of respondents opted to indicate the placement of a nasoenteric feeding tube or a gastrostomy. A large portion of them believed that the patient had the opportunity to treat severe dementia. Conclusions: There is little scientific evidence of the benefits of using artificial feeding in elderly patients with advanced dementia. Further studies are needed in addition to continuing educating initiatives to inform prescribing professionals about the potential related risks of artificial diet at the end of life.

**Keywords:** palliative care, death, diet, Brazil, elderly

## **1. Introduction**

Death is preceded by several medical decisions that directly impact how the dying process will happen [1]. Despite being a sensitive topic for many professionals, being able to make proportional decisions has a significant weight in the last days of life [2]. The process to decide should be a common practice among physicians, especially when they care for patients with advanced diseases. However, many of them still face problems associated with indications or interruption of treatments during the trajectory of some illnesses [3].

All life-limiting diseases have specificities during the final phase of life, some are better defined, such as cancer and others as dementia could be more complex to manage. The survival rate for dementia is around 3 to 10 years. Dementia has a trajectory with progressive losses and decreasing performance that can persist for years [4, 5]. An important dilemma for all progressive conditions is about feeding in the last days of life. The patient in the dying process reduces food intake, progressing in most cases to complete fasting. However, both the medical team and the family question the lack of food offered in this stage of disease evolution [6].

Evidence-based guidelines and approaches that incorporate quality of life and patient preferences as Palliative Care (PC) may help solve this problem [7]. Palliative Care is a holistic approach that aims to alleviate the suffering caused by serious and progressive illnesses. The goal is to maintain the highest possible quality of life in the face of these conditions. It is a person-centered approach where the object of care is the patient, family, and caregivers. In general, provides skills for decision-makers concerning end-of-life dilemmas and affords tools to align care trajectory with patient values and preferences [8].

The incorporation of PC approach in the standard care improves the decisionmaking process, the symptoms control in the last moments of life, and improve communication with the family [9]. However, the lack of education in palliative care among doctors has been one of the most common barriers in providing quality palliative care. Many studies have revealed that professionals often have inadequate knowledge of pain, the use of opioids, management symptoms, and the concept of palliative care and its indications. Public awareness and acceptance of the end of life should involve educational initiatives not only for health professionals but the entire community [10–12].

Given the above considerations, to understand how medical professionals deal with the decision for nutrition at the end of life and also to start studies related to this topic, the objective of the present investigation was to describe the decision experience of the indication of artificial nutrition for seriously ill patients at the end of life.
