NURSING ASSESSMENT, IMPLEMENTATION AND DOCUMENTATION A discourse analysis of difficult clinical situations in relation to nutrition and hydration during end of life care Pamela van der Riet, Isabel Higgins, Phillip Good and Ludmilla Sneesby Aim and objectives. The following discussion builds upon a previous publication that reported on the perceptions and dis- courses of palliative care nurses and doctors in relation to nutrition and hydration at the end of life. The aim of this paper is to report the discourses of nurses and doctors in relation to the challenges they faced when managing the care of patients with severe brain injury vs. the clearer cut situations when caring for terminally ill patients with cancer. The objectives of the study were to: • explore the tensions in the discourses during end of life care, • explore the challenges regarding nutrition and hydration at the end of life. Background. The decision to withdraw life support seems to be made more readily than the decision to withdraw nutrition and hydration at the end of life. The abatement of nutrition and hydration during the terminal phase of life is a controversial issue for a range reasons. Indeed, whilst it is accepted practice in the palliative care setting, nurses and doctors often struggle with the idea. Design. The design for this study used discourse analysis framed by a post structural framework. Method. Focus groups were conducted with nurses working in palliative care units. Single interviews were conducted with doctors from a tertiary palliative care unit. Results. The findings revealed contesting discourses involving quality of life and the prolongation of life. Conclusions. The provision of food and fluid has profound emotional and social meanings for patients and families. The study reported here examined these issues with health professionals. The findings point to the challenges and tensions faced by health professionals in relation to decision making and medical hydration during end of life care. The concern is that tensions arise when decisions need to be made and how best to make these. The contesting discourses for nurses and doctors when nutrition and hydration is ceased involve maintaining quality of life vs. the prolongation of life. Relevance to clinical practice. Medical and nursing staff have different attitudes and beliefs towards end of life care. Tensions arise when decisions need to be made based on quality of life or prolongation of life. The successful merging of curative and palliative care is not without challenges. There has been little exploration of this situation. Key words: end of life care, hydration, nurses, nursing, nutrition, palliative care Accepted for publication: 23 October 2008 Authors: Pamela van der Riet, RN, ICCU/CCU Cert, Dip Ed (Nursing) BA, Master of Education, PhD, Senior Lecturer and Deputy Head, School of Nursing and Midwifery, University of Newcastle, Callaghan Campus, Callaghan NSW, Australia; Isabel Higgins, RN, RICN, AssDipNurseEd, MN, PhD, Professor of Nursing, Older Person Care, School of Nursing and Midwifery, University of Newcastle, Callaghan Campus, Callaghan, NSW, Australia; Phillip Good, MBBS FRACP, Palliative Care Specialist, Division of Palliative Care, Newcastle Calvary Mater Hospital, Hunter Region Mail Centre NSW, Australia; Ludmilla Sneesby, RN, RM, BA, Nursing and Masters in Nursing (advanced clinical education), Clinical Nurse Consultant, Division of Palliative Care, Newcastle Calvary Mater Hospital, Hunter Region Mail Centre NSW, Australia Correspondence: Dr Pamela van der Riet, Senior Lecturer and Deputy Head, School of Nursing and Midwifery, University of Newcastle, Callaghan Campus, Callaghan NSW 2308, Australia. Telephone: +612 4921 6261. E-mail: Pamela.vanderiet@newcastle.edu.au 2104 Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 2104–2111 doi: 10.1111/j.1365-2702.2008.02760.x