Nutrition and Hydration at the End of Life in Intensive Care and General End-of-Life Care Settings: Balancing Clinical Evidence, Patient-Centered Care, and Ethical and Legal Principles—A Narrative Review

Background/Objectives: Nutrition at the end of life raises many dilemmas. “End of life” refers to the period associated with a progressive incurable disease, with a life expectancy of less than six months, and limited curative treatments. In intensive care units (ICUs), decisions about artificial nutrition and hydration (clinically assisted nutrition and hydration, CANH) are especially complex because patient goals shift from survival to comfort. Nutrition and hydration are often requested by patients and their families, even when clinical benefits are uncertain. This article aims to provide a multidimensional analysis of the pathophysiological, clinical, ethical and legal considerations of nutritional support in the final stages of life. Methods: We conducted a narrative review of the literature published between January 2000 and June 2025 by searching the PubMed/MEDLINE, Web of Science, and Scopus databases and included original articles, clinical trials, reviews, international guidelines, and public policy documents involving adult population at the end of life. The narrative approach enabled the multidimensional integration of the collected data. Results: Terminally ill patients often develop anorexia and cachexia leading to irreversible muscle loss and resistance to nutritional support. CANH (enteral or parenteral) has limited success and carries increased risks. In advanced cancer and dementia, studies do not show clear benefits for survival or quality of life. Nutritional counseling and oral supplements may help alleviate symptoms, but manual feeding remains the standard of care in the terminal stages. In ICU settings, starting or maintaining CANH demands careful evaluation of goals, prognosis, and burdens. Cultural legal differences and approaches between countries also influence clinical practice and family expectations. Conclusions: CANH at the end of life should be viewed as a medical intervention that requires both scientific and ethical justification. The decision to initiate or discontinue it should be individualized. Clear and empathetic communication between the medical team, patient, and family is essential to avoid inappropriate decisions.