Dying patients often lose their appetite.The Mayo Clinic lists it as one of five signs that a patient is near death the others are restlessness and agitation, withdrawal, drowsiness and pauses or other changes in breathing.The National Cancer Institute in the US explains it as a natural result of the body shutting down.It says: "The loss of appetite is caused by the body’s need to conserve energy and its decreasing ability to use foods and fluids properly.”But it is often difficult for friends and family to see a loved one not eating enough, or refusing food altogether. The dying person typically faces persistent urging and sometimes even demands by loved ones to eat.How common is it for dying patients at King Edward VII Memorial Hospital to refuse food? Bermuda Hospitals Board dietitian, Tony Ward said: “There are no official numbers but it is likely more common than people think.“Some people may be suffering from depression and lose their appetite; others may not be hungry due to their illness. Some people are also barely conscious and too weak to eat.”KEMH see the matter as an ethical issue but because of its complexity has no policy on what to do when a dying patient refuses to eat.“It’s not something we can write a policy for,’ said Sharon Alikhani, director of Palliative Care at KEMH. “For people who are terminally ill there is most often a loss of appetite or if they have appetite, it is sporadic.”She noted that this is often difficult for family to accept.“It’s human nature to want to feed our families. Most of our socialising as humans is based around food and so we fear that if someone does not eat they will die,” she said.‘It’s our job to educate the families. We explain that this is a natural process and is a protective feature of the body as it approaches death.“Loss of appetite leading up to death, ensures that at the time of death you are not hungry.”Still, many next of kin want their loved one to be fed.Chantelle Simmons, head of the hospital’s Ethics Committee, said while the facility does not have a specific policy on feeding issues at the end of life “some of the ethical principles are incorporated in the informed consent policy which outlines what information must be provided to patients to assist them in reaching a decision and how medical emergencies should be addressed”.Those uncomfortable and/or distressed with their loved one not being fed can take solace in the research findings that feeding the patient will not prolong their life.‘It’s been shown not only in cancer cases but also end-stage dementia and Alzheimer’s, that feeding does not change the outcome,” said Dr Alikhani. “The patients do not live longer.”Dr Simmons noted that feeding a dying person intravenously can actually cause them distress, resulting in them dying sooner.While most patients near death lack appetite, there are some who continue to enjoy food. In such cases at KEMH, they are allowed to eat whatever they want, irrespective of their condition.“It’s about comfort not restriction,” said Dr Alikhani. “At Agape House, where we look after the terminally ill, if they have a wish for something outlandish we try and honour it.“We had one person who wanted shrimp tempura and was even specific on the restaurant it should come from. We were able to get it for him.”