Rehydration in palliative and terminal care: if not- why not?

Abstract

Patients who are in the last few days of life are often too frail to take oral fluids and nutrition. This may be due entirely to the natural history of their disease, although the use of sedative drugs for symptom relief may contribute to a reduced level of consciousness and thus a reduced oral intake. Rehydration with intravenous (i.v.) fluids is the usual response in acute care settings, whereas the hospice movement has often argued against this approach. The issues are complex and involve not only physical, psychological and social concerns, but also ethical dilemmas. A review of the literature gives conflicting reports of the physical discomfort that may be attributed to dehydration in dying patients. There are many confounding variables, including the concomitant use of antisecretory drugs, mouth breathing and oral infection. It remains unproven whether i.v. fluids offer symptomatic relief in this situation. Hospice doctors are concerned that the use of i.v. fluids gives confusing messages to relatives about the role of medical intervention at this stage in a patient's illness. A drip may cause a physical barrier between a patient and their loved one at this important time. The use of other methods of fluid replacement are discussed. In the absence of definitive research in this area, the balance of the burdens and benefits of such treatment remains subjective. The prime goal of any treatment in terminal care should be the comfort of the patient. Decisions should be made on an individual basis, involving both patients and their carers wherever possible. Prolonging life in such circumstances is of secondary concern and i.v. fluids given in this context may be futile. The ethical dilemmas of withholding and withdrawing medical treatment in addition to those of conducting research in this area are discussed.

Determinants of the sensation of thirst in terminally ill cancer patients

“…On the other hand, existing evidence about the role of dehydration in sensation of thirst in terminal patients is at most preliminary, despite recent aggressive discussion in the palliative care literature [3,4,11,18,21,25]. Whereas several empirical studies have demonstrated that biochemical dehydration is not correlated with the symptom [5,13,23,24], these studies have considerable methodological limitations [31].…”

When to treat dehydration in a terminally ill patient?

“…Despite coming from different perspectives, there is a consensus from a number of palliative care groups [19,24,25,47,49] that:…”

“…The impact of dehydration and rehydration on the renal function and electrolyte balance of terminally ill patients, however, is still being questioned. Dunphy et al [19] have stated that the published blood biochemistry of patients dying in hospice in-patient units, suggest a "greater degree of biochemical normality than might be predicted." Waller [49] noted that a linear correlation between measurable indices of dehydration and fluid volume provided still needs to be demonstrated.…”

“…Oliver [44] has been quoted [19] as demonstrating the "biochemical normality" of terminally ill patients who had not received parenteral hydration. Oliver reported that 22 of 200 patients with advanced cancer died unexpectedly while being studied for hypercalcaemia.…”

Is there a place for artificial hydration in end of life care

“…Research indicates that fluid can be given in a number of different ways, and for those whose health and physical being is fragile, hypodermoclysis could be considered (Dalal, Del Fabbro, & Bruera, 2009;Dunphy, Finlay, Rathbone, Gilbert & Hicks, 1995;Steiner, & Bruera, 1998). The benefits and burdens of this treatment must be clearly understood by the individual and family members.…”