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Fast Fact and Concept #133
Non-Oral Hydration in Palliative Care |
| Author(s): Robin Fainsinger At the center of
the debate with regard to hydration in terminally ill patients is the
desire to maintain comfort and avoid unnecessary/distressing procedures.
There is no controversy that terminally ill patients should be encouraged
to maintain adequate oral hydration for as long as possible. However there
is debate and controversy around the use of parenteral hydration.
Arguments Against Hydration
 | comatose patients do not experience symptom distress |
| parenteral fluids may prolong dying |
| with less urine there is less need to void and use catheters |
| with less gastrointestinal fluid there can be less nausea and
vomiting |
| with less respiratory tract secretions there can be less cough and
pulmonary edema |
| dehydration can help reduce distressing edema or ascites |
| dehydration may be a “natural” anesthetic to ease the dying process
|
| parenteral hydration can be uncomfortable (e.g. needles/catheters)
and limit patient mobility |
Arguments For Hydration
| dehydration can lead to pre-renal azotemia, which in turn can lead
to accumulation of drug metabolites (notably opioids), leading to
delirium, myoclonus and seizures. Hydration can reverse these symptoms
in some patients leading to improved comfort |
| there is no evidence that fluids prolong the dying process |
| providing hydration can maintain the appearance of “doing
something”, even though there may be no medical value, and thus ease
family anxiety around the time of death |
Ethical/Legal Issues
In the United States, the following ethical/legal standards exist:
| Competent patients or their surrogate decision-makers can accept or
refuse hydration based on relevant information. |
| Non-oral hydration is considered a medical intervention,
not ordinary care--as such, there is no legal or ethical
imperative to provide a medical intervention unless the benefits
outweigh the burdens. |
Recommendation
There is research literature to support both the use of, and
withholding of, non-oral hydration in patients near death; thus, there is
no consensus on the single best approach to care. Key issues to be
considered when determining the role of non-oral hydration include the
following:
| Expressed wishes of the patient or surrogate decision-maker
regarding use of hydration; |
| Patient-defined goals; the presence of a specific goal may direct
the clinician to use hydration as a means to improve delirium and
potentially delay death; |
| Symptom burden: symptoms related to total body water excess may
improve by withholding hydration, while delirium may lessen with
hydration; |
| Burden to the patient and caregivers of maintaining the non-oral
route of hydration; |
| Family distress concerning withholding hydration/nutrition; |
| When in doubt, a time limited hydration trial is an appropriate
recommendation. |
Finally, it is important to recognize that health care providers often
have biases for or against non-oral hydration near the end-of-
life—self-reflection upon these biases is crucial to help patients and
families make decisions that are based on the best interests and goals of
the patient/family unit.
References
Fainsinger RL. Hydration. In: Ripamonti C; Bruera E. Editors.
Gastrointestinal Symptoms in Advanced Cancer Patients. Oxford University
Press, 2002: 395-410.
MacDonald N. Ethical considerations in feeding or hydrating advanced
cancer patients. In: Ripamonti C; Bruera E. Editors. Gastrointestinal
Symptoms in Advanced Cancer Patients. Oxford University Press, 2002:
411-423.
Lawlor PG. Delirium and dehydration: Some fluid for thought? Support
Care Cancer 2002; 10:445-454.
Sarhill N, Walsh D, Nelson K, Davies M. Evaluation and treatment of
cancer related fluid deficits: Volume depletion and dehydration. Support
Care Cancer 2001; 9:408-419.
Copyright/Referencing Information : Users are free to
download and distribute Fast Facts for educational purposes only. Citation
for referencing: Fainsinger R . Non-oral hydration in palliative care.
Fast Facts and Concepts #132: April 2005. End-of-Life Physician Education
Resource Center www.eperc.mcw.edu.
Disclaimer: Fast Facts provide educational information, this
information is not medical advice. Health care providers should exercise
their own independent clinical judgment. Some Fast Fact information cites
the use of a product in dosage, for an indication, or in a manner other
than that recommended in the product labeling. Accordingly, the official
prescribing information should be consulted before any such product is
used.
Creation Date: 3/2005
Purpose: Self-Study Guide, Teaching
Audience(s)
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Training: Fellows, 3rd/4th Year Medical Students,
PGY1 (Interns), PGY2-6, Physicians in Practice |
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Specialty: Anesthesiology, Emergency Medicine,
Family Medicine, General Internal Medicine, Geriatrics,
Hematology/Oncology, Neurology, OB/GYN, Ophthalmology,
Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery |
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Non-Physician: Nurses |
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