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Thread: Hydration and end of life: what's your thoughts?

  1. #1
    Super Moderator cougarnurse's Avatar
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    Hydration and end of life: what's your thoughts?

    I found this article, and was wondering what others thought about the subject. Any and all thoughts and comments appreciated.

    Hydration at the End of Life: Our Duty or a Burden to the Patient? - Oncology Nursing News

    Whether to hydrate terminally ill patients has been debated for decades and there are wide variations in practice. The decision to give or withhold fluids has depended largely on the attitudes and beliefs of the medical providers or the care setting. But other factors should also enter into these deliberations. This perspective emerged during a symposium discussing hydration at the end of life conducted at the Annual Meeting of the Multinational Association of Supportive Care in Cancer (MASCC), held July 25-27 in Rome. Sebastiano Mercadante, MD, of La Maddalena Cancer Center, Palermo, Italy, and Eduardo Bruera, MD, the F.T. McGraw Chair in the Treatment of Cancer and medical director of the Supportive Care Center at M.D. Anderson Cancer Center, deliberated the pros and cons, respectively, of end-of-life hydration, but the two also found much common ground during the session.

    I
    n the matter of hydration at the end of life, both of the speakers generally agreed that communication between patients, relatives, and care providers is low, but patients or relatives must receive information on all available options. In addition, the benefits and toxicities of hydration (and dehydration) must be carefully evaluated for each individual patient. Table 1 offers some of the arguments for and against hydration.

    According to Dr Mercadante, who argued in favor of hydration, patients treated by palliative care teams receive smaller volumes of hydration compared with those admitted to cancer centers. As a consequence of dehydration or volume depletion and the resulting intracellular changes, patients often develop symptoms such as hypotension and decreased renal function. Additionally, the pharmacokinetics of therapeutic drugs may be altered.

    The difficulty, Dr Mercadante pointed out, is that changes in symptom intensity can be hard to detect as a consequence of dehydration because often symptoms may be present regardless of the hydration level of the patient. Waller et al investigated the effect of intravenous (IV) infusion on blood and urine parameters indicating hydration and on the state of consciousness in terminal cancer patients (Am J Hosp Palliat Care. 1994;11[6]:22-27). They found that the patients receiving IV fluids were similar to dehydrated patients in terms of consciousness and that state of consciousness was inversely related with sodium and urine osmolarity. These findings, said those authors, suggest that there is no clinical benefit to intravenous infusions.

    A more recent but similar observational trial evaluating the association between hydration volume and symptoms in terminally ill cancer patients with abdominal malignancies (Morita T, et al. Ann Oncol. 2005;16[4]:640-647. Epub 2005 Jan 31) revealed no differences in sign and symptom severity between the hydrated and nonhydrated groups, including bronchial secretion, communication capacity, agitation, delirium, myoclonus, and bedsores. Also, there were no differences in changes of nitrogen and creatinine levels. A secondary analysis showed that the hydration group had hypoalbuminemia, but no differences in laboratory measures of fluid-retention signs. The dehydration symptoms would have improved in the no-hydration group if hydrated.

    Dr Mercadante discussed the trial's flaws, saying that a close-to-death assessment homogenizes patients and does not reflect individual needs in a specific situation, which can vary during disease progression. The influence of hydration volume on patients' subjective wellbeing was not evaluated, stressed Dr Mercadante, who also emphasized the findings of the original authors—that the potential benefits of hydration therapy should be balanced with the risk of worsening fluid-retention symptoms.

    Generally, the evidence surrounding hydration is sparse due to difficulties in assessing homogeneity and timing in study populations. Hydration is fundamental for maintaining living and metabolic processes, even during limited nutritional intake when catabolism or futile biochemical processes continue. A constellation of factors including the stage of the disease, patient prognosis, specific clinical conditions, patient wishes, family and physician attitudes, and the level of communication between all parties may suggest solutions other than reflexive hydyration. Although hydration must be based on individual patient issues rather than a strict conceptual framework, according to Dr Mercadante, Table 2 presents his suggestions for general considerations regarding hydration. He also offered some specific questions to ask when assessing the individual patient.

    • Is the patient drinking enough?
    • Does the patient show signs and/or symptoms of dehydration and is he or she suffering from them?
    • Are there laboratory changes in renal function due to low hydration (prerenal insuffiency)? Are the symptoms reversible?
    • What is the short-term prognosis of the patient? Hydration practice varies. Although all patients in acute care units are given fluids, dying patients in hospices are not commonly hydrated. In palliative care most patients receive fluids after admission whereas dying patients receive less and less hydration, explained Dr Bruera.

    Drawing on his own work, Dr Mercadante related his findings in an acute palliative care unit, where most patients and relatives perceived hydration to be beneficial, wanted to continue that treatment at home, and preferred administering it intravenously (Mercadante S, et al. J Pain Symptom Manage. 2005; 30[4]:354-358). Dr Mercadante also presented findings from a study by Bruera et al involving dehydrated patients who received either 1000 mL/d parenteral nutrition or 100 mL/d placebo over 2 days. Hydration resulted in a lower level of sedation, less myoclonus, and fewer hallucinations, he explained. Placebo was also relatively effective (Bruera E, et al. J Clin Oncol. 2005;23[10]:2366-2371). Dr Mercadante noted that it remains unclear whether the symptom improvement was due to the rehydration per se or was the result of a better opioid elimination.

    Dr Mercadante summed up some advantages of IV hydration: In an acute palliative care unit, an IV line allows emergency treatment, the drug availability is 100%, dose titration is expedited, there are no problems with fluid volumes, and the needle changes are similar to subcutaneous routes.

    According to Dr Bruera, whose thinking about parenteral hydration has been formed by his experiences in the United States, all
    cancer patients die in American hospitals with an IV, and the volume of infusion is excessive in acute care facilities. Subcutaneous hydration may be managed by the patient's family at home and avoid the need for expensive portable infusion devices; however, as he also pointed out, subcutaneous hydration using a butterfly needle is a method that is almost unknown in the United States. Dr Bruera argued for conducting randomized clinical trials on hydration, as withholding hydration is currently not evidence-based.

    Once again, the need to address the particular patient's situation was emphasized by Dr Bruera. Dehydration may lead to postural hypotension, asthenia, confusion, hallucination, and decreased renal function. Hydration may decrease agitated delirium and increase the elimination of hydrosoluble drugs. The results of a retrospective study suggest that hydration may help prevent the development of agitated impaired mental status (Bruera E, et al. J Pain Symptom Manage. 1995;10[4]:287-291). A smaller volume of infusion seems to have a number of advantages, including decreased body mass, decreased agitational activity, and less urinary excretion of free water.

    Patients can receive hydration at home by the simple technique of subcutaneous hydration, although, as noted by Dr Bruera, the technique is not commonly used in the United States. An alternative method to subcutaneously infuse parenteral hydration fluids is hypodermoclysis; hyaluronidase is usually added to the solution to improve absorption. A randomized, double-blind crossover study compared 300 units vs 150 units of hyaluronidase given before bolus infusion of 500 mL over 1 hour (Bruera E, et al. J Pain Symptom Manage. 1995;10[7]:505-509). There was no difference between the 2 doses of hyaluronidase and no significant difference between patients and investigators in preference for bolus infusion or overnight clysis. The results of another trial comparing hyaluronidase and placebo suggested that hyaluronidase is not necessary for routine bolus subcutaneous hydration. Steel needles can remain in place for 5±3 days.

    Session attendees heard several arguments for and against the administration of hydration at the end of life. Dr Bruera pointed out that there are no data from randomized clinical trials evaluating the benefits and toxicities of hydration in dying cancer patients. Physicians should inform patients and relatives about all available options, including subcutaneous fluid administration, which represents a minimally invasive, simple, and relatively inexpensive technique.

    Ultimately, the decision to hydrate depends on a number of biological factors as well as the wishes of patients and their family. Hydration therapy should only be given if it contributes to the patient's overall treatment goals, which in turn should be determined based on the patient's situation and the interests of the patient and the family. If the goal is to provide comfort care only, hydration may not be appropriate and may add to the patient's discomfort.


  2. #2
    Senior Member suebird3's Avatar
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    Re: Hydration and end of life: what's your thoughts?

    Here's an interesting article from OWM: To Feed or Not to Feed: Nutrition Considerations at the End of Life | Ostomy Wound Management

    Most people hope for a respectful, peaceful death, one where they just slip away into the night. Unfortunately for many patients and their families, the end of life is not a single instant but rather a long complicated period fraught with agonizing decisions. The decision on whether to feed a loved one who is at the end of life is often excruciatingly painful. The media have played out several lengthy debates involving enteral or artificial feeding — patients Nancy Cruzan and Terri Schiavo became household names as their families battled about feeding issues regarding loved ones in a persistent vegetative state. These explosive media cases are infrequent but registered dietitians (RDs) and healthcare practitioners in home care, hospitals, and extended care facilities must deal with the question of feeding at the end of life on a daily basis.

    The research on feeding patients with end-stage dementia is plentiful and growing. A search on PubMed using the keywords tube feeding and dementia found 282 articles published between 1980 and 2009. Many of these studies indicate that healthcare professionals are not adequately informed on the benefits versus the burdens of educating patients and families responsibly when no instructions on end-of-life feeding wishes pre-exist. Because our elderly population is expected to quadruple by 2050, patients with severe dementia and the accompanying nutrition and hydration problems will continue to increase, and we will need to become better prepared to provide education.1

    The evidence is sound that patients with terminal dementia, regardless of etiology, have difficulty eating, swallowing, or having food fed to them, resulting in unintended weight loss and/or aspiration, which eventually leads to death. Although it goes against commonly held beliefs, numerous studies have shown that aggressive enteral nutrition at the end of life does not necessarily extend life, increase body weight, reduce the incidence of pressure ulcers, or reduce the risk of aspiration.2

    Despite the fact that up to one third of patients with severe dementia receive tube feedings (TFs), a recent Cochrane Database Review3 suggested that TF may actually increase the death rate, increase the number of new illnesses, and reduce quality of life. A recent study4 of nursing home residents with dementia revealed mortality was 64.1% with a median survival of 56 days within 1 year following percutaneous endoscopic gastrostomy (PEG) insertion.

    Watching a loved one stop eating and/or drinking is difficult to bear, even when we know that it is that individual’s wish. The situation is even more trying when family members and caregivers do not know the patient’s terminal preference. The word starvation becomes top of mind and conjures up brutish images for most people. The phrase dying of starvation often is bandied about but is not technically accurate because the patient will likely expire from dehydration first. At the end of life, patients have a tendency to lose the desire to eat or drink because their appetite and thirst are minimized. Their metabolism changes, organ function slows, and the resultant elevated level of ketones produces a mild sense of euphoria. Starving people generally want food. Dying people do not. RDs and team members should help family members understand this change in metabolism and avoid the use of the word starvation.

    We now also know that gradual dehydration is not painful; in fact, many patients report less discomfort as dehydration runs its course and have fewer requests for pain medication. Complaints of a dry mouth are treated more effectively by good mouth care along with ice chips, if the patient is alert. If the patient is not alert, mouth swabs are recommended rather than intravenous fluids. In reality, the administration of food and fluids to dying patients can extend their general discomfort and frustrate their desire to just let go and allow nature to take its course.5

    PEG tube placement became common in 1979, providing a lower risk option to surgical placement of the traditional gastrostomy tube. However, even the PEG tube placement procedure itself is not without risks. Peristomal wound infections can range from 5% to 25%; thus, postoperative use of antibiotics is common.7–9 Patients who are malnourished often have fragile skin, while patients with diabetes may have difficulty healing. These pre-existing concerns may put the patient at higher risk for post-PEG tube placement issues. Table 1 lists the major and minor complications encountered with PEG tube placement.6

    The discussion of a patient’s feeding wishes should take place long before a decision is needed. If aggressive support is desired, PEG placement should occur when it first becomes evident the patient can no longer consume adequate nutrition to avoid unintended weight loss. Often, PEG tubes are placed too late, making it impossible to regain the benefits that may have resulted from earlier placement.

    When organ function is declining and lab values such as potassium, magnesium, and phosphorus are not monitored adequately, aggressive re-feeding of a malnourished patient is rife with risk. Additional PEG tube problems can include the need to restrain a patient’s hands to avoid tube removal because of confusion, which can raise risk for skin damage; increased urination and stool output, which can worsen existing sacral pressure ulcers; and increased coughing and congestion from improved hydration. TF also deprives the patient from contact with staff if hand feeding is no longer provided, as well as the enjoyment of the taste of food, even if oral intake was previously minimal.10

    Communication with the patient and family is of utmost importance. Often the decision to insert a feeding tube is made inappropriately because of lack of information or misinformation provided by the healthcare team. This can create unrealistic expectations of the benefits a patient actually will receive from the TF and sometimes leads to litigation. Consider the loving daughter who testified that she refused a TF for her mother because the nurse posed the question in a leading manner. According to her testimony, the nurse flippantly asked, “You’re not going to want a tube feeding, are you?” The daughter felt pressured to agree with the nurse’s negative opinion of TF, but also felt uncomfortable that she was making life-and-death decisions without all the facts. After doing some research on her own, she decided she definitely wanted a TF and had her mother transferred to another facility where her mother received a PEG tube. Her mother’s condition improved for a period of time, but she was still angered by this event and eventually sued the first facility. Another interesting point in her testimony was her comment that the discussion about TF took place in the hallway outside of her mother’s room and lasted only 3 minutes.

    Often, patients and/or family members may not ask about their choices because they do not know that foregoing food and fluids is a legitimate option at the end of life. Both the person who is ill and the caregiver should complete an Advanced Health Care Directive to designate an official spokesperson to give caregivers the ability to speak for the individual who becomes too sick or too confused to make decisions. It is important that family members keep Advanced Health Care Directives where they can find them quickly and update them when necessary. If the healthcare surrogate listed has predeceased the patient, revision is essential. Family discussions on these directives are recommended so loved ones are clear on everyone’s wishes and can honor them appropriately.

    The moral and ethical uncertainty facing patients, healthcare surrogates, and physicians when confronted with the choice to withhold nutrition and hydration likely drives the decision to place PEG tubes in many patients who are unlikely to derive any benefit. It sometimes is difficult to put ethical and religious beliefs aside when assisting families to make uncomfortable end-of-life decisions. It is essential that healthcare team members know when to switch to palliative support versus curative care. However, it is uncertain whether interventions such as improved staff education about the limitations of PEG tubes to improve outcomes, increased use of palliative care teams, and increased use of Advanced Health Care Directives will help decrease in PEG tube placement in patients with end-stage illness.

    When nutrient intake is insufficient to meet physiologic needs, competition for the available nutrient substrate occurs. Wound healing is not the biological priority so do not be discouraged if the person has stagnant or worsening wounds.

    If you do not feel comfortable addressing nutrition choices with a terminal patient’s family, educate yourself and practice what you might say. Some guidance, including a script on this sensitive topic, is found at www.RD411.com in the Conversation Starters section. Also see Helpful Resources.

    The healthcare team and family may decide to discontinue weighing a patient after a decision is made to forego TF and all attempts to improve oral intake have failed. The act of weighing may disturb the sick patient, upset the family if significant weight loss occurs, and take time away from staff that is better spent elsewhere. The attending physician can provide an order to discontinue weight monitoring if the family and team members are all in agreement.

    A medical care facility in Michigan found that providing a booklet11 with their admission packet that outlines the process of withholding nutrition and hydration near the end of life is helpful in educating families early in the end-of-life decision process.

    TF can continue once a patient is approved for hospice services; this should never deter families who wish to take advantage of the supportive and pain management services hospice can provide when life expectancy is less than 6 months.

    When poor meal intake and unintended weight loss are first noticed, an aggressive care plan should be put in place, communicated to all involved parties, and documented in the medical record. Do not wait until patients have lost 10% or more of their usual body weight to begin interventions. Early identification and timely intervention is the key.

    Set an example by taking stock of your own wishes for end of life care and complete the necessary paperwork now. This will give you and your family peace of mind.

    Enteral nutrition surely has its role in medical care, but it is not a cure-all. As with every medical intervention, it is necessary to carefully weigh the risks and benefits. Death is not a comfortable topic in American culture but in order to provide the best care for our patients, healthcare practitioners must show the ability and willingness to tackle this topic. It is only with our guidance, compassion, and knowledge that we can help patients and families explore and contemplate all the options open to them, including the choice to feed or not to feed.

  3. #3
    Ricu
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    Re: Hydration and end of life: what's your thoughts?

    This issue comes up often in the critical care unit where I work and is I believe, handled well. As was discussed in the article, educating family about the disease process, here endstage dementia, is paramount to helping them come to terms with the eventual death of their loved one. As stated, these individuals don't feel hunger or thirst so therefore, really don't experience discomfort related to not being fed. As will always be the case and appropriately so, the family wants comfort care to be given which usually includes medication to dry oral secretions and to treat pain, anxiety and so forth. If requested by family for what is perceived as pain, medications ordered should be given without question because the goal is a peaceful experience of death. This includes the family.

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