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.
In 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.