Janet Goodwin, 36, is close to death from ovarian cancer. She's receiving intravenous (I.V.) fluids and has developed peripheral and pulmonary edema. At this point, her family wants to know if I.V. therapy is worthwhile or simply causing her to suffer.
Whether to give I.V. fluids to terminally ill patients has been debated for decades. After 23 years of practicing, teaching, researching, and writing about hospice and palliative care, I believe that dehydration at the very end of life is usually more merciful than hydration. But I also believe that each situation is unique and that health care professionals should never take a hard line for or against giving infusions to a dying patient. In this article, I'll explain what we know about fluid's effects on the dying body and why dehydration is generally the better option.
The dying body can't manage fluids
Because cardiopulmonary failure reduces cardiac output and tissue perfusion, a dying patient's body can't manage fluids normally. At the same time, nature restricts fluid intake and accelerates fluid loss: Diminished energy and activity, nausea, dysphagia, or anorexia limits intake; vomiting, diarrhea, wound drainage, or bleeding increases fluid losses.
Artificial hydration in a patient who has end-stage organ failure worsens peripheral and pulmonary edema, ascites, edema around tumors, and pleural effusions. Dehydration can gradually decrease peripheral edema, relieve painful pressure around tumors, limit pulmonary secretions and effusions, and increase her comfort by:
* reducing urine output, so she's less likely to need catheterization or wet the bed
* decreasing fluid in the gastrointestinal tract, minimizing vomiting and the need for a nasogastric tube
* drying pharyngeal secretions, so they don't accumulate and cause the “death rattle”
* eliminating the need for uncomfortable infusions.
Dehydration also may provide natural analgesia at the end of life. Studies have shown that animals with terminal dehydration and starvation produce natural opioids, which provide an anesthetic effect. If humans respond in a similar way, dehydration at the very end of life can be comforting and compassionate.
What's the downside of dehydration?
Now that you're aware of how dehydration can benefit patients with terminal illness, you may wonder about the disadvantages. For example, does it hasten death? Ironically, two studies found that dehydrated dying patients survived longer than those who received fluids. No studies have clearly demonstrated that hydration prolongs survival at the end of life.
Every effort should be made to maintain fluid balance for as long as possible. Encourage oral fluid intake as the patient chooses. As ordered, administer appetite enhancers, such as corticosteroids, and appropriate medications to control fluid losses from vomiting and diarrhea. If she has reduced intake secondary to depression or confusion, treating the cause may alleviate the problem.
Dehydration is natural and predictable at the very end of life unless artificial hydration is initiated. The most common symptom in the dying is dry mouth also caused by other factors that affect terminal patients, such as mouth breathing, oxygen therapy, radiation therapy, infection, dried sputum, and adverse medication reactions. Meticulous oral care helps provide relief. Moisten your patient's mouth with sips or sprays of a favorite beverage or offer her candies or ice chips if aspiration isn't a risk.
As her kidneys fail and azotemia accelerates, she may develop neuromuscular irritability and reduced level of consciousness. Decreased blood sodium levels may further compromise her mental status. Although these cognitive and neurologic changes are troublesome, they won't improve with fluid therapy because they're caused by multiple organ failure.
When hydration can help
Although I generally advocate dehydration for dying patients, I never lose sight of the fact that hydration is sometimes appropriate. For example, it may improve the quality and length of life for someone with acute infection related to acquired immunodeficiency syndrome (AIDS) who hasn't progressed to end-stage organ failure. In someone with malignancy-related hypercalcemia who's weeks away from death, hydration can dramatically improve cognitive function. It dilutes the high levels of calcium to relieve hypercalcemic symptoms, allowing her to interact with others and make choices about her care. (Questions in Fostering Informed Choice will help your patient decide whether hydration is right for her.)
Some clinicians report that small-volume infusions at the end of life can improve patients' mental status and reduce agitation. They advocate hydration to help prevent renal failure, which causes accumulation of drug metabolites—especially opioid metabolites—that lead to confusion, myoclonus, and convulsions.
To help Ms. Goodwin and her family decide whether hydration is right for her, ask them about quality of life. If small amounts of fluid may reduce delirium and restlessness to help her stay alert, she may want a trial. Or she might choose infusions for a specified period to renew alertness, such as when out-of-state relatives are expected. Keep in mind, however, that prolonged awareness includes awareness of prolonged suffering.
As you discuss the pros and cons of hydration with your patient and her family, review the technical aspects of various techniques.
I.V. hydration. Although an I.V. line can be useful to deliver medications and patient-controlled analgesia, it requires professional insertion and management, costly equipment, and vigilant care. Complications of I.V. infusion include infiltration or infection at the insertion site, embolism, fluid overload, and septicemia.
Subcutaneous infusion. Known as hypodermoclysis, subcutaneous infusion is a low-tech option that lay caregivers can readily learn. Using a small-gauge needle for access to subcutaneous tissue, this system can deliver continuous infusions. The primary complication is inflammation at the insertion site.
Rectal infusion. This technique, known as proctoclysis, can be used when problems such as edema or bleeding prevent subcutaneous infusion and no other route is possible. A 22 French nasogastric catheter is inserted about 16 inches (40 cm) into the rectum to infuse about 100 ml/hour of tap water or 0.9% sodium chloride solution. The method is generally comfortable and family members can do it, but leakage can be a problem. Maximal infusion rates can have the effect of an enema.
Enteral nutrition. Tube feedings enhance hydration, but they pose risks of aspiration pneumonia, infection, and other complications. Recent studies on patients with advanced dementia found that tube feedings aren't necessary to prevent suffering and that insertion and restraint use may cause new problems.
Promoting up-front decisions
Discussing the pros and cons of infusion therapy helps your dying patient and her family make informed decisions. By giving them the information they need, you provide a key aspect of comfort-focused terminal care.
Fostering informed choice
At the very end of life, the goal of care is to relieve suffering. Hydration at this time should be chosen for a clearly identified benefit. Review these issues to help your patient and her family make informed choices.
Questions for the patient and family
* What's most important to you now?
* Would you like to go over the pros and cons of fluid therapy?
* How would the choice of artificial fluids support or not support your beliefs about what you value most today?
Practical questions about therapy
* Does hydration offer a reasonable chance of benefit or is it an unnecessary or even harmful burden?
* What are the potential or actual hardships of fluid therapy?
* Is artificial hydration a wise use of technologic, economic, and human resources?
SELECTED WEB SITES
Dying Well, Defining Wellness through the End of Life
Hospice and Palliative Nurses Association http://www.hpna.org
On Our Own Terms: Moyers on Dying
Palliative Care: One Vision, One Voice
Last accessed on January 2, 2003.