Guidelines for a Palliative Approach in Residential Aged Care

appear until dehydration is far advanced. Therefore, early assessment of signs of dehydration
may be important to consider (e.g. high sodium, high blood-urea-nitrogen, and creatinine).
A systematic review was conducted that examined the existing clinical evidence regarding
the effects of fluid status and fluid therapy on the dying; however, no RCTs or higher quality
studies were located. [204] Given the limitations in the studies reviewed, it was considered
impossible to draw firm conclusions regarding clinical care. The only suggestion regarding
management was to assess each person’s individual circumstances, including the person’s and
their family’s wishes, in order to formulate recommendations regarding fluid therapy for that
person [204] (Level IV).
Although there is some evidence that dehydration can increase the risk of ulcers and
constipation there is no evidence to date that rehydration makes people more comfortable [205]
(Level IV). Rehydration may also have a negative effect on cognition and anecdotal evidence
suggests that improved cognition has been reported after withdrawal of the hydrating
process [206] (Level EO). Intravenous hydration may have negative psychological effects in that
the infusion acts as a barrier between the resident and the family. It is more difficult to embrace
a person who is attached to a plastic tube, and doctors and nurses tend to become diverted from
the more human aspects of care in order to concentrate on the control of fluid balance and
electrolytes when these interventions are used. [189]
A possible indication for rehydration is that the resident feels dry despite good mouth care.
Dry mouth is a common problem in many people and is related not only to dehydration but
also to other causes such as drugs, oxygen therapy, candidiasis and mouth breathing [189] (Level
EO). Thus, artificial hydration alone is unlikely to resolve the symptom of dry mouth in most
people [201] (Level QE). Additionally, individual’s who are dying may not have any sensation of
thirst and should hydration be required it can be successfully alleviated with small sips of liquid
and adequate mouth care [185] (Level IV) or finely crushed ice chips [207] (Level EO).
Management
Regular presentation of fluids to bedridden older people can maintain adequate hydration
status [202] (Level II). A US study was conducted to explore whether the regular presentation of
fluids to 51 residents would result in an increased consumption of oral hydration [208] (Level IV).
The intervention involved the use of two colourful beverage carts (1 yellow, 1 red, because older
people can see these two colours best), which contained a variety of cold and hot beverages that
were dispensed in colourful plastic cups. (The cart was also decorated in accordance with the
season or any relevant holidays.) The results showed a significant increase in the fluid intake
for most of the residents, an increase in the number of bowel movements, a significant decrease
in the number of laxatives residents required, a decline in the number of falls, and a decrease
in cost during the hydration period (presentation of regular fluids via two beverage carts) [208]
(Level IV). This simple, cost-effective intervention resulted in a variety of improvements for
those residents who were able to swallow fluids and it is likely that similar results would be
obtained by applying this approach to Australian residents. However, for those residents unable
to swallow other approaches need to be determined.
94 Guidelines for a Palliative Approach in Residential Aged Care