Prof. Dr. John Ellershaw - Dehydration and the dying Patient

DEHYDRATION AND THE
DYING PATIENT
John Ellershaw MA FRCP
Professor of Palliative Medicine, University of Liverpool
Director, Marie Curie Palliative Care Institute
Liverpool

DEHYDRATION AND THE DYING
PATIENT
Clinical scenario
Dehydration
Hydration
Study of terminal dehydration
National Council Guidelines
Clinical scenario

Clinical Scenario

DEHYDRATION AND THE DYING
PATIENT
Clinical scenario
DEHYDRATION
Hydration
Study of terminal dehydration
National Council Guidelines
Clinical scenario

DEHYDRATION
Symptoms relieved by local measures
(Billings 1985, Burge 1993)
May be beneficial: e.g. decreased
respiratory tract secretions (R.T.S.)
(Regnard
1991)
Fluid therapy: has complications, may
act as a barrier ( Lancet Ed. 1986)

DEHYDRATION SYMPTOMS OF
PALLIATIVE CARE PATIENTS (Burge 1993)
Cross sectional survey (6 months)
Objectives
Describe the distribution of symptoms
Association between dehydration and measures
of dehydration

INCLUSION CRITERIA
> 18 yrs
diagnosis of cancer
prognosis < 6/52
52 included in the study
27% survived < 14 days

THIRST vs
CONFOUNDING VARIABLES
Iatrogenic:
98% of subjects on drugs that decreased saliva:
relationship not analysed
Oral disease:
VAS increased by 15mm

CONCLUSION
Symptoms:
Increased fatigue / dry mouth / thirst
Pleasure in drinking - relieves symptoms
No association between thirst and;
Fluid intake
Biochemical measures

DEHYDRATION AND THE DYING
PATIENT
Clinical scenario
Dehydration
HYDRATION
Study of terminal dehydration
National Council Guidelines
Clinical scenario

HYDRATION
Decreases distress of patients/carers
(Michetich
1983)
Relief of distressing symptoms
(Fainsinger 1994)
Emotive
(Craig 1994)

“No relatives should be forced to watch a loved one
die while other medical staff insist on witholding
hydration. This has happened to my knowledge.
Such an experience is deeply disturbing and could
haunt a person forever. Is all this agony worth it for
the sake of avoiding a drip.”
Craig 1994

“It has become our standard of care to offer
hydration by hypodermoclysis to all patients who are
dehydrated or at risk of becoming dehydrated.”
Fainsinger 1994

USE OF HYPODERMOCLYSIS FOR REHYDRATION
IN TERMINALLY ILL CANCER PATIENTS
(Fainsinger 1994)
100 consecutive patients
69 received HDC - average 14 days
1200mls subcutaneously per day
Hyaluronidase 750 units/litre

SITE CHANGES OF SUBCUTANEOUS
NEEDLE
71 cases - Leakage/Swelling
56 cases - Inflammation
16 cases - Bleeding/ Bruising
NO ASSESSMENT OF SYMPTOM CONTROL

REASONS FOR
DISCONTINUING HDC
1 - Family request
2 - Renal failure
1 - Increased ADH
3 - Oedema
1 - Patient request
1 - Pulmonary oedema
2 - Allergic reaction
Total = 11

CONCLUSION
Standards of care
16% complications
2 side effects regarding the site of the
subcutaneous needle per patient
No evidence of improved symptom control

DEHYDRATION AND THE DYING
PATIENT
Clinical scenario
Dehydration
Hydration
STUDY OF TERMINAL DEHYDRATION
National Council Guidelines
Clinical scenario

The Dying Patient and Dehydration
(Ellershaw et al 1995)
Investigation into the symptoms thought to be
related to the level of hydration in the dying patient.
Respiratory tract secretions
Dry mouth and thirst
Efficacy of palliation of these symptoms in a
hospice setting

AIMS OF STUDY
Investigation into the symptoms thought to be
related to the level of hydration in the dying
patient:
Respiratory tract secretions
Dry mouth and thirst
Efficacy of palliation of these symptoms in the
hospice setting

CRITERIA FOR INCLUSION
Patients admitted to the hospice with advanced
cancer.
Consent
Patients taking sips of fluid or no longer taking
oral medication

RESULTS
Number of subjects 82
Age range 43 - 89 years (median 73)
Days until death 1 - 5 days (median 2)
No artificial fluid therapy given

BIOCHEMICAL ANALYSIS (N = 82)
Mean Median N.R.
Osmolality
mOsm/kg 298 295 274 - 295
Creatinine
umol/l 177 111 60 - 120
Urea
mmol/l 15.5 11.9 2.5 - 6.5
Sodium
mmol/l 139 140 133 - 148

CONCLUSIONS
Respiratory Tract Secretions
Increased in primary lung cancer
Respiratory tract infection?
22% of subjects had persistent R.T.S.
3 subjects required suction for R.T.S.

Do You Have a Dry Mouth ?
100
80
%
60
40
Yes
No
20
0
n=23 Group A n=7 Group B n=16

Do You Feel Thirsty ?
%
90
80
70
60
50
40
30
20
10
0
n=23 Group A n=7 Group B n=16
Yes
No

Use Of Drugs Known to Cause
Dry Mouth (n = 23)
Antidepressant
Antihistamine
Hyoscine
Phenothiazine
Opiate
0 20 40 60 80 100
%

Biochemistry
CONCLUSIONS
Dry Mouth & Thirst
Very symptomatic patients
Not solely related to level of hydration
Iatrogenic
Thirst not centrally mediate

Health Care Professionals Perceptions of Hydration in
Terminally Ill Patients (Morita et al 2004)
Questionnaire doctors and nurses
Clinical observations
– increase of fluid retention symptoms
– limited response to symptoms
Routine artificial hydration is not recommended

Laboratory findings and fluid balance in
terminally ill patients (Morita et al 2006)
Patients with abdominal malignancy
Hydration group n=44 Non-hydration group n=81
Hydration > 1 litre per day at 1 & 3 weeks before
death
Results
– hydration may cause hypoalbuminaemia
– no clear benefits biochemically
– no clear benefits for symptom control

DEHYDRATION AND THE DYING
PATIENT
Clinical scenario
Dehydration
Hydration
Study of terminal dehydration
NATIONAL COUNCIL GUIDELINES
Clinical scenario

Ethical Decision making in Palliative Care:
Artificial hydration for people who are terminally ill
National Council for Hospice and Specialist Palliative
Care Services Ethics Committee of the Association of
Palliative Medicine of Great Britain and Ireland

A blanket policy of artificial hydration, or of no
artificial hydration, is ethically indefensible.

Towards death, a person’s desire for food
and drink lessens.
Study evidence is limited but suggests that
artificial hydration in imminently dying
patients influences neither survival nor
symptom control. As such it may constitute
an unnecessary intrusion.

Thirst or dry mouth in people who are
terminally ill may frequently be caused by
medication. In such circumstances artificial
hydration is unlikely to alleviate the symptom.
Good mouth care and reassessment of
medication become the most appropriate
interventions.

Appropriate palliative care will involve
consideration of the option of artificial
hydration, where dehydration results from a
potentially correctable cause (eg overtreatment
with diuretics and sedation,
recurrent vomiting, diarrhoea and
hypercalcaemia).

It is a responsibility of the clinical team to
make assessments concerning the relevance
of hydration to the experience of individual
patients.
The appropriateness of artificial hydration
should be judged on a day-to-day basis,
weighing up the potential harms and benefits.

DEHYDRATION AND THE DYING
PATIENT
Clinical scenario
Dehydration
Hydration
Study of terminal dehydration
National Council Guidelines
CLINICAL SCENARIO

Clinical Decision Scenarios
Patient is dying and does not have artificial
hydration insitu
Patient is dying and has artificial hydration insitu

Case History 1
Patient is dying and does not have artificial
hydration insitu
In general it is not appropriate to commence
artificial hydration

Case History 2
Patient is dying and has artificial hydration insitu
Options
Reduce fluids to 1 litre / 24hours
Discontinue fluids
- team decision - documented
- one part of care of the dying patient