Self Directed Learning Package - University of Queensland

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36 • The Palliative Approach ToolkitBiochemical testsBiochemical tests can assist in determining the cause of apotentially reversible dehydration.Thinking PointAlfred is in the terminal stage and appearsdehydrated. Palliative care is often about rationalisingand reducing the number of invasive or burdensometests and procedures so why consider bloodtests now?Alfred was always clear that he did not want artificialnutrition or hydration at the end of life. Determiningthat he is clinically dehydrated or has an electrolyteimbalance will not change the focus on quality-of-lifemeasures and symptom management.Key PointOnly investigate something if the result will changethe care being provided.Key PointFluid intake charts alone are not recommended forassessing dehydration. They are not an accurateway of determining dehydration unless they alsotake into account urine output, perspiration andother fluid losses.Helping families understandThe PA Toolkit contains a brochure “Understanding the DyingProcess” which can be given to family members when theresident is in the palliative or terminal phase.Table 3 provides a brief segment from the “Understandingthe Dying Process” brochure. This brochure is included in thePA Toolkit and we recommend you familiarise yourself withthe document.Table 3Segment from “Understanding the Dying Process” brochureMost people lose their appetite in the last few weeks of life. Thisis a very natural and normal part of the dying process becausemetabolism is slowing down and the body requires less nutrition.At this time your instincts may be to try and feed the personin order to keep up their strength. The giving of food is oftensymbolic of loving and nurturing and to deprive someone ofthis may feel like neglect. However, as the person becomesincreasingly weak and drowsy, swallowing and digesting food andfluids often becomes harder and can place strain upon the body.Whilst the person may have a reduced oral intake, it is importantto maintain good oral care. Regular moistening of the mouthand lips will add to the person’s comfort.SayReport your assessmentThinking PointWhich of the following do you think will get the bestresponse?Nurse to GP:‘Alfred reports that he has had trouble swallowingfor a few days. Careworkers observed that he wascoughing when eating his cereal this morning’.Is better than:‘Alfred is having problems eating’.
37 • Self Directed Learning Package - Introductory Registered & Enrolled NurseDoManage the problemDiligent hand feeding and offering drinks frequently is importantfor all residents. 4If Alfred becomes unable to swallow, staff should cease offeringfood and drink, instead focusing on excellent mouth care.When a resident cannot swallow food or fluids by themselves, itis possible to provide these by artificial means such as through atube (PEG tube) or SC (subcutaneous cannula) ‘drip’.Decision makingThere is no simple answer to whether these interventions are rightor wrong. The benefits of artificial nutrition or hydration need tooutweigh the potential burden and side effects for the resident.Residents and family members cannot make the best decisionsif they do not have enough information. Conversations with thenurse and doctor about the positive and negative aspects ofartificially providing food or fluids are very important at this stage.Artificial nutritionKey PointFor residents requiring a palliative approach,there is no evidence that tube feeding prolongslife, improves comfort or quality-of-life, preventsaspiration pneumonia, leads to better nourishmentor decreases the risk of pressure sores. 6Although artificial hydration can be useful to treat reversiblecauses of dehydration such as over treatment of diuretics,unintended sedation from medications or recurrent vomiting ordiarrhoea, it is not normally used when a resident is expected todie within 48 - 72 hours.Thinking PointThink about how you feel if you forget to have a drinkduring your eight hour shift at work. Do you feel alittle drowsy, have a headache, dry mouth or dizzinessif you stand up quickly? Perhaps you just feel thirsty.Having a drink makes you feel better because itmoistens your mouth.Similarly, moistening the mouth of a resident who can no longerswallow fluids will keep them comfortable as much as or moreso than a ‘drip’.Key PointMedication side effects, oxygen therapy andmouth breathing can cause a dry mouth. Artificialhydration does not usually relieve the feeling ofdry mouth and can actually worsen respiratorysecretions, incontinence, vomiting, swelling(oedema) or breathing difficulties.You will learn more about the importance of oral care in a latersection of this learning package.Artificial hydrationThinking PointAlfred is unconscious and you would not be surprisedif he dies in the next two to three days. A careworkeris upset that Alfred cannot drink. He says ‘How badmust it be for Alfred being so dehydrated, he shouldhave a saline drip’.Do you agree with his comments?
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Self Directed Learning Package - University of Queensland

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