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Hydration

Clinical practice guideline on palliative care for adults in the last days of life
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Question

Is artificial hydration effective in improving the symptoms and general comfort of patients in the last days of life?

Recommendations

  1. In general, do not provide artificial hydration in patients in the last days of life. Exceptionally, consider it if:
    • There is poor control of symptoms that could be related to dehydration (for example, delirium) and other control measures have failed.
    • The reduction in oral intake causes unrest or emotional concern in the patient and their relatives despite appropriate communication with the care team.

  1. Review medical records to check whether the patient has previously expressed preferences regarding artificial hydration in an advance directive when considering artificial hydration in the last days of life and the patient is unable to decide.
  2. If artificial hydration is indicated:
    • Address the concerns of the patient and their family and inform them about the evidence of the benefits and risks of artificial hydration in the last days of life
    • Consider it a measure to be taken for a limited time (previously agreed with the patient/relatives)
    • Do not use a daily volume of more than 1 l
    • Do not use the enteral route of administration; rather, subcutaneous administration is the route of choice in home care patients or when an IV line is not already in place.
  3. One artificial hydration has been set up:
    • Monitor changes in signs or symptoms of dehydration and any evidence of benefit or harm approximately every 24 h
    • Continue hydration if there are benefits perceived by the patient and/or family
    • Reduce or stop hydration if there are signs of potential harm such as fluid overload or increased respiratory secretions, or if the patient or their family or close friends request its withdrawal.
  4. In cases in which artificial hydration (via the enteral or parenteral route) is already in place before the last days of life:
    • Review the risks and benefits of continuing this type of hydration in the last days of life with the patient and family/close friends
    • Consider whether to continue, reduce or stop artificial hydration as the patient approaches death.

 

Rationale

These recommendations have been formulated seeking to promote appropriate clinical management of hydration in the last days of life, based on the evidence of the risks and benefits and taking into account the values and preferences of patients and their families.

Complete clinical question

For full information on this question (available in Spanish), see:
http://portal.guiasalud.es/guia-en-capas/gpc_612__atencion_paliativa_sud-2/#question-4

References

22. National Institute for Health and Care Excellence. Care of dying adults in the last days of life. London: National Institute for Health and Care Excellence; 2015. [accessed 12 Oct 2018]. Available from: www.nice.org.uk/guidance/ng31.

98. Raijmakers NJ, van Zuylen L, Costantini M, Caraceni A, Clark J, Lundquist G, et al. Artificial nutrition and hydration in the last week of life in cancer patients. A systematic literature review of practices and effects. Ann Oncol. 2011;22(7):1478-86. DOI: 10.1093/annonc/mdq620.

99. Del Rio MI, Shand B, Bonati P, Palma A, Maldonado A, Taboada P, et al. Hydration and nutrition at the end of life: a systematic review of emotional impact, perceptions, and decision-making among patients, family, and health care staff. Psychooncology. 2012;21(9):913-21. DOI: 10.1002/pon.2099..

100. Good P, Richard R, Syrmis W, Jenkins-Marsh S, Stephens J. Medically assisted hydration for adult palliative care patients. Cochrane Database Syst Rev. 2014 (4):Cd006273. DOI: 10.1002/14651858.CD006273.pub3.

101. Druml C, Ballmer PE, Druml W, Oehmichen F, Shenkin A, Singer P, et al. ESPEN guideline on ethical aspects of artificial nutrition and hydration. Clin Nutr. 2016;35(3):545-56. DOI: 10.1016/j.clnu.2016.02.006.

102. Bruera E, Hui D, Dalal S, Torres-Vigil I, Trumble J, Roosth J, et al. Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial J Clin Oncol. 2013;31(1):111-8. DOI: 10.1200/jco.2012.44.6518.

103. Bruera E, Sala R, Rico MA, Moyano J, Centeno C, Willey J, et al. Effects of parenteral hydration in terminally ill cancer patients: a preliminary study. J Clin Oncol. 2005;23(10):2366-71. DOI: 10.1200/jco.2005.04.069.

104. Cerchietti L, Navigante A, Sauri A, Palazzo F. Hypodermoclysis for control of dehydration in terminal-stage cancer. Int J Palliat Nurs. 2000;6(8):370-4. DOI: 10.12968/ijpn.2000.6.8.9060.

105. Viola R. Studying fluid status and the dying: The challenge of clinical research in palliative care. 1997.

106. Morita T, Hyodo I, Yoshimi T, Ikenaga M, Tamura Y, Yoshizawa A, et al. Association between hydration volume and symptoms in terminally ill cancer patients with abdominal malignancies. Ann Oncol. 2005;16(4):640-7. DOI: 10.1093/annonc/mdi121.

107. Davies AN, Waghorn M, Webber K, Johnsen S, Mendis J, Boyle J. A cluster randomised feasibility trial of clinically assisted hydration in cancer patients in the last days of life. Palliat Med. 2018;32(4):733-43. DOI: 10.1177/0269216317741572.

108. Gent MJ, Fradsham S, Whyte GM, Mayland CR. What influences attitudes towards clinically assisted hydration in the care of dying patients? A review of the literature. BMJ Support Palliat Care. 2015;5(3):223-31. DOI: 10.1136/bmjspcare-2013-000562.

Shared decision-making and development of a care plan
Management of symptoms