artificial hydration in terminally ill patients

Introduction

Ethical issues:

• there is no right answer
• ethically & legally there is no difference between witholding & withdrawing treatment
• some patients or families believe that hydration must always be provided even if it causes discomfort, usually based on personal or religious beliefs (Muslim tradition)
• little benefit in the dying patient & may cause unwanted symptoms

Adverse effects

• fluids may prolong the dying process
• pulmonary symptoms
  • increased secretions with dyspnea
  • cough
  • congestion
  • "death rattle"
• increased urine output
  • need for catheterization, bedpan, urinal or commode
  • urinary incontinence
• edema, ascites, fluid accumulation
• vomiting, bloating, diarrhea
• increased pain
• general risks associated with tubes, IVs, etc

Laboratory

• intravenous hydration will reduce the BUN/creatinine ratio

Management

• if request for artificial hydration/IV fluids has a religious basis, start IV fluids at a low rate if breathing comfortably (even if anasarca) & advise that fluids may be stopped if respiratory distress develops

Notes

Palliative effects of dehydration:*

• easier to breath
  • reduced pulmonary secretions
  • less coughing & congestion
  • relief from choking & drowning sensation
  • no need for pharyngeal suctioning
• decreased GI fluid; less vomiting, bloat, diarrhea
• decreased edema & peripheral fluid accumulation
• diminished pain
  • less pain from edema
  • electrolyte imbalances act as natural anesthetics, with diminished level of consciousness & less suffering
• no need for restraints used to prevent a patient from removing tube or IV

* Dry mouth is the most frequent complication of dehydration in the dying patient. Sips of water, ice chips & lubricants can alleviate this symptom. Hunger & thirst are rarely a problem.

Prognosis (in absence of hydration):

• death will generally occur within days of ceasing intake
• often the patient survives much longer than expected
• terminally ill patients not given artificial hydration may actually survive longer than those that are hydrated

More general terms

• intravenous hydration

Additional terms

• end of life