Tuesday, August 23, 2005

Dehydration at the End of Life

The standard of practice has been established for some time now that it is best not to provide intravenous fluids to patients who are imminently dying. This practice, however, continues to be an area of concern for some family members.

There are a number of reasons why we do not hydrate imminently dying patients:

1. Forcing fluids into the body intravenously can cause excess fluid build-up in the lungs, in the throat, around tumors, and in the extremities. This excess fluid builds up because the kidneys naturally slow down and are less efficient at processing fluids at the end of life. These excess fluids cause discomfort in a number of ways: fluid in the throat and lungs causes death rattle, fluid build-up around tumors can cause pain, and fluid build-up in the extremities can cause discomfort and decreased mobility.

2. Patients who are at the end of life are at an increased risk of developing bed sores or pressure ulcers. Increasing the frequency of urination with intravenous hydration increases the risk of bed sores, as incontinence occurs as death becomes imminent.

Some patients and family members are concerned that the patient will feel thirsty if they are not hydrated. A majority of patients who are imminently dying breathe through their mouths, creating a local dry mouth that would not be alleviated with intravenous hydration. Frequent mouth care using moistened sponges or swabs is more effective and may occur without the added risks of intravenous hydration.

Dehydration releases pain-relieving chemicals which may cause a feeling of mild euphoria and general well-being (Sullivan, 1993). However, severe dehydration can lead to metabolite imbalances that can cause confusion and aggitation. A current study is underway to determine if a very small amount of fluids (10-30 mL per hour of fluid as opposed to 75-150 mL per hour) may avoid the negative side effects of artificial hydration while preventing possible confusion and aggitation.

Some people also see hydration as an ethical issue. "If we have the technological means to provide support that may extend a person's life, even if just by a few hours, aren't we obliged to do it?" First of all, I have not seen evidence that hydrating an imminently dying patient will extend their life. And as many of you have pointed out in previous comments, the ethics of these decisions must weigh into account: what is in the best interests of this person and their potential suffering as well as the financial implications for our society (though hydration is relatively cheap and therefore may not apply in this particular scenario).

What are your concerns about hydration at the end of life? Would you want intravenous fluids if you were at the point where you were dying and were no longer able to swallow liquids on your own?

1 comment:

Karen said...

Thank you for this lovely and informative article. I am a big proponent of Dehydration Euphoria at the end of life. Years ago my sister-in-law was dying with lung cancer and I was able to explain this to her husband. She was more comfortable after they stopped "pushing" food and fluids. Families need to feel they are doing something for their loved ones. We have to help them to understand just being there, holding a hand, and soft kind words are wonderful. Karen Bonn, RN