June 2004

Dear Readers: Here's the Article for this Month:

Name of article:

Hydration Management at the end of life

Author(s): Lanuke K, Fainsinger RL, deMoissac D

Abstract: The management of hydration in patients at the end of life has become a controversial issue and has brought about important debates both in ethical and clinical-scientific fields. As far as hydration is concerned, one notes quite often an attitude which goes from everything to absolutely nothing, depending on the setting where the patient is cared for as well as the preference to the use of intravenous (IV) or hypodermoclysis (HDC) methods.

In this regard, the authors of the article wished to profile the routine clinical practice of physicians involved in the care of dying patients in a palliative care unit (PCU) at Norwood Capital Care and in acute care wards at the Royal Alexandra Hospital (RAH) where one group received and another did not receive advice from the Palliative Care Program.

The clinical records of 50 consecutive patients hospitalized in these 3 different settings were retrospectively reviewed (totalling 150 patients) and the following data of the last 7 days prior to death, including the date of death (day 0) were obtained:

• Patients' demographics, diagnosis (cancer/noncancer), the speciality of the attending physician

• the volume of hydration ordered each day and the change in hydration volume from day 6 to day 0

• the route of fluid administration (IV/HDC)

• the use or not of diuretics (furosemide and spironolactone)

In the RAH acute care group the number of patients with a non-malignant diagnosis was higher (p<0.05) compared to the other two groups. Most patients in all 3 settings received hydration in the last week of life with an increasing number of patients receiving hydration from the sixth day until death both in the PCU (from 40 to 49) and the RAH Acute care (from 33 to 44), and only a slight increase was observed in the RAH Palliative Care group (from 42 to 44).

A statistically significant difference was found for the volumes of hydration administered between the PCU setting where the lowest volumes were prescribed, and both RAH groups on all days studied (p<0.005).

The RAH palliative care group showed a trend towards lower hydration volumes compared to the RAH acute care group; this difference was different on days 2 and 1 (p<0.05).

The trend of mean hydration volume from day 6 to day 0 was as follows: PCU from 1281 to 1227; RAH Palliative Care from 1906 to 1636; RAH acute care from 1876 to 2037. The hydration volume from day 6 to day 0 increased in 15 patients cared in the RAH Palliative Care, in 9 patients cared for the PCU and in 29 patients cared for the RAH acute care.

All patients admitted at the PCU were hydrated via HDC, most of the hydrated patients in the RAH acute care group received IV fluids, whereas in the RAH Palliative Care group 1/3 of the hydrated patients received HDC and 2/3 IV administration. The RAH acute care group represented the largest percentage of hydrated patients receiving diuretics, whereas the hospice PCU setting represented the lowest. It is possible to theorize that more patients treated in the acute care group were over hydrated and might have presented oedema, ascites and respiratory distress?

Why I chose this article

The necessity to apply scientific criteria in the palliative care field together with
particular attention to the individual person has revealed the senselessness of an
aprioristic decision to either hydrate everyone or no one at all. In view of the importance of the problem in this field, it is not surprising that a lively debate on the controversial issue of hydration in the terminal phase of life was stirred up over the last few years. This indicates, once again, the importance of decision making regarding the necessity of a personalized treatment for every single patient which should be the guideline for every physician caring for a patient in the different stages of his illness.

Regards,

Carla Ripamonti, MD
Member of the Board of Directors, IAHPC