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Robin L. Fainsinger, M.D.
Director - Palliative Care Program, Royal Alexandra Hospital.
Assistant Professor, Division of Palliative Medicine, Department
of Oncology, University of Alberta.
The need to treat dehydration in terminally
ill patients has become a very controversial topic. Numerous
reports in the literature have illustrated opposing view points
from both a clinical and ethical perspective. Arguments for
the maintenance of hydration in terminally ill patients have
tended to come from "the traditional medical model".
Many health care professionals looking after terminally ill
patients have reacted to the generalized use of intravenous
fluids in dying patients, and the perceived negative effects
of this management. The arguments against rehydration have
traditionally been: - Comatose patients do not experience
symptom distress; parenteral fluids may prolong dying; less
urine results in less need to void or use catheters; less
gastrointestinal fluid, nausea and vomiting; less respiratory
tract problems such as cough and pulmonary edema; decreased
edema and ascites; dehydration may act as a natural anesthetic
for the central nervous system; and parenteral hydration is
uncomfortable and limits patient mobility. The arguments for
rehydration can be summarized as: - Dying patients are more
comfortable with parenteral hydration; no evidence fluids
prolong life; dehydration can cause confusion, restlessness
and neuromuscular irritability; oral hydration is given to
dying patients complaining of thirst, therefore parenteral
hydration can also be administered; emphasis on poor quality
of life detracts from efforts to improve comfort and life
quality; parenteral hydration is a minimum standard of care;
withholding fluid to dying patients may result in withholding
therapies to other compromised patient groups (1, 2).
Our palliative care group has argued
that the view point that dehydration in dying patients is
never a cause of symptom distress, overlooks the fact that:
- 1) dehydration is well recognized in nonterminal patients
to cause confusion and restlessness, problems often reported
in terminally ill patients; 2) reduced intravascular volume
and glomerular filtration rate caused by dehydration is accepted
as a cause for prerenal failure, with opioid metabolite accumulation
in the presence of renal failure causing confusion, myoclonus
and seizures, having been well documented (1, 2, 3). In previous
publications we have reviewed the traditional arguments surrounding
this topic, the biochemical parameters reported in terminally
ill cancer patients, the use of hypodermoclysis and rectal
hydration, the findings of recent research on this topic,
and presented our perspective on this controversy (2, 3).
In common with other reviews (4, 5), we have concluded that
the data reported to date is insufficient to reach a final
conclusion on the benefit or harm of dehydration in terminally
ill patients. Nevertheless, it is worth considering that while
some dying patients may not suffer any ill effects from dehydration,
there may be others who do manifest symptoms such as confusion
or opioid toxicity that may be alleviated or prevented by
parenteral hydration. In addition a dehydrated patient with
renal failure, should at least have medications such as opioids
gradually decreased to avoid accumulation and the development
of toxic side effects.
References
- Fainsinger RL, Bruera E. Hypodermoclysis
for symptom control vs the Edmonton injector. J of Palliat
Care 1991; 7:5-8.
- Fainsinger RL, Bruera E. The
management of dehydration in terminally ill patients.
J of Palliat Care 1994; 10:55-59.
- Fainsinger RL, Bruera E. When
to treat dehydration in the terminally ill patient? Support
Care Cancer (in press).
- Dunphy K, Finlay I, Rathbone
G, Gilbert J, Hicks F. Rehydration in palliative and terminal
care: If not - why not? Palliative Medicine 1995; 9:221-228.
- Burge FI. Dehydration and provision
of fluids in palliative care. Can Fam Physician 1996;
42:2383-2388.
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