Artificial Hydration at End of Life

Artificial Hydration at End of Life - #77

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Patients and family members in the inpatient or outpatient setting.

Provide information and guidance to be used in decision-making for patients and family members regarding hydration in advanced dementia patients or in patients nearing the end of life.

Dementia is characterized by a progressive, irreversible, and expected cognitive and physical decline. The leading causes of mortality in advanced dementia patients are infection and dysphagia (1). Generally, dysphagia increases slowly over time, however, there may be periods where fluid intake abruptly decreases or stops completely.  The onset of abruptly decreased oral intake should cue providers and family to search for reversible causes such as painful swallowing, depression, acute medical illness or delirium. However, in many cases no reversible causes are identified. Family members may inquire about the possibility of artificial hydration. Artificial hydration (AH) is defined as providing liquids through non-oral routes, such as intravenous (IV), subcutaneous (SQ), or enteral or parental nutrition (2, 3).  Open discussions with family members and patients regarding the risks and benefits of AH when nearing end of life are essential to patient care.

  1. Identify key points for discussion of risks and benefits of AH nearing the end of life.
  2. Improve provider’s comfort level with difficult discussions with patients and family members.
  1. Mitchell, S. L., Teno, J. M., Kiely, D. K., Shaffer, M. L., Jones, R. N., Prigerson, H. G., Volicer, L., Givens, J. L., and Hamel, M. B. (2009) The clinical course of advanced dementia. New England Journal of Medicine 361, 1529-1538
  2. Casarett, D., and Kapo, J. (2005) Appropriate use of artificial nutrition and hydration-fundamental principles and recommendations. The New England Journal of Medicine 353, 2607
  3. Vidal, M., Hui, D., Williams, J., and Bruera, E. (2016) A prospective study of hypodermoclysis performed by caregivers in the home setting. Journal of pain and symptom management 52, 570-574. e579
  4. Morita, T., Tei, Y., and Inoue, S. (2003) Agitated terminal delirium and association with partial opioid substitution and hydration. Journal of palliative medicine 6, 557-563
  5. Hui, D., Dev, R., and Bruera, E. (2015) The last days of life: symptom burden and impact on nutrition and hydration in cancer patients. Current opinion in supportive and palliative care 9, 346
  6. Mercadante, S., Ferrera, P., Girelli, D., and Casuccio, A. (2005) Patients' and relatives' perceptions about intravenous and subcutaneous hydration. Journal of pain and symptom management 30, 354-358
  7. Bruera, E., Hui, D., Dalal, S., Torres-Vigil, I., Trumble, J., Roosth, J., Krauter, S., Strickland, C., Unger, K., and Palmer, J. L. (2013) Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial. Journal of clinical oncology 31, 111
  8. Good, P., Cavenagh, J., Mather, M., and Ravenscroft, P. (2008) Medically assisted hydration for adult palliative care patients. Cochrane Database of Systematic Reviews 2
  9. Bear, A. J., Bukowy, E. A., and Patel, J. J. (2017) Artificial Hydration at the End of Life. Nutrition in Clinical Practice 32, 628-632
This GFF ___ my competence in geriatrics.

Elizabeth A. Bukowy, DO, Division of Geriatrics/Gerontology, Medical College of Wisconsin, Milwaukee, WI

Alexandria J. Bear, MD, Section of Palliative Care, Medical College of Wisconsin, Milwaukee, WI