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To do or not to do?
Investigations and Artificial
Hydration in Palliative Care
Caroline Hockett
Dr Sarah Yardley
Camden, Islington ELiPSE and UCLH & HCA Palliative Care
Service, Central and North West London NHS Foundation
Trust (CNWL)
Priorities for Care
When it is thought that a person may die within the
next few days or hours it is essential to:
• RECOGNISE - patient may be in last days of life
• COMMUNICATE - sensitive communication to
INVOLVE - dying person and those important to them
SUPPORT - ensure needs of patients/carers are respected
PLAN & DO - individual plan of care is drawn up and
delivered with compassion
Contrasting Dying Trajectories for (A) Obvious late decline of cancer; (B)
End stage heart or lung disease with episodic crises; and (C) Dwindling
course of dementia
What to investigate and when?
• What are we trying to achieve?
– Best clinical estimate of prognosis and trajectory
– Patient priorities? What can be done where?
• Will investigations potentially change:
– Symptom control options / recommendations?
• E.g. path # or new disease suitable for XRT, Prescribing approach
– Patient choices?
• Is there an acute/step change?
– What is the differential? Might there be a reversible cause?
Medication toxicity or side effects
Renal failure
• Have previous attempts to intervene been successful?
– Hypercalcaemia
– Blood Transfusions
Artifical Hydration
• Hydration and nutrition a key issue for
those critical of the application of the LCP
& in the new NICE guidelines
• Perception of patients and family members that
hydration offers
– Hope: life sustaining, healing
– Comfort: reducing pain, enhancing medications,
nourishing, improving quality of life
• But can it prolong suffering?
Cohen et al, the meaning of parenteral hydration to family
caregivers and patients, 2012
The debate…
For artificial hydration
Against artificial hydration
• Provides a basic human need
• Relieves thirst
• Prevents/treats
uncomfortable symptomsconfusion, agitation
• Does not prolong life to any
meaningful degree
• Provides minimum standards
of care
• Prolonged dying phase (eg
stroke) – can give
intermittently according to
• Interferes with acceptance of
terminal condition
• Prolongs suffering and the dying
• Artificial hydration is intrusive
and possibly painful
• Less oedema, pulmonary
secretions, congestion, vomiting,
and reduced need to pass urine
• Decreased levels of
consciousness and suffering
through production of natural
• Can reassess need
Knowns & unknowns
• RCP Oral feeding difficulties and dilemmas 2010, pp16-17
– Hydration without nutrition leads to death in 9-10 weeks in healthy,
hydrated people
– Removal of hydration may shorten this to 3 to 14 days
• “giving hydration… may prolong dying”
• “lack of hydration… accelerated the dying process”
• Cochrane review: Medically assisted hydration for adult palliative care
patients (2008, updated 2011)
– 5 studies (2 RCTs)
– None looked at survival
– 1 study: sedation and myoclonus improved
No significant difference in all other outcomes in all other studies (Sedation, myoclonus, fatigue, hallucinations,
MMSE, thirst, nausea, delirium, anguish, agitation, bedsores, cognition)
• Bruera et al, JCO 2013: multicenter, double-blinded, placebocontrolled randomized trial – hydration vs placebo.
– n=129
– Intervention: 1L / day
– All subjects were dehydrated
• Did not improve symptoms, quality of life or survival
The law
• Basic care includes warmth, shelter, pain and
symptom relief, hygiene measures and the offer
of oral hydration and nutrition. It should always
be provided unless actively resisted by the
• Hydration provided by a tube or drip is regarded
in law as a medical treatment
GMC guidance(Treatment and care
towards the end of life, 2010)
• Consider the views of the patient and of those close to them
• Explain the issues
• Ensure all understand that clinically assisted hydration will
always be offered if of benefit, and that if not of benefit, the
patient will continue to receive high quality care
• If a patient is expected to die within hours or days, and you
consider that the burdens of clinically assisted hydration
outweigh the benefits, it will not usually be appropriate to start
or continue treatment
• If a patient has previously requested that nutrition or hydration
be provided until their death, or those close to the patient
are sure that this is what the patient wanted, the patient’s
wishes must be given weight and, when the benefits, burdens
and risks are finely balanced, will usually be the deciding
How much is enough?
• NICE Guidance on IV therapy for adults
• If patients need IV fluids for routine maintenance
alone, restrict the initial prescription to 25–30
ml/kg/day of fluid
• 40kg adult: 1-1.2 L/day
• 70kg adult: 1.75-2.1 L/day
(NICE, Guidance on IV
therapy for adults, 2013)
Recommendations for the very
end of life
• Lack of interest in food is a poor
prognostic indicator
• In the dying phase, desire for food/drink
• Good mouth care most appropriate
• Review NGT/PEG feeding and hydration
• Fluids may only exacerbate oedema and
increase secretions
Bruera E, Hui D, et al, “Parenteral hydration in patients with advanced cancer: a multicenter,
double-blinded, placebo-controlled randomized trial” (JCO, Jan 2013, 31;1:111-118)
Cohen M, Torres-Vigil I, et al, “The meaning of parenteral hydration to family caregivers and
patients waith advanced cancer receiving hospice care” (JPSM, May 2012, 43;5:855-865)
Davies A, “Clinically Assisted Hydration at the end of life” Presentation at the Guildford Advanced
Pain and Symptom Management Course (Manchester, 2013)
The General Medical Council, Treatment and care towards the end of life: good practice in
decision making. Ethical Guidance I. 978-0-901458-46-9 (London, General Medical Council, 2010)
Good P, Cavenagh J, et al "Medically assisted hydration for adult palliative care patients"
Cochrane Database of Systematic Reviews (2008b)
Neuberger J, Guthrie C, et al, More care, less pathway. A review of the Liverpool Care Pathway,
(London, DoH, 2013)
NICE Guideline, Intravenous fluid therapy in adults in hospital, draft for consultation, (London,
NICE, 2013)
Royal College of Physicians and British Society of Gastroenterology, Oral feeding difficulties and
dilemmas: A guide to practical care, particularly towards the end of life (London, Royal College of
Physicians, 2010)
Parry R, Seymour J, et al, Evidence briefing: pathways for the dying phase in end of life care,
(National End of Life Care Programme, 2013)
Case discussion
• Current or previous challenging cases?
• SC fluids in the community
– Need to check which pharmacies stock what /
may need to order in: boxes of 10
– V rare more than 1-2l over 24 hours
– DNs – need to order equipment and have
MAR chart / Px completed by GP
– Daily monitoring for side effects