How to manage terminal dehydration

Hydration status in adults with metabolic disorders in relation to socioeconomic, lifestyle and health factors

INTRODUCTION

Adequate hydration is essential for maintaining the health and functionality of the human body. This study aimed to examine the association between selected socioeconomic, lifestyle, and health factors and the hydration status of adults with metabolic disorders by analyzing their urine osmolality.

METHODS

The study involved 290 adults aged 18-70 years with metabolic disorders. Separate multivariate logistic regression models were conducted to evaluate the factors associated with urine osmolality in tertiles for women and men. Odds Ratios (OR) and 95% Confidence Intervals (95% CI) were calculated.

RESULTS

In women, the following factors of urine osmolality were identified in 1st tertile: age (OR:1.04), physical activity (moderate/high vs. no/low; OR:0.38), and headaches (no vs. yes; OR:1.55), in 2nd tertile: physical activity (moderate/high vs. no/low; OR:2.46) and fatigue during the day (sometimes vs. never/very rarely; OR:0.45), and in 3rd tertile: age (OR:0.94), professional status ('I work part-time/I study and I work' vs. 'I do not work/I study'; OR:0.27), fatigue during the day (very often vs. never/very rarely; OR:2.55), and headaches (no vs. yes; OR:0.44). In men, the following factors of urine osmolality were identified in 1st tertile: place of residence (city vs. village; OR:2.72) and health assessment (average vs. poor; OR:0.32).

CONCLUSION

Different factors affecting urine osmolality have been identified in women and men. These results highlight the need to implement studies to clarify the relationship between socioeconomic, lifestyle and health factors, and hydration status in adults with metabolic disorders.

Multinational Association of Supportive Care in Cancer (MASCC) expert opinion/guidance on the use of clinically assisted hydration in patients with advanced cancer

PURPOSE

The provision of clinically assisted hydration (CAH) in patients with advanced cancer is controversial, and there is a paucity of specific guidance and so a diversity in clinical practice. Consequently, the Palliative Care Study Group of the Multinational Association of Supportive Care in Cancer (MASCC) formed a sub-group to develop evidence-based guidance on the use of CAH in patients with advanced cancer.

METHODS

This guidance was developed in accordance with the MASCC Guidelines Policy. A search strategy for Medline was developed, and the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were explored for relevant reviews/trials, respectively.

RESULTS

Due to the paucity of evidence, the sub-group was not able to develop a prescribed guideline, but was able to generate a number of "expert opinion statements": these statements relate to assessment of patients, indications for CAH, contraindications for CAH, procedures for initiating CAH, and reassessment of patients.

CONCLUSIONS

This guidance provides a framework for the use of CAH in advanced cancer, although every patient requires individualised management.

The why and how of maintaining hydration during cancer therapy

PURPOSE OF REVIEW

To provide an overview of the role hydration plays in the oncology population while providing a synopsis of recent scientifically relevant published practice advancements.

RECENT FINDINGS

Dehydration causes substantial symptom burden in cancer patients, secondary to both disease process and treatment complications. Maintaining fluid and electrolytes balance is the key to hydration therapy. When oral intake is diminished, artificial hydration can be delivered via enteral, intravenous and subcutaneous routes. Use of artificial hydration in end-of-life care for cancer patients remains a highly debated topic with unclear benefits and lack of established standards. A holistic approach is required in the decision-making process.

SUMMARY

Maintaining adequate hydration is important in patients receiving cancer therapy. Challenges exist, secondary to limited clinical guidelines of hydration in patients with advanced cancer. Artificial hydration may be indicated for selected patients at the end of life if used on an individualized basis as medical treatment.

[Legal considerations in the care of patients with "terminal dehydration" in Germany]

BACKGROUND

The legal framework for fluid management in the palliative care setting varies between continents and even between countries.

OBJECTIVES

What legal implications must be taken into account in Germany in dealing with "terminal" dehydration?

MATERIALS AND METHODS

Relevant publications in English and German have been identified. Notably, German recommendations and guidelines were reviewed, whereas national mindsets were contrasted with those of other countries like the United Kingdom and Canada.

RESULTS

Our legal considerations are in line with the recommendations of the German Federal Medical Association. Key components are "patient autonomy", "best possible symptom control" and a "steady therapeutic risk-benefit assessment". Dehydration should then continue to be regarded as a "symptom" that must be "controlled" as long as it can be improved by therapeutic means and as long as the patient is not opposed to this approach. However, if dehydration remains therapeutically refractory, it is justified either not to initiate clinically assisted hydration (CAH) or to stop the ongoing therapy. The "shared decision-making model" practiced in Canada is diametrically opposed to this approach, where paternalistic decision-making is possible, provided that patients or relatives appear to be ill-informed and unprepared to decide "correct" according to expert opinion.

CONCLUSIONS

A "non-refractory" state of dehydration at the end of life must not be left untreated under German law and must not be used as an option to hasten the death process if the development of dehydration does not correspond to the patient's will or if this will cannot be determined.

[Ethical implications in the therapeutic management of dehydrated patients at the end of life]

BACKGROUND

The ethical framework for fluid management in the palliative care setting can vary.

OBJECTIVES

What are the relevant ethical implications related to dehydration during end-of-life care and what are the special requirements we need to consider as far as "terminal dehydration" is concerned?

MATERIALS AND METHODS

A comprehensive literature search was conducted to identify relevant articles published in English and German.

RESULTS

Our inferences represent an attitude rather than an evidence-based position-a fact that is due to the underlying normative and ethical references which are hardly amenable to statistical evaluation. As far as ethical considerations are concerned, evidence is lacking to support clear decision-making and, thus, does not justify moving away from established concepts of clinically assisted hydration (CAH) at the end of life as long as measures can be effectually implemented.

CONCLUSIONS

Dehydration must not be considered a measure to hasten death. Hence, dehydration in the palliative care setting must be regarded a "symptom" that should be "controlled" if it can be corrected by therapeutic means and if the patient's will does not contradict that approach. However, if CAH is futile, it is justified to refuse or stop it.