Association between hydration volume and symptoms in terminally ill cancer patients with abdominal malignancies

Fluid therapy is associated with lower care quality and higher symptom burden during last days of life of patients with cancer - a population-based register study

BACKGROUND

Parenteral fluid (PF) therapy of patients in end-of-life (EOL) is controversial. The purpose of this study was to assess associations between PF, quality of the EOL care process and symptom burden in dying cancer patients, using a population-based approach.

METHODS

This was a nationwide retrospective register study of all adult cancer deaths with documented information on PF in the last 24 h of life as reported to the Swedish Register of Palliative Care during a three-year period (n = 41,709). Prevalence and relief of symptoms during the last week of life as well as EOL care process quality indicators were assessed in relation to PF in those patients who had a documented decision to focus on EOL care (immediately dying, n = 23,112). Odds ratios were calculated, adjusting for place of death (hospital vs. non-hospital).

RESULTS

PF was administered to 30.9% of immediately dying patients in hospitals compared to 6.5% outside of hospitals. PF was associated with a higher likelihood for breathlessness and nausea. In patients screened for EOL symptoms with a validated instrument, PF was inversely associated with the likelihood of complete relief of breathlessness, respiratory secretions, anxiety, nausea and pain. Several palliative care quality indicators were inversely associated with PF, including EOL conversations and prescriptions of injectable drugs as needed. These associations were more pronounced in hospitals.

CONCLUSIONS

Parenteral fluid therapy in the last 24 h of life was associated with inferior quality of the EOL care process and with increased symptom burden in imminently dying cancer patients.

Interventional Prospective Studies on Xerostomia in Patients Undergoing Palliative and End-of-Life Care: A Scoping Review

Patients undergoing palliative care often develop debilitating oral conditions, including xerostomia. These conditions may significantly impact patients' quality of life. Despite the high prevalence and adverse impact of xerostomia, effective management strategies remain unclear. This scoping review was performed to elucidate effective interventions for xerostomia in patients undergoing palliative and end-of-life care. A comprehensive search strategy was employed to identify relevant studies up to August 2023. Full-text primary articles focusing on xerostomia in patients receiving palliative care were included in the review. Eleven articles were selected for analysis, and data were extracted by six reviewers. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Among the 11 studies, interventions ranged from oral care to saliva substitutes and methods to stimulate saliva secretion. The primary method of assessing xerostomia was the performance of subjective evaluations using visual analog scale scores or numerical rating scale scores. Various interventions including oral care regimens, topical treatments, and mixed efficacy outcomes were reported. Notably, only one study directly measured the saliva volume, highlighting a reliance on subjective endpoints in most studies. Although no definitive conclusions can be drawn regarding the most effective intervention, oral care was a preferred option for managing xerostomia in patients undergoing palliative care. Additionally, adjunctive treatments such as ice cubes, saline, and moisturizers showed promise but require further investigation. Objective measures should be incorporated into future intervention trials to complement subjective assessments and provide a comprehensive evaluation of xerostomia management strategies in this patient population.

Parenteral Hydration in Dying Patients With Cancer: A National Registry Study

CONTEXT

Clinically assisted hydration during end-of-life care among patients with cancer is controversial; practice varies between clinical settings and countries, and there is a lack of evidence.

OBJECTIVES

To examine whether breathlessness, respiratory secretion, or confusion correlates with receiving parenteral hydration during end of life, adjusted for sex, age, and place of death.

METHODS

The Swedish Register of Palliative Care database was used to collect data about the usage of parenteral hydration during the last day of life, and the occurrence of three symptoms during the last week. Adults dying from cancer during 2011-2021 in hospitals, in residential care homes, and within specialized palliative care were included. Correlation between parenteral hydration and symptoms was examined using χ2-test and logistic regression.

RESULTS

A total of 147,488 patients were included in the study. Parenteral hydration was more often prescribed to younger persons, to men, and in acute hospitals (compared to other settings), p < 0.001 in all three comparisons. Patients with hematological malignancies (20%) and ovarian cancer (16%) were most likely to receive parenteral hydration, while those with brain tumors (6%) were least likely. The presence of all three analyzed symptoms during the last week (breathlessness, respiratory secretion, and confusion) were significantly correlated with having received parenteral hydration during the last day of life (p < 0.001). In the final logistic regression model adjusted for age, sex, and place of death, the only symptom with remaining correlation to parenteral hydration was breathlessness (OR 1.56, 95% CI 1.50-1.6).

CONCLUSION

There is an association between parenteral hydration and increased breathlessness in patients with cancer. Provision of parenteral hydration is more prevalent in men, younger patients, and those with hematological malignancies or ovarian cancer, and most widespread in acute hospital settings.

Psychological Barriers to the Use of Opioid Analgesics for Treating Pain in Patients With Advanced Recurrent Cancer: A Multicenter Cohort Study

Background

We aimed to gain insight into psychological barriers toward initiation of strong opioid analgesic use in patients with advanced recurrent cancer.

Methods

This study included 46 patients who were prescribed with opioid analgesics for advanced recurrent cancer. The primary outcome was psychological barriers assessed using the Japanese version of the Barriers Questionnaire-II (JBQ-II). The secondary outcomes were psychological changes and pain relief one week after the induction of strong opioid analgesics.

Results

The mean age of participants was 63.6 years. Furthermore, 26.1% had an Eastern Cooperative Oncology Group (ECOG) performance status of ≥3. The mean JBQ-II total score was 1.97 (95% confidence interval: 1.75-2.19). At the initiation of opioid therapy, there was no difference in the total scores between the baseline and one week later. Nevertheless, there was a significant difference in the subscale "disease progression" score (mean 2.97 vs. 2.59, difference in means 0.38, standard error 0.16, p = 0.026). Personalized Pain Goal (PPG) was achieved in about half of the participants, and a trend toward a higher score in the subscale "harmful effects" (concern about adverse events) was observed in those who did not achieve PPG.

Conclusion

This study showed that patients with advanced recurrent cancer have psychological barriers to opioid induction. The relationship between the presence of psychological barriers before and after induction of opioid analgesics and the speed of pain improvement was determined. The results may provide fundamental information for prospective intervention studies to develop individualized education programs for patients with psychological barriers to opioids.Clinical Trial Registration Number UMIN000042443.

Medically assisted hydration for adults receiving palliative care

BACKGROUND

Many people receiving palliative care have reduced oral intake during their illness, and particularly at the end of their life. Management of this can include the provision of medically assisted hydration (MAH) with the aim of improving their quality of life (QoL), prolonging their life, or both. This is an updated version of the original Cochrane Review published in Issue 2, 2008, and updated in February 2011 and March 2014.

OBJECTIVES

To determine the effectiveness of MAH compared with placebo and standard care, in adults receiving palliative care on their QoL and survival, and to assess for potential adverse events.

SEARCH METHODS

We searched for studies in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, CANCERLIT, CareSearch, Dissertation Abstracts, Science Citation Index and the reference lists of all eligible studies, key textbooks, and previous systematic reviews. The date of the latest search conducted on CENTRAL, MEDLINE, and Embase was 17 November 2022.

SELECTION CRITERIA

We included all relevant randomised controlled trials (RCTs) of studies of MAH in adults receiving palliative care aged 18 and above. The criteria for inclusion was the comparison of MAH to placebo or standard care.

DATA COLLECTION AND ANALYSIS

Three review authors independently reviewed titles and abstracts for relevance, and two review authors extracted data and performed risk of bias assessment. The primary outcome was QoL using validated scales; secondary outcomes were survival and adverse events. For continuous outcomes, we measured the arithmetic mean and standard deviation (SD), and reported the mean difference (MD) with 95% confidence interval (CI) between groups. For dichotomous outcomes, we estimated and compared the risk ratio (RR) with 95% CIs between groups. For time-to-event data, we planned to calculate the survival time from the date of randomisation and to estimate and express the intervention effect as the hazard ratio (HR). We assessed the certainty of evidence using GRADE and created two summary of findings tables.  MAIN RESULTS: We identified one new study (200 participants), for a total of four studies included in this update (422 participants). All participants had a diagnosis of advanced cancer. With the exception of 29 participants who had a haematological malignancy, all others were solid organ cancers. Two studies each compared MAH to placebo and standard care. There were too few included studies to evaluate different subgroups, such as type of participant, intervention, timing of intervention, and study site. We considered one study to be at high risk of performance and detection bias due to lack of blinding; otherwise, risk of bias was assessed as low or unclear. MAH compared with placebo Quality of life One study measured change in QoL at one week using Functional Assessment of Cancer Therapy - General (FACT-G) (scale from 0 to 108; higher score = better QoL). No data were available from the other study. We are uncertain whether MAH improves QoL (MD 4.10, 95% CI -1.63 to 9.83; 1 study, 93 participants, very low-certainty evidence). Survival One study reported on survival from study enrolment to last date of follow-up or death. We were unable to estimate HR. No data were available from the other study. We are uncertain whether MAH improves survival (1 study, 93 participants, very low-certainty evidence).  Adverse events One study reported on intensity of adverse events at two days using a numeric rating scale (scale from 0 to 10; lower score = less toxicity). No data were available from the other study. We are uncertain whether MAH leads to adverse events (injection site pain: MD 0.35, 95% CI -1.19 to 1.89; injection site swelling MD -0.59, 95% CI -1.40 to 0.22; 1 study, 49 participants, very low-certainty evidence).  MAH compared with standard care Quality of life No data were available for QoL. Survival One study measured survival from randomisation to last date of follow-up at 14 days or death. No data were available from the other study. We are uncertain whether MAH improves survival (HR 0.36, 95% CI 0.22 to 0.59; 1 study, 200 participants, very low-certainty evidence).  Adverse events Two studies measured adverse events at follow-up (range 2 to 14 days). We are uncertain whether MAH leads to adverse events (RR 11.62, 95% CI 1.62 to 83.41; 2 studies, 242 participants, very low-certainty evidence).  AUTHORS' CONCLUSIONS: Since the previous update of this review, we have found one new study. In adults receiving palliative care in the end stage of their illness, there remains insufficient evidence to determine whether MAH improves QoL or prolongs survival, compared with placebo or standard care. Given that all participants were inpatients with advanced cancer at end of life, our findings are not transferable to adults receiving palliative care in other settings, for non-cancer, dementia or neurodegenerative diseases, or for those with an extended prognosis. Clinicians will need to make decisions based on the perceived benefits and harms of MAH for each individual's circumstances, without the benefit of high-quality evidence to guide them.

Anticholinergic drugs for death rattle in dying patients with cancer: multicentre prospective cohort study

BACKGROUND

This study aimed to investigate the effectiveness of anticholinergics (AC) for death rattle in dying patients with cancer.

METHODS

This is a prospective cohort study enrolled Terminally ill adult (20 years or older) patients with cancer who developed substantial death rattle (Back score ≥2) from 23 palliative care units in Japan. AC treatment for death rattle was prescribed according to primary physician's decision. The primary outcome was the proportion of patients whose death rattle improved, which was defined as a Back score of ≤1. We compared the proportion of improved cases in patients treated with (AC group) and without (non-AC group) AC, controlling potential confounders by employing propensity score weighting.

RESULTS

Of the 1896 patients enrolled, we included 196 who developed a substantial death rattle. Of these, 81 received AC. 56.8% in the AC group and 35.4% in the non-AC group had an improved death rattle at 8 hours after baseline. In the weighted analysis, AC group showed significant improvements in death rattle, with an adjusted OR of 4.47 (95% CI 2.04 to 9.78; p=0.0024). All sensitivity analyses achieved essentially the same results. In the subgroup analysis, ACs were strongly associated with death rattle improvement in men, patients with lung cancer, and type 1 death rattle (adjusted OR 5.81, 8.38 and 9.32, respectively).

CONCLUSIONS

In this propensity score-weighted analysis, ACs were associated with death rattle improvement in terminally ill patients with cancer who developed substantial death rattle.

TRIAL REGISTRATION NUMBER

UMIN-CTR (UMIN00002545).

Nutrition provided during the final weeks to patients with non-gastrointestinal solid malignancies

BACKGROUND & AIMS

Data regarding the delivery of nutrition and nutritional infusions to patients with terminal cancer remain limited; therefore, this real-world analysis investigated differences in nutrition delivery and infusion statuses for patients with terminal-stage cancers.

METHODS

Patients who had died following hospitalization for more than seven days due to neoplasms between April 2014 and December 2018 were identified using the medical claims database of Japan. Data regarding oral diets, enteral feeding, infusion volumes, and infusion energies were extracted. The maximum observation period was 28 days prior to patient death.

RESULTS

A total of 12,908 patients were included in our analysis. The proportion of patients without dietary or enteral nutrition increased closer to their dates of death. Observations were recorded at 28 (18.9%), 21 (20.9%), 14 (24.6%), 7 (33.0%), and 0 (80.2%) days prior to death. The infusion volumes given to the patients, as well as their energy contents, decreased near death (P-value for the trend <0.001).

CONCLUSIONS

Our study revealed the current status of nutritional therapy for patients with terminal cancer in Japan. The number of patients receiving only parenteral nutrition increased near death, while the amount of nutritional intake was low.

Comparison of Symptom Severity and Progression in Advanced Cancer Patients Among Different Care Settings: A Secondary Analysis

Background

Most people in Japan wish to spend their final days at home, but the majority fail to do so; earlier studies indicated a more pronounced worsening of symptoms if treated at home.

Objectives

This study compared the prevalence of symptom worsening and explored associated factors between patients with advanced cancer receiving palliative care in palliative care units (PCUs) and at home.

Design

We conducted a secondary analysis of two multicenter, prospective cohort studies involving patients with advanced cancer receiving palliative care in PCUs or at home.

Setting/Subjects

One study was conducted at 23 PCUs (January to December 2017) and the other on 45 palliative home care services (July to December 2017) in Japan.

Measurements

Symptom changes were categorized as stable, improved, or worse.

Results

Of the 2998 registered patients, 2877 were analyzed. Among them, 1890 patients received palliative care in PCUs, and 987 at home. Patients receiving palliative care at home were more likely to have worsening of pain (17.1% vs. 3.8%; p < 0.001) and drowsiness (32.6% vs. 22.2%; p < 0.001) than those in PCUs. By multivariate logistic regression analysis, palliative care at home was significantly associated with worsening of the Palliative Prognostic Index dyspnea subscale in the unadjusted model (odds ratio, 1.42 [95% confidence interval, 1.08-1.88]; p = 0.014) but not for any symptoms in the adjusted model.

Conclusions

After adjusting for patient background, the prevalence of symptom worsening was not different between patients with advanced cancer receiving palliative care at home and in PCUs.

Prevalence and severity of symptoms and signs in patients with advanced cancer in the last days of life: the East Asian collaborative cross-cultural study to elucidate the dying process (EASED)

PURPOSE

Few large-scale studies have focused on the prevalence of symptoms and signs during the last days of patients diagnosed with advanced cancer. Identifying the patterns of specific symptoms according to cancer type is helpful to provide end-of-life care for patients with advanced cancer. We investigated the prevalence and severity of symptoms and signs associated with impending death in patients with advanced cancer.

METHODS

In this secondary analysis of an international multicenter cohort study conducted in three East Asian countries, we compared the severity of symptoms and signs among dying patients in the last 3 days of life according to the type of primary cancer using one-way analysis of variance (ANOVA). Post hoc analysis was conducted for multiple comparisons of each symptom according to the type of primary cancer.

RESULTS

We analyzed 2131 patients from Japan, Korea, and Taiwan. The prevalence of most symptoms and signs were relatively stable from 1 week after admission to the last 3 days of life. According to cancer type, edema of the lower extremities was the most common symptom and fatigue/ ascites were the most severe symptoms in digestive tract cancer. For lung cancer, respiratory secretion was the most prevalent and dyspnea/respiratory secretion were the most severe symptoms.

CONCLUSION

We demonstrated the prevalence and severity of symptoms and signs associated with the impending death of patients with advanced cancer in East Asia. Our study can enable clinicians to recognize the specific symptoms and signs at the very end of life.

Association between the amount of artificial hydration and quality of dying among terminally ill patients with cancer: The East Asian Collaborative Cross-Cultural Study to Elucidate the Dying Process

BACKGROUND

Artificial hydration (AH) is a challenging issue in terminally ill patients with cancer, because it influences patients' symptoms control, quality of life, and quality of dying (QOD). To date, it is not clear how much AH supply is proper for imminently dying patients. This study aimed to investigate the association between the amount of AH and QOD.

METHODS

This study is part of the East Asian Collaborative Cross-Cultural Study to Elucidate the Dying Process (EASED) conducted in Japan, Korea, and Taiwan from January 2017 to September 2018. Patients' demographics, symptoms, and managements on admission to palliative care units (PCUs) and before death were recorded. The AH amount was classified into different groups by 250-mL intervals to compare their difference. The Good Death Scale (GDS) was used to measure QOD, with patients classified into higher or lower QOD groups using GDS = 12 as the cutoff point. We used logistic regression analysis to assess the association between AH amount and QOD.

RESULTS

In total, 1530 patients were included in the analysis. Country, religion, spiritual well-being, fatigue, delirium, dyspnea, AH, and antibiotics use before death were significantly associated with QOD. After conducting regression analysis, patients administered with 250 to 499 mL AH had significantly better QOD (odds ratio, 2.251; 95% confidence interval, 1.072-4.730; P = .032) than those without AH.

CONCLUSIONS

AH use impacts the QOD of terminally ill patients with cancer admitted to PCUs. Communication with patients and their families on appropriate AH use has a positive effect on QOD.

LAY SUMMARY

Our prospective cross-cultural multicenter study aims to investigate the relationship between artificial hydration (AH) amount and quality of dying among terminally ill patients with cancer. The findings reveal that country, religion, spiritual well-being, fatigue, delirium, dyspnea, AH, and antibiotics use before death were significantly associated with quality of death (QOD). After multivariable logistic regression, patients administered with AH amount 250 to 499 mL had significantly better QOD (odds ratio, 2.251; 95% confidence interval, 1.072-4.730; P = .032) than those without AH. Communication with patients and their families regarding AH is recommended as it may help them be better prepared for the end-of-life stage and achieve a good death.

Difficulties in Addressing Artificial Hydration and Nutrition Therapy for Terminal Cancer Patients: What to do if Patients/Families' Wishes Differ From the Medically Appropriate Treatment Plans?

PURPOSE

Artificial hydration and nutrition therapy (AHNT) initiated by patients/families sometimes differs from medically appropriate treatment plans. We aimed to identify the causes of these differences and examine the ensuing responses and outcomes.

METHODS

Of 133 adult cancer patients receiving end-of-life care in the last 2 years, these discrepancies occurred in 41 patients. We retrospectively examined the following issues: (1) The reason why these discrepancies occurred. (2) Based on the causes identified in (1), the following actions were taken: 1) If the consent to change to medically appropriate AHNT was obtained, physical findings using Japan Palliative Oncology Study (JPOS) group and Edmonton Symptom Assessment System (ESAS) were compared before and 1 week after the intervention. 2) If consent was not obtained, time-limited trial (TLT) was conducted, and these results were compared. (3) The communication between patients/families and medical professionals was compared using Support Team Assessment Schedule.

RESULTS

(1) Causes: a) the lack of understanding of the disease condition in 26 cases and b) faulty expectation of AHNT in 15 cases. (2) In 30 cases of 1) (20 of a) and 10 of b)) and 11 of 2) in which TLT was performed, JPOS and ESAS improved significantly. (3) The communication above was improved significantly in 1) and 2) (P = .0027 and .0039, respectively).

CONCLUSION

Providing medically appropriate AHNT with the consent of patients/families is expected to not only alleviate distressing symptoms but also improve the communication between patients/families and medical professionals, as well as improve the quality of palliative care.

A Case of Advanced Gastric Cancer With Multiple Liver Metastases in Which Hypoglycemic Symptoms Triggered the Diagnosis

We experienced a case of gastric cancer with multiple liver metastases characterized by frequent hypoglycemic attacks. Hypoglycemia was observed on admission. We suspected that the cause of this hypoglycemia was non-islet cell tumor hypoglycemia (NICTH). Staining of the tissue with an insulin-like growth factor (IGF)-II antibody revealed that IGF-II was present in the tumor cells. This finding suggested that the tumor was producing IGF-II, which leads to NICTH. After starting parenteral nutrition, the patient emerged from the hypoglycemic coma. He remained out of the coma until he died of liver failure.

Hydration Volume Is Associated with Development of Death Rattle in Patients with Abdominal Cancer

Background: Death rattle occurs frequently in dying patients with malignancies. The association the between hydration volume and death rattle development is controversial. Design and Setting: A secondary analysis using data from two multicenter prospective observational studies, including a total of 471 consecutive advanced cancer patients. Of these, we analyzed patients with abdominal malignancies. Measurements: The association of an artificial hydration volume one week before death with the development of death rattle 48 hours before death was evaluated with the adjustment of potential confounders using the propensity score-weighting method. Results: We analyzed 300 patients. The prevalence of death rattle was significantly higher in those receiving artificial hydration >500 mL/day than those receiving ≤500 mL/day (23.1% vs. 13.6%, respectively; adjusted odds ratio: 2.56; 95% confidence interval: 1.37-4.80; p = 0.0036). Conclusion: The hydration volume might be associated with death rattle development in patients with abdominal malignancies. Volume reduction may alleviate or prevent death rattle.

Identification of Remaining Life Expectancy Less Than Two Weeks by C-Reactive Protein/Albumin Ratio, Prognostic Nutritional Index, Fibrosis-4 Index, and Albumin-Bilirubin Score in Terminal Cancer Patients

Background: Accurate prognosis in terminal cancer patients is useful to improve their quality of life and also to decide the cessation of fluid administration. Nonetheless, few prognostic indicators are available for prediction of such a short-term life expectancy. Objectives: The present study aimed at evaluating the efficacy of C-reactive protein (CRP)/albumin (CRP/Alb) ratio, prognostic nutritional index (PNI), fibrosis-4 (FIB-4) index, and albumin-bilirubin (ALBI) score in identifying terminal cancer patients who have a life expectancy less than two weeks. Design: Retrospective study. Setting/Subjects: Of 483 patients who died between April 2019 and March 2020 at a single center in Japan, 102 who met the inclusion criteria were enrolled in this study. Measurements: CRP/Alb, PNI, FIB-4, and ALBI were calculated from the laboratory data collected 1-13, 14-27, 28-83, and 168-365 days before death and subjected to statistical analyses. Results: CRP/Alb, PNI, FIB-4, and ALBI values were significantly associated with the time before death during terminal 365 days. CRP/Alb ≥4.4, PNI <30, FIB-4 ≥ 9.4, and ALBI ≥ -1.26 were significantly associated with the transition from the first half to the second half of terminal four weeks. Of those prognostic indicators, three and four combinations provided significantly reliable estimation of a life expectancy less than two weeks. Conclusions: CRP/Alb, PNI, FIB-4, ALBI, and their combinations are considered to help identify cancer patients who have a life expectancy less than two weeks, which is useful to make appropriate end-stage treatment decisions, for example, cessation of artificial hydration therapy.

Top Ten Tips Palliative Care Clinicians Should Know About Prognostication in Oncology, Dementia, Frailty, and Pulmonary Diseases

Prognostication has been described as "Medicine's Lost Art." Taken with diagnosis and treatment, prognostication is the third leg on which medical care rests. As research leads to additional beneficial treatments for vexing conditions like cancer, dementia, and lung disease, prognostication becomes even more difficult. This article, written by a group of palliative care clinicians with backgrounds in geriatrics, pulmonology, and oncology, aims to offer a useful framework for consideration of prognosis in these conditions. This article will serve as the first in a three-part series on prognostication in adults and children.

Molecular and physical technologies for monitoring fluid and electrolyte imbalance: A focus on cancer population

Several clinical examinations have shown the essential impact of monitoring (de)hydration (fluid and electrolyte imbalance) in cancer patients. There are multiple risk factors associated with (de)hydration, including aging, excessive or lack of fluid consumption in sports, alcohol consumption, hot weather, diabetes insipidus, vomiting, diarrhea, cancer, radiation, chemotherapy, and use of diuretics. Fluid and electrolyte imbalance mainly involves alterations in the levels of sodium, potassium, calcium, and magnesium in extracellular fluids. Hyponatremia is a common condition among individuals with cancer (62% of cases), along with hypokalemia (40%), hypophosphatemia (32%), hypomagnesemia (17%), hypocalcemia (12%), and hypernatremia (1-5%). Lack of hydration and monitoring of hydration status can lead to severe complications, such as nausea/vomiting, diarrhea, fatigue, seizures, cell swelling or shrinking, kidney failure, shock, coma, and even death. This article aims to review the current (de)hydration (fluid and electrolyte imbalance) monitoring technologies focusing on cancer. First, we discuss the physiological and pathophysiological implications of fluid and electrolyte imbalance in cancer patients. Second, we explore the different molecular and physical monitoring methods used to measure fluid and electrolyte imbalance and the measurement challenges in diverse populations. Hydration status is assessed in various indices; plasma, sweat, tear, saliva, urine, body mass, interstitial fluid, and skin-integration techniques have been extensively investigated. No unified (de)hydration (fluid and electrolyte imbalance) monitoring technology exists for different populations (including sports, elderly, children, and cancer). Establishing novel methods and technologies to facilitate and unify measurements of hydration status represents an excellent opportunity to develop impactful new approaches for patient care.

Analysis of end-of-life treatment and physician perceptions at a university hospital in Germany

Purpose

Providing state-of-the-art palliative care is crucial in all areas of in- and outpatient settings. Studies on the implementation of palliative care standards for dying patients are rare.

Methods

N = 141 physicians from all internal departments were polled anonymously about the treatment of dying patients using a self-designed questionnaire. Furthermore, we evaluated the terminal care of n = 278 patients who died in internal medicine departments at University Hospital Mannheim between January and June, 2019 based on clinical data of the last 48 h of life. We defined mandatory criteria for good palliative practice both regarding treatment according to patients' records and answers in physicians' survey.

Results

Fifty-six physicians (40%) reported uncertainties in the treatment of dying patients (p < 0.05). Physicians caring for dying patients regularly stated to use sedatives more frequently and to administer less infusions (p < 0.05, respectively). In multivariate analysis, medical specialization was identified as an independent factor for good palliative practice (p < 0.05). Physicians working with cancer patients regularly were seven times more likely to use good palliative practice (p < 0.05) than physicians who did not. Cancer patients received good palliative practice more often than patients dying from non-malignant diseases (p < 0.05).

Conclusion

Guideline-based palliative care for dying patients was found to be implemented more likely and consistent within the oncology department. These results point to a potential lack of training of fellows in non-oncological departments in terms of good end-of-life care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00432-021-03652-0.

Prognostic factors, symptoms and consequences of dehydration and dyselectrolytemia in patients with terminal stomach cancer

BACKGROUND

Dyselectrolytaemia and dehydration are common symptoms in people with terminal stomach cancer.

AIMS

To determine factors related to dyselectrolytemia and dehydration in patients with terminal stomach cancer.

METHODS

An analysis of 134 patients with terminal stomach cancer admitted to the palliative care unit was conducted, through an audit of the patients' medical records. The average age of women was 63.1 years and that of men was 64.9 years.

FINDINGS

Dehydrated patients were more likely to: have dyselectrolytaemia; have a higher PS scale score; be taking opioids as an analgesic; have a high sodium concentration; experience dyspnoea, constipation, nausea and vomiting during hospitalisation; and require glucocorticoids administration both during and before hospitalisation. Patients with dyselectrolytaemia were more likely to: be admitted to the palliative care unit from the emergency department; experience cachexia and dehydration during hospitalisation and constipation at discharge; have a lower albumin level; and have a higher glucose level. Patients with dyselectrolytaemia also had a shorter duration of treatment and a 2.48 greater chance for death compared with those who did not have it.

CONCLUSIONS

Knowledge of the adverse factors connected with dehydration and dyselectrolytaemia will allow health professionals to avoid dangerous clinical symptoms and prolong the life of those with terminal stomach cancer, as they might be able to foresee the occurrence of these conditions based on the medication the patient has been taking and symptoms they have been experiencing. Nurses will have a greater understanding of the importance of fluid therapy to resolve ionic disturbances and the need to address dehydration and dyselectrolytemia as a means to prolong and improve quality of life.

To hydrate or not to hydrate? The effect of hydration on survival, symptoms and quality of dying among terminally ill cancer patients

Background

Artificial nutrition and hydration do not prolong survival or improve clinical symptoms of terminally ill cancer patients. Nonetheless, little is known about the effect of artificial hydration (AH) alone on patients’ survival, symptoms or quality of dying. This study explored the relationship between AH and survival, symptoms and quality of dying among terminally ill cancer patients.

Methods

A pilot prospective, observational study was conducted in the palliative care units of three tertiary hospitals in Taiwan between October 2016 and December 2017. A total of 100 patients were included and classified into the hydration and non-hydration group using 400 mL of fluid per day as the cut-off point. The quality of dying was measured by the Good Death Scale (GDS). Multivariate analyses using Cox’s proportional hazards model were used to assess the survival status of patients, the Wilcoxon rank-sum test for within-group analyses and the Mann-Whitney U test for between-groups analyses to evaluate changes in symptoms between day 0 and 7 in both groups. Logistic regression analysis was used to assess the predictors of a good death.

Results

There were no differences in survival (p = 0.337) or symptom improvement between the hydration and non-hydration group, however, patients with AH had higher GDS scores.

Conclusions

AH did not prolong survival nor significantly improve dehydration symptoms of terminally ill cancer patients but it may influence the quality of dying. Communication with patients and their families on the effect of AH may help them better prepared for the end-of-life experience.

Nurses' perceived knowledge and benefits of artificial nutrition and hydration for patients nearing death: A survey among Jordanian nurses

OBJECTIVE

Existing research highlights the importance of nurses' knowledge and attitudes towards the provision of artificial nutrition and hydration (ANH) for patients with advanced cancer; however, the perspectives of Arabic and Islamic nurses have not yet been investigated. Therefore, we aimed to examine Jordanian nurses' knowledge, attitudes and perceived benefits in providing ANH for patients with advanced cancer.

METHOD

A descriptive cross-sectional design was employed.

RESULTS

Participants comprised 183 nurses (93.5% response rate). Around 80% received no training on ANH. Nurses had poor knowledge regarding ANH, with a mean score of 5.12 (SD=2.27) out of 15. Overall, nurses had positive attitudes towards ANH care (M = 3.09, SD = 0.29); however, the subscale analysis showed that nurses held inconspicuous beliefs about ANH benefits (M = 2.67, SD = 0.71) and strongly believed that ANH places a high burden on patients (M = 3.50, SD = 0.69). Nurses from government hospitals showed significantly higher ANH knowledge, as well as positive beliefs regarding ANH benefits, compared to less educated nurses.

CONCLUSION

Jordanian nurses have limited knowledge of ANH. Their positive attitude regarding ANH for terminally ill patients could be driven by cultural norms and beliefs, rather than education. Introducing ANH in nursing curricula and in-hospital services could have a positive impact on nurses' knowledge.

Pharmacist's Intervention Considering the Prognosis for a Terminal Cancer Patient: A Case Report

Prognostic prediction has been reported to affect the decision of doctors and non-physician health care providers such as nurses, social workers, pastors, and hospice volunteers on the selection of appropriate medical interventions. This was a case of a 65-year-old woman who presented with a poor oral intake. The patient had a history of sigmoid colon cancer with abdominal wall metastasis and peritoneal dissemination. On the day of admission, nausea, anorexia, and malaise were noted, requiring immediate intervention. The patient’s prognosis was predicted using the Palliative Prognostic Index. The pharmacist suggested the use of dexamethasone tablets in order to alleviate the patient’s symptoms. Indeed, the administration of dexamethasone alleviated the symptoms of nausea, loss of appetite, and malaise. To the best of our knowledge, this is the first case report to demonstrate that prognosis prediction is important not only for other medical staff but also for pharmacists when deciding the need to initiate a treatment and continue such treatment, and when providing pharmacist interventions.

Physical and psychological symptoms and signs in dying digestive tract cancer patients: the East Asian collaborative cross-cultural Study to Elucidate the Dying process (EASED)

BACKGROUND

Well detection of the symptoms and signs of dying patients is essential for providing proper palliative care. Our goal is to evaluate the predominant symptoms and compare the changes in dying patients with digestive tract cancer in Japan, South Korea, and Taiwan.

METHODS

A total of 1057 cancer patients aged 18 years or older admitted in palliative care units with locally advanced or metastatic gastroesophageal, colorectal, and pancreaticobiliary cancer were enrolled from January 2017 to March 2019. The severity of physical and psychological symptoms and signs assessed by physicians and/or nurses upon admission, 1 week after admission, and within 3 days of death, was compared according to cancer type and country of origin.

RESULTS

Among the 338 gastroesophageal, 358 pancreaticobiliary, and 361 colorectal cancer patients, 894 (93.1%) died during the observation period. Fatigue was the most severe symptom in all cancer groups before dying. Dyspnea, fatigue, drowsiness, and ascites improved after hospitalization albeit they worsened prior to death. In particular, ascites was a marked symptom in patients with pancreaticobiliary cancer. Delirium and hallucination gradually worsened during the period leading to death. Differences in manifestations with respect to the country of origin were not significant.

CONCLUSION

We identified the most prevalent signs and symptoms in patients from East Asia who were dying from digestive tract cancers. Proper management, based on these prevalent signs and symptoms during the dying period, plays a vital role in providing adequate palliative care.

What is the impact of clinically assisted hydration in the last days of life? A systematic literature review and narrative synthesis

Background

Clinically assisted hydration (CAH) can be provided in the last days of life as drinking declines. The impact of this practice on quality of life or survival in the last days of life is unclear. Practice varies worldwide concerning this emotive issue.

Method

Systematic literature review and narrative synthesis of studies evaluating the impact of, or attitudes toward, CAH in the last days of life. Databases were searched up to December 2019. Studies were included if the majority of participants were in the last 7 days of life, and were evaluated using Gough’s 'Weight of Evidence' framework. Review protocol registered with PROSPERO, registration number CRD42019125837.

Results

Fifteen studies were included in the synthesis. None were judged to be both of high quality and relevance. No evidence was found that the provision of CAH has an impact on symptoms or survival. Patient and family carer attitudes toward assisted hydration were diverse.

Conclusion

There is currently insufficient evidence to draw firm conclusions on the impact of CAH in the last days of life. Future research needs to focus on patients specifically in the last days of life, include those with non-malignant diagnoses, and evaluate best ways to communicate effectively about this complex topic with patients and their families.

Artificial hydration at the end of life: balancing benefits and risks in the absence of conclusive evidence

There is a lack of clear evidence regarding the benefits and harm of artificial hydration at the end of life. Trial findings are conflicting and inconclusive, offering little basis for recommendations. As a result, the advantages and disadvantages of artificial hydration remain largely anecdotal, and decisions about its use, withholding or withdrawal are often based on opinion rather than evidence. In certain circumstances, some patients who are dying might derive benefit from artificial hydration in terms of reducing specific symptoms, such as delirium. This article explores the central questions pertaining to artificial hydration at the end of life by undertaking a critical exploration of the relevant literature.

When they stop drinking-examining end-of-life hydration practices and death rattle occurrence

PURPOSE

To characterize the practice of subcutaneous hydration provision in the Beer-Sheva home care hospice unit. We also explore the potential connection between the provision of subcutaneous hydration and the incidence of death rattle.

METHODS

This was a prospective observational study involving 120 hospice patients. During the 6 days before death, hospice staff recorded whether or not fluids were administered orally and/or subcutaneously; the duration, timing, and quantity of fluid administration; the incidence, timing, and duration of death rattle; and whether medications that can affect death rattle were given.

RESULT

Fifty-three percent of the patients received subcutaneous hydration. The mean daily volume administered in the hydration group was 434 ml. There was a significant association between the duration of treatment in the hospice unit and provision of subcutaneous hydration (mean of 51 days in hydration group vs. 31 days in non-hydration group, p = 0.03). Although not statistically significant, males were more likely to receive subcutaneous hydration than females (62% of males vs. 46% of females, p = 0.09). There was a higher incidence of death rattle in men compared to women (54.7% in men vs. 32.8% in women, p = 0.025). A statistically significant association between death rattle and the provision of subcutaneous hydration wasn't demonstrated.

CONCLUSION

The decision of whether to provide subcutaneous hydration is individualized taking into consideration the values of the patients and their families. The provision of 500 ml per day of subcutaneous saline during the last 6 days of life does not significantly increase the incidence of death rattle.

The Effectiveness of Artificial Hydration Therapy for Patients With Terminal Cancer Having Overhydration Symptoms Based on the Japanese Clinical Guidelines A Pilot Study

BACKGROUND

Recently, there has been a growing interest in the use of artificial hydration therapy (AHT) for patients with terminal cancer. The Japanese Society for Palliative Medicine published the guideline for AHT in 2007, and it was revised in 2013 based on the concept of cancer cachexia.

OBJECTIVES

The purpose of this study was to evaluate the effects of AHT for patients with terminal cancer having overhydration symptoms based on this revised guideline.

METHODS

This is a before-and-after study. We retrospectively analyzed 121 patients, of the 523 patients with terminal cancer who were admitted during the last 4 years, who were receiving "inappropriate hydration therapy." We performed guideline-based AHT and examined the effects on the alleviation of hydration-related symptoms, quality of life (QOL), patient satisfaction, and the feeling of benefit from AHT using a numeric rating scale, European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire-C30, satisfaction scale, and benefit scale on day 7 ± 1 compared to those at baseline.

RESULTS

Hydration-related symptoms (nausea: 32, abdominal pain/distention: 35, peripheral edema: 42, and dyspnea: 28 cases) were significantly improved after performing guideline-based AHT (5.35 ± 1.26→4.00 ± 1.51, P = .002; 5.41 ± 1.44→4.12 ± 1.52; P = .005; 5.16 ± 1.38→3.29 ± 1.66; P < .0001; and 5.24 ± 1.22→4.21 ± 1.53, P = .002, respectively). The general QOL scores, overall satisfaction, and feeling of benefit were also significantly improved (2.67 ± 1.21→3.98 ± 1.55, P < .0001; 2.25 ± 1.35→3.48 ± 1.44, P < .0001; and 3.12 ± 1.24→4.31 ± 1.38, P = .0001, respectively).

CONCLUSIONS

An appropriate AHT could alleviate overhydration-related symptoms and improve the QOL, patient satisfaction, and feeling of benefit.

Management of drainage for malignant ascites in gynaecological cancer

BACKGROUND

Ascites is the accumulation of fluid within the abdominal cavity. Most women with advanced ovarian cancer and some women with advanced endometrial cancer need repeated drainage for ascites. Guidelines to advise those involved in the drainage of ascites are usually produced locally and are generally not evidence-based. Managing drains that improve the efficacy and quality of the procedure is key in making recommendations that could improve the quality of life (QoL) for women at this critical period of their lives.

OBJECTIVES

To evaluate the effectiveness and adverse events of different interventions for the management of malignant ascites drainage in the palliative care of women with gynaecological cancer.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase to 4 November 2019. We checked clinical trial registries, grey literature, reports of conferences, citation lists of included studies, and key textbooks for potentially relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of women with malignant ascites with gynaecological cancer. If studies also included women with non-gynaecological cancer, we planned to extract data specifically for women with gynaecological cancers or request the data from trial authors. If this was not possible, we planned to include the study only if at least 50% of participants were diagnosed with gynaecological cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data, evaluated the quality of the included studies, compared results, and assessed the certainty of the evidence using Cochrane methodology.

MAIN RESULTS

In the original 2010 review, we identified no relevant studies. This updated review included one RCT involving 245 participants that compared abdominal paracentesis and intraperitoneal infusion of catumaxomab versus abdominal paracentesis alone. The study was at high risk of bias in almost all domains. The data were not suitable for analysis. The median time to the first deterioration of QoL ranged from 19 to 26 days in participants receiving paracentesis alone compared to 47 to 49 days among participants receiving paracentesis with catumaxomab infusion (very low-certainty evidence). Adverse events were only reported among participants receiving catumaxomab infusion. The most common severe adverse events were abdominal pain and lymphopenia (157 participants; very low-certainty evidence). There were no data on the improvement of symptoms, satisfaction of participants and caregivers, and cost-effectiveness.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence to recommend the most appropriate management of drainage for malignant ascites among women with gynaecological cancer, as there was only very low-certainty evidence from one small RCT at overall high risk of bias.

Nutrition and hydration in palliative care

Anorexia, weight loss and muscle wasting commonly affect people approaching the end of life. It is critical that clinicians caring for people with advanced illness and progressive frailty can assess the nutritional and hydration needs of these people, engage them in shared decision making and support them to plan ahead regarding their nutritional care preferences as their health deteriorates.

Hydration and symptoms in the last days of life

OBJECTIVES

At the end of life oral fluid intake is often reduced. Consensus about the most appropriate management for terminally ill patients with limited oral fluid intake is lacking. The objective of this study is to investigate to what extent the amount of fluid intake, preceding and during the dying phase, is related to the occurrence of death rattle and terminal restlessness.

METHODS

A multicentre prospective observational study was performed. Data on the occurrence of death rattle and terminal restlessness, fluid intake and opioid use of patients expected to die within a few days or hours were collected.

RESULTS

371 patients were included. Death rattle was reported at least once in 40% (n=149) of patients during the dying phase. Death rattle occurrence was not associated with the amount of fluid intake during the days before dying. Terminal restlessness was reported in 26% of patients (n=96). Terminal restlessness was not associated with a lower amount of fluid intake during the days before dying. Terminal restlessness during the last 24 hours of life was associated with a higher amount of fluid (ie, >250 mL/day) during 48-25 hours before death.

CONCLUSIONS

Caution with fluid intake to prevent development of death rattle does not seem to be necessary. Our study suggests that a higher amount of fluid intake during 48-25 hours before death may be associated with the occurrence of terminal restlessness during the last 24 hours of life. These results suggest that actively providing dying patients with artificial fluid may not be beneficial.

A survey of practice in management of malignancy-related ascites in Japan

Although ascites is a distressing complication observed commonly in the course of advanced cancer, there is no effective treatment established for malignancy-related ascites. We conducted a nationwide survey of cancer physicians in Japan who treat malignancy-related ascites in order to determine what kind of therapeutic approach is thought to be significant and what kind of diuretic prescriptions are thought to be standard for malignancy-related ascites. From 2017 to 2018, we sent a one-page memo to oncologists in Japan asking them to participate in a questionnaire-style survey that they could complete online. The significance of each of the nine representative interventions was measured on a 5-stage Likert scale. At the same time, participants were asked about what type and dosage of diuretics they thought to be standard as a treatment for malignancy-related ascites. Ultimately, 187 oncologists responded to our invitation. The interventions that were particularly significant were reducing hydration volume, paracentesis, and symptom management with analgesics. The respondents indicated that the importance of diuretics was significantly lower than that of these three interventions. Furthermore, 86.2% of the respondents in Japan regarded the use of loop diuretics ± aldosterone antagonists as the standard of diuretic therapy for malignancy-related ascites, and the most common regimen was 20 mg of oral furosemide ± 25 mg of spironolactone daily at the start, and 30-40 mg ± 50 mg daily at the time of initial escalation. Although our study revealed that the attitude of oncologists in Japan toward therapeutic options for malignancy-related ascites was nearly consistent with that of previous reports from other countries, it was newly found that they seemed to commonly be concerned with preventing overhydration of terminally ill cancer patients and that analgesics were also thought to be a significant form of intervention.

A cluster randomised feasibility trial of clinically assisted hydration in cancer patients in the last days of life

BACKGROUND

The provision of clinically assisted hydration at the end-of-life is one of the most contentious issues in medicine.

AIM

The aim of this feasibility study was to answer the question 'can a definitive (adequately powered) study be done?'

DESIGN

The study was a cluster randomised trial, with sites randomised on a one-to-one basis to intervention 'A' (regular mouth care and usual other care) or intervention 'B' (clinically assisted hydration, mouth care and usual other care). Participants were assessed every 4 h, and data collected on clinical problems, therapeutic interventions and overall survival.

SETTING/PARTICIPANTS

The study was conducted at 12 sites/'clusters' with specialist palliative care teams (4 cancer centres and 8 hospices), and participants were cancer patients in the last week of life who were unable to maintain sufficient oral fluid intake.

RESULTS

The study achieved its pre-determined criteria for success. Two hundred patients were recruited to the study, and 199 participants completed the study, over a 1-year period. A total of 38.5% participants discontinued clinically assisted hydration due to adverse effects: none of these adverse events were rated as 'severe' or worse in intensity. The primary reasons for discontinuation were site problems ( n = 2), localised oedema ( n = 13), generalised oedema ( n = 5), respiratory secretions ( n = 6) and nausea and vomiting ( n = 1).

CONCLUSION

The results of this feasibility study suggest that a definitive study can be done, but that minor changes are needed to the protocol to standardise the administration of clinically assisted hydration (which may reduce the incidence of certain adverse effects).

Is parenteral hydration beneficial in terminally ill cancer patients?

INTRODUCTION

It is common for terminally ill patients to have a reduced fluid intake, which often results in a need for more medical support. However, it is not clear if this measure has a real clinical impact.

METHODS

To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data from primary studies and generated a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS

We identified four systematic reviews including 51 studies overall, from which three were randomized trials. We concluded the administration of parenteral hydration might make little or no difference in terms of survival and quality of life in terminally ill cancer patients, and that it is not clear whether it has any other benefit because the certainty of the evidence is very low.

The Association of Hydration Status with Physical Signs, Symptoms and Survival in Advanced Cancer-The Use of Bioelectrical Impedance Vector Analysis (BIVA) Technology to Evaluate Fluid Volume in Palliative Care: An Observational Study

BACKGROUND

Hydration in advanced cancer is a controversial area; however, current hydration assessments methods are poorly developed. Bioelectrical impedance vector analysis (BIVA) is an accurate hydration tool; however its application in advanced cancer has not been explored. This study used BIVA to evaluate hydration status in advanced cancer to examine the association of fluid status with symptoms, physical signs, renal biochemical measures and survival.

MATERIALS AND METHODS

An observational study of 90 adults with advanced cancer receiving care in a UK specialist palliative care inpatient unit was conducted. Hydration status was assessed using BIVA in addition to assessments of symptoms, physical signs, performance status, renal biochemical measures, oral fluid intake and medications. The association of clinical variables with hydration was evaluated using regression analysis. A survival analysis was conducted to examine the influence of hydration status and renal failure.

RESULTS

The hydration status of participants was normal in 43 (47.8%), 'more hydrated' in 37 (41.1%) and 'less hydrated' in 10 (11.1%). Lower hydration was associated with increased symptom intensity (Beta = -0.29, p = 0.04) and higher scores for physical signs associated with dehydration (Beta = 10.94, p = 0.02). Higher hydration was associated with oedema (Beta = 2.55, p<0.001). Median survival was statistically significantly shorter in 'less hydrated' patients (44 vs. 68 days; p = 0.049) and in pre-renal failure (44 vs. 100 days; p = 0.003).

CONCLUSIONS

In advanced cancer, hydration status was associated with clinical signs and symptoms. Hydration status and pre-renal failure were independent predictors of survival. Further studies can establish the utility of BIVA as a standardised hydration assessment tool and explore its potential research application, in order to inform the clinical management of fluid balance in patients with advanced cancer.

Physician and Nurse Attitudes Toward Artificial Hydration for Terminally Ill Cancer Patients in Japan: Results of 2 Nationwide Surveys

This study investigated physician and nurse attitudes toward artificial hydration in terminally ill cancer patients and compared differences in attitudes between these 2 professions and among clinical settings in Japan. The response rate was 53% (584/1123) for physicians and 79% for nurses (3328/4210). More physicians answered that artificial hydration alleviates the sensation of thirst. More palliative care unit physicians and nurses answered that withholding artificial hydration alleviated several physical symptoms. Oncologists answered that artificial hydration alleviated the sensation of thirst and fatigue. Discussion among patient-centered teams and individualized decision making are important. Because the differences identified here are attributable to differences in knowledge of artificial hydration for terminal cancer patients, oncologists should place greater emphasis on the opinion of palliative care specialists. Medical practitioners caring for terminal cancer patients should consider a broader range of views on hydration therapy, with a focus on effective hydration techniques and alternative interventions.

Level of Discomfort Decreases After the Administration of Continuous Palliative Sedation: A Prospective Multicenter Study in Hospices and Palliative Care Units

CONTEXT

A gold standard or validated tool for monitoring the level of discomfort during continuous palliative sedation (CPS) is lacking. Therefore, little is known about the course of discomfort in sedated patients, the efficacy of CPS, and the determinants of discomfort during CPS.

OBJECTIVES

To identify the course of discomfort in patients receiving CPS.

METHODS

A prospective observational multicenter study in nine hospices and palliative care units was performed. The Discomfort Scale-Dementia of Alzheimer Type (DS-DAT) was independently assessed for monitoring of patient discomfort during CPS. The DS-DAT scores range from 0 (no observed discomfort) to a maximum of 27 (high level of observed discomfort). Using a mixed model, the mean group score of discomfort between four predefined time frames of CPS was compared, correcting for confounding patient characteristics.

RESULTS

A total of 130 patients were sedated, and the DS-DAT was completed in 106 patients at least once. The median duration of the sedation in these 106 patients was 25.5 hours (range 2-161). The mean score of the DS-DAT in the phase before sedation was 12.16 (95% CI 9.83-14.50) and decreased significantly to 8.06 (95% CI 5.53-10.58) in the titration phase of sedation. The mean score of the DS-DAT in the final phase of sedation was 7.42 (95% CI 4.90-9.94).

CONCLUSION

This study shows that CPS is associated with a decrease in the level of discomfort within an acceptable time frame, although in some sedated patients higher levels of discomfort in the last hours of life occurred. Although the DS-DAT seems to be of value for monitoring the level of discomfort during CPS, the results of this study should be interpreted within the constraints of the limitations, and further research on the psychometric properties of this tool is needed before the DS-DAT can be used in clinical practice.

Alternative forms of hydration in patients with cancer in the last days of life: study protocol for a randomised controlled trial

Background

The provision of clinically assisted hydration at the end of life is one of the most contentious issues in medicine, and indeed within the general population. The reasons for contention include: a) the lack of evidence for or against; b) the disparate opinions of healthcare professionals; and c) the generally positive opinions of patients and their carers about clinically assisted hydration.

Methods/design

The study is a cluster randomised trial to assess the feasibility of conducting an adequately powered, randomised controlled trial of clinically assisted hydration in patients with cancer in the last days of life. Twelve sites, four National Health Service (NHS) hospitals and eight NHS/voluntary sector hospices in the United Kingdom, will be randomised to give either standard intervention A: continuance of oral intake and regular mouth care, or standard intervention B: continuance of oral intake, regular mouth care and clinically assisted hydration. Patients will be included if they: i) have a diagnosis of cancer; ii) are aged ≥ 18 yr; iii) have an estimated prognosis of ≤ 1 week and iv) are unable to maintain sufficient oral intake (1 L per day, measured/estimated); and v) are able to give informed consent. Patients will be excluded if they have contra-indications to receiving clinically assisted hydration. The primary endpoint of interest is the frequency of hyperactive delirium (‘terminal agitation‘), and this will be assessed using the Modified Richmond Agitation and Sedation Scale (administered every four hours). Other data to be collected include the frequency of pain, respiratory secretions (‘death rattle‘), dyspnoea, nausea and vomiting, adverse effects to clinically assisted hydration and overall survival. In addition, data will be collected on the use of anti-psychotic drugs, sedative drugs, analgesics, anti-secretory drugs and other end-of-life medication. The study has obtained full ethical approval.

Discussion

A randomised controlled trial of clinically assisted hydration in end-of-life care is urgently required. This feasibility study will allow methodological and ethical issues to be understood and addressed to ensure that a robust, adequately powered, randomised controlled trial is designed.

Trial registration

ClinicalTrials.gov NCT02344927 (registered 4 June 2014).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0988-3) contains supplementary material, which is available to authorized users.

[Nutrition and hydration at the end of life]

At the end of life the pleasure function of alimentation is to be preferred to its nutritive function. Artificial nutrition and hydration in an enteral or parenteral way are artificial life support techniques. Artificial nutrition and hydration are systematically justified for patients in curative phase that require it but not for patients in a terminal or agonal phase. The fear of death from hunger and thirst is not justified. It is more relevant of a symbolic and phantasmic dimension than of an objective reality. The practice of oral care is much more effective than installing an artificial hydration to improve the comfort of a patient at the very end of life. Withdrawing or withholding an artificial nutrition and hydration can prevent an unreasonable obstinacy prohibited by law.