The experiences of family members witnessing the diminishing drinking of a dying relative: An adapted meta-narrative literature review

The responsibility to quench thirst by providing drinks when a relative is dying spouses' experience in specialist palliative home care

BACKGROUND

Thirst and dry mouth are common symptoms in terminally ill patients. It is known that family members usually request drips for their dying relative. Few studies have focused on thirst in terminally ill patients and their spouses' experience of this, leading to a knowledge gap in this area.

AIM

The aim of this study was to explore spouses' experiences of observing and managing thirst in a dying relative admitted to specialist palliative home care.

METHODS

A qualitative interview study with an inductive approach was conducted. Eighteen spouses caring for their husband or wife admitted to specialist palliative home care in different hospitals in Sweden were interviewed. The interviews were transcribed verbatim and analysed with a reflexive thematic analysis.

RESULTS

Three main themes emerged regarding spouses' experiences of patients' thirst: Knowledge and views of thirst; Control of fluid intake provides vital information; and Taking charge of their drinking is a life and death responsibility.

CONCLUSIONS

Spouses experience a responsibility to serve the dying person with fluids so that they will not get thirsty. It is so obvious and commonplace to them. To be able to fulfil this responsibility, they need to keep track of the patient's fluid intake and know what quenches thirst. There is a need for research in this area to assist carers and patients in identifying which drinks best quench the patient's thirst. Interventions are also needed to help provide/make available knowledge on suitable thirst-quenching drinks.

The experiences of family members witnessing the diminishing drinking of a dying relative in hospital: A narrative inquiry

BACKGROUND

The optimal management of diminishing drinking at the end of life is contentious. Clinicians and family members may understand the phenomenon differently and hold divergent priorities regarding care. Family members can be distressed by diminishing drinking and its management, particularly when in a hospital environment.

AIM

To explore the experiences of family members when witnessing the diminishing drinking of a dying relative.

DESIGN

A narrative inquiry methodology, derived from pragmatism.

SETTING AND PARTICIPANTS

Thirteen recently bereaved family members were recruited through the bereavement services of three UK hospitals. Inclusion criteria included having an adult relative who died in hospital of any diagnosis more than 48 hours from admission and who had had noticeable diminishing drinking.

FINDINGS

Participants experienced diminishing drinking as an unfolding process that was part of overall decline. They all believed it to be detrimental. Three groups of responses were identified: promoting, accepting and ameliorating. Supportive measures included offering equipment to support drinking, staff being present and communicating about expectations and care management aims.

CONCLUSIONS

There is potential to improve family members' experiences through re-conceptualisation of diminishing drinking aligned to their experiences, supporting family members by listening to their experiences with insight and strengthening their agency within the management of their relatives with diminishing drinking.

Medical communication and decision-making about assisted hydration in the last days of life: A qualitative study of doctors experienced with end of life care

BACKGROUND

The impact of assisted hydration on symptoms and survival at the end of life is unclear. Little is known about optimal strategies for communicating and decision-making about this ethically complex topic. Hydration near end of life is known to be an important topic for family members, but conversations about assisted hydration occur infrequently despite guidance suggesting these should occur with all dying people.

AIM

To explore the views and experiences of doctors experienced in end-of-life care regarding communicating with patients and families and making decisions about assisted hydration at the end of life.

DESIGN

Qualitative study involving framework analysis of data from semi-structured interviews.

SETTING/PARTICIPANTS

Sixteen UK-based Geriatrics and Palliative Medicine doctors were recruited from hospitals, hospices and community services from October 2019 to October 2020.

RESULTS

Participants reported clinical, practical and ethical challenges associated with this topic. The hospital setting provides barriers to high-quality communication with dying patients and their families about assisted hydration, which may contribute to the low incidence of documented assisted hydration-related conversations. Workplace culture in some hospices may make truly individualised decision-making about this topic more difficult. Lack of inclusion of patients in decision-making about assisted hydration appears to be common practice.

CONCLUSIONS

Proactive, routine discussion with dying people about hydration-related issues is indicated in all cases. There is room for debate regarding the limits of shared decision-making and the benefits of routine discussion of assisted hydration with all dying people. Clinicians have to navigate multiple barriers as they strive to provide individualised care.

Experiences of food and mealtime from the perspective of patients with chronic life-limiting disease: A mixed-method systematic review

AIM

To describe and synthesise experiences of food and mealtimes from the perspective of patients with chronic life-limiting disease.

DESIGN

A mixed-method systematic review.

DATA SOURCES

The databases Academic Search Complete, CINAHL, Nursing and Allied Health Database, PsycINFO, PubMed, Soc Index and Web of Science Core Collection were searched (January 2000 to March 2019).

REVIEW METHODS

Out of 3151 identified articles, 24 were included for appraisal and synthesis, using a data based convergent design.

RESULTS

Four themes were derived: 'understanding hampered eating-perhaps it is best to let nature run its course'; 'food and meals evoke distress-reducing joy, testing interim ways'; 'struggling with food and meals-eating to please others and to postpone death'; and 'food and meals as caring and love-flanked by social disconnecting'.

CONCLUSION

For patients with chronic life-limiting disease, food entailed potential to remain healthy, improve well-being and prolong life. Meanwhile, eating difficulties were experienced as fundamentally affecting social life and interactions; consequently, joy around food and meals was lost.

The known unknowns of assisted hydration at the end of life

Much is unknown about assisted hydration at the end of life: why rates of usage vary so highly between institutions, cultures and countries, what beneficial or burdensome effects this treatment has, whether there is a place for subcutaneous hydration in the home setting, and how best to communicate about this difficult topic with dying people and their families. In light of a recently published systematic review concerning the impact of assisted hydration at the end of life, this article explores these questions and related issues, concluding that individualisation and shared decision-making are essential aspects of high-quality end-of-life care.

Views of Registered Dietitians Compared to Speech-Language Pathologists on Artificial Nutrition and Hydration at the End of Life

OBJECTIVE

To analyze and compare the knowledge and opinions of registered dietitian nutritionists (RDNs) about artificial nutrition and hydration (ANH) in a terminal illness. Beliefs of speech-language pathologists (SLPs) were also considered and compared against RDN data.

METHODS

This is a descriptive analysis utilizing survey responses from RDNs and SLPs regarding ANH in a case study patient with advanced dementia.

RESULTS

There was a strong belief among RDNs that ANH at end of life (EOL) would improve nutritional status, although a correlation was found between those in favor of ANH and believing it was ethical to withhold ANH at EOL (R² = 0.109, p = 0.002). Responses indicated that SLPs need more education regarding ANH techniques, while RDNs felt ANH would improve aspiration risk. Place of employment, religion and age of respondents were also found to impact beliefs.

CONCLUSION

Clinicians, specifically RDNs, working with patients at EOL need more evidenced-based education on the risks and benefits of ANH. Decisions regarding care of patients at EOL should be void of clinicians' personal bias which may affect ethical treatment in the clinical setting. Further controlled trials must be performed before claims can be made regarding ANH at EOL.

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.

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.