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

BackgroundClinically 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.MethodSystematic 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.ResultsFifteen 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.ConclusionThere 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.

Section: Discussionmentioning

confidence: 93%

Section: Resultsmentioning

confidence: 99%

Section: Box 3 Quality Appraisal Using Gough's Weight Of Evidence (mentioning

confidence: 99%

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

Kingdon

Spathis

Brodrick

et al. 2020

“…We conducted a prospective observational study to explore variations in fluid intake in daily practice. A recent study by Davies et al 26 indicates that a cluster randomised trial is feasible in the last days of life and therefore future studies should preferably use such a design. Second, the patient's oral intake was based on nurses' estimation.…”

Section: Discussionmentioning

confidence: 99%

Hydration and symptoms in the last days of life

Lokker

Heide²,

Oldenmenger

et al. 2019

ObjectivesAt 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.MethodsA 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.Results371 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.ConclusionsCaution 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.

“…Adequately powered palliative care clinical studies conducted solely in hospices are relatively few, with a recent review showing that only 10% of palliative and end-of-life studies conducted in Scotland (2006–2015) were undertaken in a hospice 6. Yet, larger-scale recruitment is possible 7. As studies in the hospice setting which have recruited either to, or above, target are infrequent, in this paper, we describe the recruitment strategies used in a successful prevalence cohort study which recruited 343 patients over 16 months from five hospice sites, the H ospice I npatient D eep vein thrombosis (DVT) De tectio n (HIDDen) study 8…”

Section: Introductionmentioning

confidence: 99%

Optimised clinical study recruitment in palliative care: success strategies and lessons learned

White

Noble

Watson

et al. 2019

Recruitment challenges to clinical research studies in palliative care settings, particularly in hospices, are well documented. However, a recent study (Hospice Inpatient Deep vein thrombosis Detection (HIDDen) study) performed across five hospices in the UK recruited above target and on time. We describe strategies that aided successful recruitment in this study, and the lessons learnt for improving future studies. A recent review suggested that the ‘Social Marketing Mix Framework’ (SMMF) could help researchers with recruitment strategies in palliative care. We describe the recruiting strategies employed through the Social Marketing Mix lens and consider if it would be a useful framework for future researchers to use at the planning stage. Successful recruitment strategies employed in HIDDen study included: (i) addressing particular study-related factors, (ii) ensuring all patients were screened and offered participation if eligible, (iii) reducing impact on the clinical team through dedicated research nurses at sites, (iv) addressing research team issues with cross-cover between sites, where geographically possible, and (v) regular video conferencing meetings for support and collaborative solving of challenges. Limited pre-existing research infrastructure at most of the recruiting hospices created particular challenges. The SMMF provides a potential structure to help researchers to plan recruitment. However, to fully streamline trial set up and in order for hospice involvement in research to be realised systematically, a centralised approach to governance, organisational culture change whereby hospices embrace research as a legitimate purpose and consistent access to research staff are identified as key strategic elements promoting recruitment to studies in hospices.