Fluid retention and intravenous hydration in the dying

Abstract

After observing what appeared to be the frequent misuse of intravenous (IV) hydration in terminally ill patients, we conducted a small research study in an active oncology department to determine the effects of IV hydration on signs of fluid retention in terminally ill patients. Dyspnoea 1.2 and edemas have been reported as two common symptoms experienced by patients with advanced cancer; shortness of breath and swollen legs were ranked 9 and 10 respectively in a list of distressing symptoms experienced by these patients.3 Although there are several reasons why terminal patients may experience dyspnoea and dependent edema, fluid overload may be one of the causes. Zerwekh suggested that administration of IV fluids increases the incidence of pulmonary secretions, peripheral edema and ascites.4We therefore chose to assess the presence and absence of rales, leg edema and ascites in those receiving IV hydration. We also wanted to observe any relationship between IV fluid volume, fluid output and these clinical signs.Data were collected on 21 patients who were receiving IV hydration on the day of death to determine the presence of rales, ascites and swollen legs. We found evidence of rales in 81%, ascites in 62% and leg edema in 52%. All except one patient showed evidence of one or more of these clinical signs (one sign 28%; two signs 28%; three signs 38%). However, little relationship was found between the incidence of signs and the net fluid balance (see table below). Two relationships did emerge, although, in view of the small numbers, neither reached statistical significance: patients with a history of hypertension or cardiac disease had a higher incidence of clinical signs than those patients who did not (two signs -43% vs. 19%; three signs -43% vs. 35%). There was also a relationship between fluid retention signs and age. The group of patients who showed evidence of one clinical sign had a mean age of 40 years (range 18-72), while those with two clinical signs had a mean age of 56 years (range 37-67), and those with three clinical signs had a mean age of 61 years (range 36-75).Previous published literature on the prevalence of dyspnoea and swollen legs among the terminally ill did not record the percentage of patients that were receiving IV fluids.'-' In one study on the use of hypodermoclysis (HDC) for the treatment of dehydration in terminal patients, the authors had only to discontinue HDC on three patients due to increased generalised edema and only one of their patients suffered from pulmonary edema 5 The differences between this study and ours may have been due to the difference in the method of fluid delivery. Further research needs to be conducted, into the management of dehydration in these patients, including a comparison of the effect of IV fluids, hypodermoclysis and no parenteral fluids on the incidence of signs of fluid retention.

Non-surgical oncology – Guidelines on Parenteral Nutrition, Chapter 19

“…The “dry mouth” is one of the main symptoms of the dying [163]. However, thirst and “dry mouth” do neither correlate with the degree of hydration [164] nor with the volume of intravenous infusion [165]. Terminal patients appear to receive too much fluid in general [162], increasing the risks for peripheral oedema, ascites, pleural effusions and the development of a pulmonary oedema.…”

When to treat dehydration in a terminally ill patient?

“…No relationship was demonstrable between level of thirst, intravenous fluids and biochemical parameters. In a further study reported by Musgrave [41], an attempt was made to determine the effects of intravenous hydration on fluid retention signs in terminally ill cancer patients. To this end, 21 patients receiving intravenous hydration on the day of death were studied to determine the presence of crepitations, ascites and leg oedema.…”

“…As we have previously noted, many articles criticizing parenteral hydration in terminally ill patients have only referred to parenteral hydration by the intravenous route [24,25]. Increasingly, hypodermoclysis has been acknowledged as having advantages over other methods of parenteral hydration for terminally ill patients [41,50]. The safety of hypodermoclysis has been well documented and reported in noncancer patients [24,25].…”