Hydration and symptoms in the last days of life

Abstract

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.

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

“…CAH was not associated with severity of respiratory secretions in six of eight studies. 9 20–25 Two, providing medium 23 and low 25 WoE, respectively, found secretions to be worse in the group that received more hydration.…”

“… 22 23 26 27 An observational study showed no association between terminal restlessness and volume of fluid intake overall, but did see a significant association between higher fluid intake in the final 25–40 hours, and worse restlessness in the 24 hours preceding death. 9 …”

“… 7 Demonstrating the impact of cultural norms on practice in this field, a Dutch study found 74% of dying hospitalised patients received intravenous hydration, compared with 2% of dying hospice patients. 9 A Delphi study defining optimal palliative care in older people with dementia found high or very high consensus for 51 out of 57 domains but only moderate consensus around the statement ‘Hydration… is inappropriate in the dying phase’. 10 Clinical guidance is also vague; UK guidelines state that hydration decisions should be ‘individualised’, but provide little specific information.…”

Care of the adult cancer patient at the end of life: ESMO Clinical Practice Guidelines

“…or s.c. administration at EoL remains controversial. 39 Artificial hydration given through i.v. or s.c. routes in the last days of life has not been demonstrated to prevent or relieve symptoms of thirst, dehydration or delirium in randomised trials.…”

Understanding relatives’ experience of death rattle

“…This study is part of a larger study focusing on hydration, death rattle and terminal restlessness in the dying phase. Details of this study, that was performed in 13 clinical sites, are described elsewhere [13]. The study involved four-hourly registration of the intensity of death rattle, for which the scoring scale as proposed by Back et al was used [2].…”