Methods of Hydration in Palliative Care Patients

Abstract

A strong and often polarized debate has taken place during recent years concerning the consequences of dehydration in the terminally ill patient. When a patient has a severely restricted oral intake or is found to be dehydrated, the decision to administer fluids should be individualized and made on the basis of a careful assessment that considers problems related to dehydration, potential risks and benefits of fluid replacement, and patients’ and families’ wishes. This review discusses the assessment of hydration status in the terminal cancer patient and the options for fluid administration in the cases where evaluation of the patients’ condition has led to this indication. These include different modes of hypodermoclysis, intravenous hydration, use of the nasogastric route, and proctoclysis. Arguments for and against rehydration have been previously addressed by other authors and fall outside the scope of this review.

Delirium and dehydration: some fluid for thought?

“…Formulae designed for estimation of the deficit are often of limited use in advanced disease, and as their discussion is beyond the scope of this review the reader is referred to other texts [91,92]. A number of potential explanations have been proposed for the general finding that lower hydration volumes are needed in patients with advanced cancer than in the general medical population [98]. Ironically, while the reduced total body water as a proportion of body weight in elderly and cachectic patients may predispose to volume depletion and dehydration, it also partly explains the lower fluid requirements in these groups.…”

“…Although this technique was widely used in the 1940s and 1950s, its subsequent fall into disuse was possibly due to severe adverse reactions related to infusions of electrolyte-free or hypertonic solutions [90]. This method involves the simple and minimally painful procedure of inserting a butterfly needle subcutaneously and attaching a fluid line for fluid to run in via an infusion pump, or via gravity in the home setting [98]. It requires minimal training for insertion and surveillance, and family caregivers can easily be trained to attach a fluid line to the needle, thereby obviating the need for hospitalization.…”

“…However, caution must be used in interpreting many of these signs in patients with advanced cancer, where changes particularly associated with aging and cachexia may have a significant contribution [60,98]. Skin turgor may be altered in cachexia and in the elderly.…”

“…The classic findings in the volume-depleted patient include elevations of blood urea nitrogen, creatinine, plasma proteins, hematocrit, and sodium. Again, for many reasons these investigations must be interpreted with caution in the patient with advanced cancer [98]. Low plasma protein levels and low red cell counts are associated with advanced disease and must be considered in this context.…”

“…Hypodermoclysis or clysis is a technique commonly employed in palliative care units and in the elderly [26,34,49,90,98]. Although this technique was widely used in the 1940s and 1950s, its subsequent fall into disuse was possibly due to severe adverse reactions related to infusions of electrolyte-free or hypertonic solutions [90].…”