Practice Patterns and Perceptions About Parenteral Hydration in the Last Weeks of Life: A Survey of Palliative Care Physicians in Latin America

Abstract

Context Parenteral hydration at the end of life is controversial and has generated considerable debate for decades. Objectives To identify palliative care physician parenteral hydration prescribing patterns and the factors that influence prescribing levels for patients during their last weeks of life. Methods A cross-sectional, representative online survey of Latin American palliative care physicians was conducted in 2010. Physicians were asked to report the percentage of their terminally ill patients for whom they prescribed parenteral hydration. Predictors of parenteral hydration prescribing levels were identified using logistic regression analysis. Results Two hundred thirty-eight of 320 physicians completed the survey (74% response rate). Sixty percent of physicians reported prescribing parenteral hydration to 40–100% of their patients during the last weeks of life. Factors influencing moderate/high prescribing levels were: agreeing that parenteral hydration is clinically and psychologically efficacious (odds ratio [OR] 3.5; 95% confidence interval [CI] 1.5 – 8.3), disagreeing that withholding parenteral hydration alleviates symptoms (OR 3.3, 95% CI 1.3 – 8.1), agreeing that parenteral hydration is essential for meeting the minimum standards of care (OR 3.2, 95% CI 1.4– 7.5), preferring the subcutaneous route of parenteral hydration for patient comfort and home use (OR 2.9, 95% CI 1.3 –6.5), and being younger than 45 years old (OR 2.6, 95% CI 1.3–5.2). Conclusion The strongest determinant of prescribing patterns was agreement with the clinical/psychological efficaciousness of parenteral hydration. Our results reflect parenteral hydration prescribing patterns and perceptions that substantially differ from the conventional/traditional hospice philosophy. These findings suggest that the decision to prescribe or withhold parenteral hydration is largely based on clinical perceptions and that most palliative care physicians from this region of the world individualize treatment decisions.

Perceptions of health professionals on subcutaneous hydration in palliative care: A qualitative study

“…With regard to the second theme, the choice of the infusion route, the care setting and the perceptions of the subcutaneous route were the factors which appeared most frequently. Quantitative studies such as the one carried out by Torres-Vigil et al 10 state that subcutaneous hydration is prescribed with greater frequency in home care units than in hospital units. With regard to the perceptions of the subcutaneous administration of fluids, the literature results show that patients and families prefer the intravenous route, despite it being more uncomfortable.…”

Factors Influencing Intensive Care Unit Nurses’ Behavioral Intentions Regarding Providing Artificial Nutrition and Hydration

“…The scholars indicated that clinical and psychological efficaciousness of parenteral hydration was the strongest determinant for physicians to prescribe hydration orders, rather than personal beliefs. 18 The researchers argued that ANH is ''symbolic care'' that exposes physicians' unfamiliarity with clinical ethics and their inability to accept ''medical failure.'' 19 Wurzbach 20 pointed out that nurses who are moderately morally convinced to act upon personal choices and beliefs nevertheless followed their agency policies or physician orders.…”

The last days of life

“…[30] Indeed, there is wide variation in the prescription of artificial hydration among clinicians, which is driven by their beliefs toward the clinical/emotional benefits of hydration. [31]…”