Paper
Most patients and families are aware that without fluids, death will occur quickly. Current literature suggests that fluids should not be routinely administered to dying patients, nor automatically withheld from them. Instead the decision should be based upon careful, individual assessment. Consideration of the following when the choice to initiate and continue hydration is evaluated:
Is the patient’s well-being enhanced by the overall effect of hydration?
Which current symptoms are being relieved by artificial hydration?
Are other end of life symptoms being aggravated by the fluids?
Does hydration improve the patient’s level of consciousness? If so, is this within the patient’s goals and wishes for end of life care?
Does it appear to prolong the patient’s survival? If so, is this within the patient’s goals and wishes for end of life care?
What is the effect of the infusion technology on the patient’s well being, mobility, ability to interact and be with family?
What is the burden of the infusion technology on the family in terms of caregiver stress, finance? Is it justified by benefit to the patient?
Terminal dehydration refers to the process in which the dying patient’s condition naturally results in a decrease in fluid intake. A gradual withdrawal from activities of daily life may occur as symptoms of dysphagia, nausea, and fatigue become more obvious.
Artificial hydration has the potential to result in fluid accumulation, resulting in distressful symptoms such as edema, ascites, nausea and vomiting, and pulmonary congestion.
Nursing Interventions:
Dry mouth – sips of beverages, ice chips or hard candy, spraying normal saline into the mouth with a spray bottle or atomizer. Meticulous mouth care. Swabbing the mouth with cool water is another comfort measure.
Secretions – Secretions usually thicken and build up in the back of the throat or lungs. Breathing may sound moist or congested. Secretions can be best managed with medications, turning and positioning the person every few hours, keeping the head of the bed up and frequent mouth care.
These measures will prevent pooling of the secretions and allow gravity to assist with drainage. Deep suctioning is not usually helpful and may increase secretions or make the person uncomfortable.
Medications:
Appetite Stimulants:
1. Prednisone 5-10 mg TID: more appropriate if prognosis is 4-8 week range
2. Megace (megastrol) 160mg po TID for optimum effect. Costly, but most likely to be effective in improving appetite and weight gain if prognosis in the 2-month or greater range.
3. Antidepressants such as Elavil (amitriptyline) 10-25 mg TID or 25-75 mg @ HS.
4. Marinol now approved for appetite stimulation in HIV patients: 2.5 mg before lunch and before dinner.
5. Periactin (cyproheptadine) 4mg PO TID 30 min before meals.