By: Emily Alpers, Marianne Lannen, By: Emily Alpers, Marianne Lannen, Ryan Peggar, Deanna Warnock, and Ryan Peggar, Deanna Warnock, and

John WoodcoxJohn Woodcox

Ferris State UniversityFerris State University

In end of life patients, what is the effect of

natural dehydration on the process of dying/suffering when compared with providing interventions?

PICO Statement

Does allowing natural dehydration cause

discomfort for a patient during end of life care? Does providing a patient with artificial hydration

increase comfort levels during end of life care?

“One view is that the provision of ANH decreases suffering and discomfort by alleviating thirst and improving energy levels. The opposing view is that when ANH is introduced in advanced illness, it is poorly tolerated and results in increased discomfort” (Suter, Rogers, & Strack, 2008, p. 23).

Different Views

Artificial Nutrition and Hydration

Patient’s wishes Family wishes Prognosis Religious views Legal Ethical Comfort

Other Considerations

Misperceptions regarding ANH

◦ Patients feel starvation◦ Patients feel dehydration◦ Association of thirst with xerostomia

Evidence regarding ANH◦ Starvation and dehydration do not contribute to

suffering and may in fact contribute to comfort and the end of life.

Literature Review

Most hospice patients deny thirst and hunger Practitioners in many fields are split in their

beliefs with ANH Hospice setting seems to be unified in their

position

Investigation

ANH and the Counterpalliative Effects:

◦ Increased urinary output = Increased need for urinary catheterization

◦ Diarrhea◦ Nausea◦ Vomiting: increased gastrointestinal fluid

accumulation◦ Pain◦ Respiratory problems: increased need for suctioning◦ Increased incidence of aspiration pneumonia

Investigation

Benefits of dehydration in the dying patient

◦ Analgesic effects◦ Less frequent need for urination◦ Decreased episodes of incontinence◦ Decreased respiratory secretions

Studies show no relationship between biochemical signs of dehydration and thirst

Investigation

Articles chosen for research were specific to our

PICO in regards to hospice patients. These chosen articles were also current and written by individuals with experience in the field.

Articles were excluded for the following reasons: Focus on ethical considerations based on New

York law. Research proved >15 years old. Narrow focus only on cancer patients. Written by authors and no verifiable credentials.

Methods

Articles chosen:

Artificial Nutrition and Hydration at the End of Life by Heuberger

Artificial Nutrition and Hydration at the End of Life: Ethics and Evidence by Ganzini

Artificial Nutrition and Hydration: Clinical Issues by Ersek

Comfort and Incidence of Abnormal Serum Sodium, Bun, Creatinine and Osmolality in Dehydration of Terminal Illness by Vullo-Navich et al.

Artificial Nutrition and Hydration for the Terminally Ill: A Research Approach by Suter et al.

Critical Appraisal of the Evidence

The author’s conclusions in this article suggest a

stance discouraging use of artificial nutrition and hydration through educating patients and families on the lack of proven data of the benefits and existing data that supports natural progression and anesthetic value of starvation and dehydration for end of life. The author does suggest avoiding using a single approach regarding ANH and encourages individual assessment of patient wishes and needs. This conclusion is congruent with several other articles reviewed.

Artificial Nutrition and Hydration at the End of Life by Heuberger

The authors concluded that utilizing small

amounts of intravenous fluids to improve quality of life or comfort in end of life cancer patients needs to be further studied. They did not find support that using PEG tubes for artificial nutrition prolonged life for dementia patients. They do support that theory may be benefits to using PEG tubes for comfort of ALS patients.

Artificial Nutrition and Hydration at the End of Life: Ethics and Evidence

by Ganzini

While ANH is currently used frequently in the

care of critically ill patients in order to achieve quality of life and prolong survival, the limited evidence currently suggests that ANH is not likely to promote comfort and enhance quality of life for end of life patients.

Artificial Nutrition and Hydration: Clinical Issues by Ersek

The conclusions of this study reinforce the idea

that fluid depletion in dying patients has relatively benign symptoms. The limitations of a very small sample size would diminish the confidence of utilizing this data in a clinical setting without additional clinical research. This study recommends that hydration decisions should be closely related to patient’s comfort rather than lab values without identifying what comfort level goals would or would not initiate the need for hydration.

Comfort and Incidence of Abnormal Serum Sodium, BUN, Creatinine and Osmolality in Dehydration of Terminal Illness by Vullo-

Navich et al.

This article did not provide a definitive support

of either administering or withholding artificial nutrition. The authors suggest that nurses use the research discussed to educate patients and families about ANH and honor the goals and values of the patient in an unbiased way.

Artificial Nutrition and Hydration for the Terminally Ill: A Research Approach by

Sutter et al.

Research has shown that a provider's

experience and/or personal professional preference often determines whether or not ANH is utilized (Ersek, 2003).

It is important for the nurse to be aware of his or her personal feelings and/or experiences towards end of life care.

Personal Experience

In some cases, a provider may feel it is their

ethical obligation to provide ANH to maximize comfort, regardless of what the evidence shows.

Other providers may have been giving ANH for years and are reluctant to change their practice.

A nurse who is used to regular inpatient hospital treatment may not realize the different physiological/pathological aspects of the terminally ill, thus not fully understanding the hydration decision (Suter et al, 2008).

Biases

Covers both ends of experiential spectrum:

A couple of the members who have no experience with hospice patients at all.

A couple members who have encountered patients who are preparing to enter a hospice program.

Some members of the group actually work in a hospice setting.

Group Experiences

There are many considerations when utilizing

this evidence in practice: Patient and family education Pros and cons of its administration Establish goals for the patient Open lines of communication Cost vs. effectiveness

Utilization in EBP

Ersek, M. (2003). Artificial nutrition and hydration. Journal of Hospice and

Palliative Nursing, 5(4), 221-230. Retrieved from http://0-www.ncbi.nlm.nih.gov.libcat.ferris.edu

Ganzini, L. (2006). Artificial nutrition and hydration at the end of life: Ethics and evidence. Palliative and Supportive Care, 4(2), 135-143. doi: 10.1017/S1478951506060196

Heuberger, R. A. (2010). Artificial nutrition and hydration at the end of life. Journal of Nutrition for the Elderly, 29(4), 347-385. doi: 10.1080/01639366.2010.521020

Sutter, P. M., Rogers, J., & Strack, C. (2008). Artificial nutrition and hydration for the terminally ill. Home Health Care Nurse, 26(1), 23-29. Retrieved from http://0-www.ncbi.nlm.nih.gov.libcat.ferris.edu

Vullo-Navich, K., Smith, S., Andrews, M., Levine, A. M., Tischler, J. F.& Veglia, J. M. (1998). Comfort and incidence of abnormal serum sodium, bun, creatinine and osmolality in dehydration of terminal illness. American Journal of Hospice and Palliative Medicine, 15(2), 77-84. doi: 10.1177/104990919801500205

References