clipart of man scratching his headHow does fluid deprivation affect the terminally ill?

by PAUL C. ROUSSEAU, MD - "RN Magazine" 1991

Many physicians routinely order IV fluids for terminally ill patients to prevent what they believe to be the agonizing effects of dehydration and electrolyte imbalance.

Many nurses, particularly those who work with the dying, believe otherwise. In a survey conducted recently, eight out of ten hospice nurses agreed that dehydration is not painful; more than half of them said that it's beneficial.

Clinical studies back up both assertions.

As death approaches, dehydration occurs naturally from inadequate oral intake, gastrointestinal and renal loses, and the loss of secretions from the skin and lungs. Transitory thirst, dry mouth, and changes in mental status have been found to develop - but the headache, nausea, vomiting, or cramps frequently associated with water deprivation rarely occur. The mental changes - while upsetting to relatives - bring relief to patients by lessening their awareness of suffering.

This effect stems from the production of ketones, which caloric deprivation stimulates. Serum levels of the ketone betahydroxybutyrate increases significantly. The brain converts this derivative of metabolic fat to gamma-hydroxybutyrate, a substance with anesthetic properties that is believed to dull consciousness.

The administration of IV fluids may produce a feeling of well-being, but it's usually a fleeting sensation. In time, artificial hydration is likely to heighten the discomfort of a terminally ill patient, and often exacerbates underlying symptoms:
Renal: Unless renal function has declined, IV fluids increase urine output, often creating a need for an indwelling catheter. Fluid deprivation eliminates the frequent use of a urinal or bedpan and the discomfort that goes along with it.
Pulmonary: Pharyngeal and pulmonary secretions increase causing cough, dyspnea, and often pulmonary edema. If pneumonia is present, IV fluids make it worse. Dehydration relieves congestion and the symptoms associated with it.
Gastrointestinal: An increase in gastrointestinal fluids brings greater likelihood of nausea and vomiting, particularly for patients with intestinal strictures or neoplasms. Dehydration makes such painful symptoms unlikely.
Artificial hydration also contributes to peri-tumor and peripheral edema, the latter predisposing a patient to painful pressure sores. Dehydration diminishes the risk.

Oral discomfort, then, is dehydration's only drawback. Xerostomia is prevalent, leading to mucosal inflammation, viral or bacterial infection, or candidiasis. Scrupulous oral care and comfort measures bring relief.

To ease a patient's oral discomfort, use saliva substitutes as moisturizers, and frequent rinses with nonalcoholic mouthwashes. You can remove food debris with a peroxide and water rinse. Offer ice chips an the patient's favorite liquid frequently. If there is inflammation, use dyphenhydramine (Benadryl) and viscous Xylocaine to reduce mucosal irritation. Apply lip balm or petroleum jelly to chapped, dry lips. Avoid lemon and glycerin swabs though, they promote dryness.
Accompanied by comfort measures and emotional support, dehydration is a humane therapeutic response to terminal illness. Honest and compassionate discussions with your patients and their families is the way to help more dying patients benefit from this natural means of pain relief.

PAUL C. ROUSSEAU, MD the author, chief of geriatrics at the Veteran Affairs Medical Center in Phoenix and an adjunct professor of adult development and aging at Arizona State University in Tempe, is board-certified in internal and geriatric medicine.
from LEGALLY SPEAKING, RN Magazine, January 1991


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