Assisted Hydration & Nutrition 1

Clinically Assisted Hydraon and Nutrion in the Last

Days of Life
There are clinical situations in palliative care when clinically assisted hydration or nutrition might be
useful. However there are few studies addressing the issue of clinically assisted hydration and no
convincing evidence that either the giving or withholding of fluids interferes with the length of
remaining life or affects comfort.1 There is evidence to suggest that hydration status of severely ill
and dying patients is biochemically different to other populations, and this is an area of ongoing
research.2 The more fluid available, the more likely that it will gather in the lungs and other
dependant parts of the body particularly in the presence of hypoalbuminaemia which is common in
the last days of life.
This may lead to worsening respiratory secretions, increased vomiting, raised intracranial pressure
due to intracerebral disease, and an increased urinary output, which may be difficult to manage
comfortably (systematic reviews of evidence, no controlled or RCT studies).
When someone is felt to be dying irreversibly, neither the routine giving nor routine withholding of
systemic fluids or nutrition is appropriate. An individual assessment needs to be made for each dying
person.
The burdens and risks of providing clinically assisted nutrition or hydration must be weighed
against likely benefits. Nutritional and hydration needs should be considered separately3
Patient preferences, when known, must be considered and if benefits, risks and burdens are finely
balanced then preferences should be the deciding factor
Decisions must be regularly reviewed, especially if the patient lives for longer than anticipated,
and usually on a daily basis.
If dehydration is thought to be due to a potentially correctable cause, the option of clinically
assisted hydration should be considered.
In practice, patients are often able to take small amounts of fluids until shortly before death.
Meticulous mouth care is essential to prevent the common symptom of a dry mouth (Evidence
level 5).

Subcutaneous Fluids - Hypodermoclysis

This method of giving parenteral fluid has the advantage of being simple to set up and requires
little supervision. It is therefore useable in the community
Subcutaneous fluid administration involves placing a small butterfly needle in the subcutaneous
tissue in an area of intact skin, and dripping in fluids by an ordinary giving set
The site for administration is often on the trunk, or abdomen
Up to 2000 mls/24h can be administered by this route4
Normal saline is the crystalloid of choice and there should usually be no additives
The butterfly needle site needs to be examined regularly to ensure that the fluid is draining well
and that the tissues are not being damaged by the infusion (Evidence level 5)

References
1. Good P, Richard R, Syrmis W, et al. Medically assisted hydration for adult palliative care patients. Cochrane Database
Syst Rev 2014;(4):CD006273
2. Nwosu AC, Mayland CR, Mason SR, et al. Hydration in advanced cancer: can bioelectrical impedance analysis improve
the evidence base? A systematic review of the literature. J Pain Symptom Manage 2013;46(3):433-446.e6
3. General Medical Council. Treatment and care towards the end of life. 2010. Available from:
www.gmc-uk.org/guidance/ethical_guidance/end_of_life_contents.asp (accessed 21 June 2015)
4. Moriarty D, Hudson E. Hypodermoclysis for rehydration in the community. Br J Community Nurs 2001;6(9):437-43

2022-12-11 Palliative Care Guidelines Plus

2 Assisted Hydration & Nutrition

Printed on Sun 11 Dec 2022 21:29:51 GMT

Palliative Care Guidelines Plus 2022-12-11