RESUMEN
BACKGROUND: The legal framework for fluid management in the palliative care setting varies between continents and even between countries. OBJECTIVES: What legal implications must be taken into account in Germany in dealing with "terminal" dehydration? MATERIALS AND METHODS: Relevant publications in English and German have been identified. Notably, German recommendations and guidelines were reviewed, whereas national mindsets were contrasted with those of other countries like the United Kingdom and Canada. RESULTS: Our legal considerations are in line with the recommendations of the German Federal Medical Association. Key components are "patient autonomy", "best possible symptom control" and a "steady therapeutic risk-benefit assessment". Dehydration should then continue to be regarded as a "symptom" that must be "controlled" as long as it can be improved by therapeutic means and as long as the patient is not opposed to this approach. However, if dehydration remains therapeutically refractory, it is justified either not to initiate clinically assisted hydration (CAH) or to stop the ongoing therapy. The "shared decision-making model" practiced in Canada is diametrically opposed to this approach, where paternalistic decision-making is possible, provided that patients or relatives appear to be ill-informed and unprepared to decide "correct" according to expert opinion. CONCLUSIONS: A "non-refractory" state of dehydration at the end of life must not be left untreated under German law and must not be used as an option to hasten the death process if the development of dehydration does not correspond to the patient's will or if this will cannot be determined.
Asunto(s)
Deshidratación , Cuidado Terminal , Deshidratación/terapia , Fluidoterapia , Alemania , Humanos , Cuidados Paliativos , Reino UnidoRESUMEN
BACKGROUND: The ethical framework for fluid management in the palliative care setting can vary. OBJECTIVES: What are the relevant ethical implications related to dehydration during end-of-life care and what are the special requirements we need to consider as far as "terminal dehydration" is concerned? MATERIALS AND METHODS: A comprehensive literature search was conducted to identify relevant articles published in English and German. RESULTS: Our inferences represent an attitude rather than an evidence-based position-a fact that is due to the underlying normative and ethical references which are hardly amenable to statistical evaluation. As far as ethical considerations are concerned, evidence is lacking to support clear decision-making and, thus, does not justify moving away from established concepts of clinically assisted hydration (CAH) at the end of life as long as measures can be effectually implemented. CONCLUSIONS: Dehydration must not be considered a measure to hasten death. Hence, dehydration in the palliative care setting must be regarded a "symptom" that should be "controlled" if it can be corrected by therapeutic means and if the patient's will does not contradict that approach. However, if CAH is futile, it is justified to refuse or stop it.
Asunto(s)
Cuidado Terminal , Muerte , Fluidoterapia , Humanos , Cuidados PaliativosRESUMEN
Dehydration in palliative care patients can be associated with increased morbidity and mortality and is nevertheless therapeutically controversial. This article provides an overview of possible causes of dehydration at the end of life and places special emphasis on "terminal" dehydration in the dying. Empirical attitudes of healthcare professionals and persons concerned (patients and relatives) as well as evidence-based findings on "terminal" dehydration are elucidated and the limitations are described. Finally, it is concluded that the appropriate detection of the mode of dehydration (including its underlying pathophysiology) as well as the clinical evaluation of the "reversibility" of the symptoms after fluid therapy, is of central importance in establishing the indications for clinically assisted hydration (CAH).
Asunto(s)
Deshidratación , Cuidados Paliativos , Cuidado Terminal , Deshidratación/diagnóstico , Deshidratación/etiología , Diagnóstico Diferencial , Fluidoterapia , HumanosRESUMEN
Although dehydration is a serious condition associated with significant morbidity and mortality in palliative care patients, as in any other patient group, treatment remains controversial. A narrative review of the causes of dehydration during end of life was conducted paying special attention to the nature of terminal dehydration. A comprehensive search of the literature was performed to identify relevant articles published in English and German languages between 1960 and 2018. Currently available options for bed-side evaluation and therapeutic approaches were critically appraised and areas of future research are emphasized. The following inferences can be derived: 1) the available evidence does not support a clear decision in favor or against fluid therapy during the dying phase. 2) There is inadequate precision of the term end of life care (ELC) and insufficient differentiation between modes of dehydration of palliative care patients. 3) Evaluation of dehydration based on its clinical appearance is considered the method of choice compared to invasive procedures. 4) Detailed clinical assessment of symptom reversibility in terminal dehydration by an appropriate fluid challenge is mandatory in the decision-making process. 5) If despite adequate rehydration measures, complete reversibility of the clinical picture of dehydration can no longer be achieved since organ systems are gradually deteriorating, the cessation of clinically assisted hydration (CAH) can be considered. 6) If symptoms of dehydration are reversible after fluid challenge and no other patient wishes to the contrary are known, fluid management should be continued in the context of symptom control. 7) Hyperhydration represents a considerable threat during fluid management that needs to be prevented by noninvasive monitoring procedures. In conclusion, if CAH is applied as a part of ELC the hydration status needs to be individually appraised and all therapeutic measures constantly need to be adapted to the findings of diligent monitoring procedures.
Asunto(s)
Deshidratación/terapia , Fluidoterapia/métodos , Cuidado Terminal/métodos , Toma de Decisiones , Humanos , Cuidados Paliativos/métodosRESUMEN
The approach in the clinical fluid management of the dying is still controversially discussed in specialist circles and also in the general population. In this article the importance of establishing the therapeutic indications is emphasized against the background of a lack of evidence. Options to achieve noninvasive objectification of assumed dehydration as well as assessment of the reversibility of the symptoms are shown and the importance of monitoring of all therapeutic actions is discussed. The pathophysiological foundation of reversible disorders of fluid homoeostasis are described and distinguished from the irreversible disorders leading to terminal dehydration. If clinically assisted hydration (CAH) is indicated, the hydration status must be assessed individually as well as in advance and all therapeutic measures must be constantly adjusted to the results of non-invasive monitoring procedures.
Asunto(s)
Deshidratación/terapia , Cuidado Terminal/métodos , Fluidoterapia/métodos , Humanos , Cuidados Paliativos/métodosRESUMEN
Dehydration in palliative care patients can be associated with increased morbidity and mortality and is nevertheless therapeutically controversial. This article provides an overview of possible causes of dehydration at the end of life and places special emphasis on "terminal" dehydration in the dying. Empirical attitudes of healthcare professionals and persons concerned (patients and relatives) as well as evidence-based findings on "terminal" dehydration are elucidated and the limitations are described. Finally, it is concluded that the appropriate detection of the mode of dehydration (including its underlying pathophysiology) as well as the clinical evaluation of the "reversibility" of the symptoms after fluid therapy, is of central importance in establishing the indications for clinically assisted hydration (CAH).