What is the impact of clinically assisted hydration in the last days of life? A systematic literature review and narrative synthesis

BackgroundClinically assisted hydration (CAH) can be provided in the last days of life as drinking declines. The impact of this practice on quality of life or survival in the last days of life is unclear. Practice varies worldwide concerning this emotive issue.MethodSystematic literature review and narrative synthesis of studies evaluating the impact of, or attitudes toward, CAH in the last days of life. Databases were searched up to December 2019. Studies were included if the majority of participants were in the last 7 days of life, and were evaluated using Gough’s 'Weight of Evidence' framework. Review protocol registered with PROSPERO, registration number CRD42019125837.ResultsFifteen studies were included in the synthesis. None were judged to be both of high quality and relevance. No evidence was found that the provision of CAH has an impact on symptoms or survival. Patient and family carer attitudes toward assisted hydration were diverse.ConclusionThere is currently insufficient evidence to draw firm conclusions on the impact of CAH in the last days of life. Future research needs to focus on patients specifically in the last days of life, include those with non-malignant diagnoses, and evaluate best ways to communicate effectively about this complex topic with patients and their families.

End-of-life care in stroke

‘End-of-life care in stroke’ examines the specific challenges in stroke, the challenges and difficulties of decision-making, identifiers of poor outcome, defining what is ‘good stroke death’, effective communication, role of resuscitation, clinically assisted hydration and nutrition, prepalliative care plans, personalized end-of-life care for the dying patient, symptom control, and issues concerning grieving and caring for the staff members. Over 80% of stroke deaths happen in those over 75. In most cases of life-threatening stroke, mental capacity is lost. Advanced care planning is rarely done and issues around decision-making are often challenging for those close to the patient. Families need an active communication process from day one with a realistic discussion of options. Where a poor outcome is feared, this needs communicating with reassurance and decisions made that would reflect the wishes and best interests of the person.

A cluster randomised feasibility trial of clinically assisted hydration in cancer patients in the last days of life

Background: The provision of clinically assisted hydration at the end-of-life is one of the most contentious issues in medicine. Aim: The aim of this feasibility study was to answer the question ‘can a definitive (adequately powered) study be done?’ Design: The study was a cluster randomised trial, with sites randomised on a one-to-one basis to intervention ‘A’ (regular mouth care and usual other care) or intervention ‘B’ (clinically assisted hydration, mouth care and usual other care). Participants were assessed every 4 h, and data collected on clinical problems, therapeutic interventions and overall survival. Setting/participants: The study was conducted at 12 sites/‘clusters’ with specialist palliative care teams (4 cancer centres and 8 hospices), and participants were cancer patients in the last week of life who were unable to maintain sufficient oral fluid intake. Results: The study achieved its pre-determined criteria for success. Two hundred patients were recruited to the study, and 199 participants completed the study, over a 1-year period. A total of 38.5% participants discontinued clinically assisted hydration due to adverse effects: none of these adverse events were rated as ‘severe’ or worse in intensity. The primary reasons for discontinuation were site problems ( n = 2), localised oedema ( n = 13), generalised oedema ( n = 5), respiratory secretions ( n = 6) and nausea and vomiting ( n = 1). Conclusion: The results of this feasibility study suggest that a definitive study can be done, but that minor changes are needed to the protocol to standardise the administration of clinically assisted hydration (which may reduce the incidence of certain adverse effects).