REHYDRATION IN PALLIATIVE AND TERMINAL CARE - IF NOT WHY NOT

Patients who are in the last few days of life are often too frail to t ake oral fluids and nutrition. This may be due entirely to the natural history of their disease, although the use of sedative drugs for symp tom relief may contribute to a reduced level of consciousness and thus a reduced oral intake. Rehydration with intravenous (i.v.) fluids is the usual response in acute care settings, whereas the hospice movemen t has often argued against this approach. The issues are complex and i nvolve not only physical, psychological and social concerns, but also ethical dilemmas. A review of the literature gives conflicting reports of the physical discomfort that may be attributed to dehydration in d ying patients. There are many confounding variables, including the con comitant use of antisecretory drugs, mouth breathing and oral infectio n, It remains unproven whether i.v. fluids offer symptomatic relief in this situation. Hospice doctors are concerned that the use of i.v. fl uids gives confusing messages to relatives about the role of medical i ntervention at this stage in a patient's illness. A drip may cause a p hysical barrier between a patient and their loved one at this importan t time. The use of other methods of fluid replacement are discussed. I n the absence of definitive research in this area, the balance of the burdens and benefits of such treatment remains subjective. The prime g oal of any treatment in terminal care should be the comfort of the pat ient. Decisions should be made on an individual basis, involving both patients and their carers wherever possible. Prolonging life in such c ircumstances is of secondary concern and i.v. fluids given in this con text may be futile. The ethical dilemmas of withholding and withdrawin g medical treatment in addition to those of conducting research in thi s area are discussed.