The known unknowns of assisted hydration at the end of life
Much is unknown about assisted hydration at the end of life: why rates of usage vary so highly between institutions, cultures and countries, what beneficial or burdensome effects this treatment has, whether there is a place for subcutaneous hydration in the home setting, and how best to communicate about this difficult topic with dying people and their families. In light of a recently published systematic review concerning the impact of assisted hydration at the end of life, this article explores these questions and related issues, concluding that individualisation and shared decision-making are essential aspects of high-quality end-of-life care.
The use of assisted hydration (AH) at the end of life has long been the subject of controversy. Practice is highly varied between countries and cultures (Raijmakers et al, 2011a), and it may be that social and religious factors play a pivotal role. For example, beliefs about the sanctity of life in Orthodox Jewish or Catholic-majority countries, or about the importance of food and drink in some East Asian cultures, may increase the use of AH at the end of life (Musgrave et al, 1996; Chiu et al, 2004; Morita et al, 2006).
The frequency of provision of fluids for dying patients in a community setting is not known. A Dutch study (Lokker et al, 2019) demonstrated large differences in rates of administration of AH for patients in hospital and hospice (74% and 4%, respectively). What might explain these differences? AH may be considered conventional practice in hospital, or it may be provided because dying is not recognised promptly, or because conversations about stopping parenteral fluids are considered to be too difficult. In hospice settings, AH may be indicated on occasion, but may not be prescribed due to it not being perceived as standard practice.
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