011014-Using-subcutaneous-fluids-in-end-of-life-care

Nursing Practice
Review
End of life
Keywords: Subcutaneous fluids/
Hydration/End-of-life care
●This
article has been double-blind
peer reviewed
Evidence supporting the use of subcutaneous fluids in patients nearing the end of life
is limited. The benefits of this intervention must be considered on an individual basis
Using subcutaneous
fluids in end-of-life care
In this article...
Indications and contraindications for this administration route
Management of patients receiving subcutaneous fluids
When giving subcutaneous fluids at end of life is controversial
Author Patricia Bowen is staff nurse;
Alison Mansfield is ward sister; Helen
King is clinical educator; all at Trinity
Hospice, London.
Abstract Bowen P et al (2014) Using
subcutaneous fluids in end-of-life care.
Nursing Times; 110: 40, 12-14.
There are currently no universally accepted
medical or nursing guidelines for the
administration of subcutaneous fluids at
the end of life. Each case must be
considered individually as it is unclear
whether giving parenteral fluids to people
who are dying causes, rather than
alleviates, symptoms. This article discusses
how to give fluids safely and suggests
that relatives, who often feel very strongly
about giving parenteral fluids, should
be supported and involved in the
decision making and care of their family
member at the end of life.
W
hen people are unable to
take fluids orally those
fluids can be administered
artificially either intravenously or by infusion into the subcutaneous tissues, a process known as hypodermoclysis. Subcutaneous fluids can be
given in this way to maintain hydration in
patients who have mild to moderate dehydration. The procedure is relatively simple
and involves inserting a butterfly needle
into the subcutaneous layer of skin, where
an extensive network of lymphatic and
blood vessels allows the fluids to be readily
absorbed (Mei and Auerhahn, 2009). This
is the route most commonly used in palliative and end-of-life care settings.
Barton et al (2004) showed there was
little difference between the rate of fluid
absorption whether from the intravenous
or subcutaneous route. There is a suggestion that the enzyme hyaluronidase can be
used to increase absorption by temporarily
increasing the permeability of subcutaneous tissue, but randomised studies have
not shown any benefit from its use (Mei
and Auerhahn, 2009).
Subcutaneous fluids have many advantages over IV infusions, including less discomfort to the patient, ease of administration and cost effectiveness (Doherty and
Lister, 2011). They can also be administered
in a range of settings including the
patient’s own home (Lopez and ReyesOrtiz, 2010).
Controversy about end-of-life
hydration
Media coverage of the use of the Liverpool
Care Pathway highlighted concerns by relatives about hydration at the end of life.
This was also emphasised by Neuberger et
al (2013), who suggested that not giving
hydration caused more distress to patients
and their families than the patients’ lack of
ability or desire to eat. Lack of fluids was
felt to add to suffering and cause people to
die from dehydration. Relatives gave distressing evidence that the LCP had been
badly implemented, with food and drink
being withdrawn without discussion. This
led to a suspicion from some relatives that
withholding fluids was sometimes done to
hasten death (Neuberger et al, 2013).
Schmidlin (2008) suggested that among
health professionals there are different
attitudes about the usefulness of artificial
hydration at the end of life and these attitudes influence whether it is used. Cohen
et al (2012) noted that the practice of
hydrating patients who are terminally ill is
more usual in acute hospital settings,
12 Nursing Times 01.10.14 / Vol 110 No 40 / www.nursingtimes.net
5 key
points
1
Using
subcutaneous
fluids to reverse
dehydration at the
end of life is a
practice that is
controversial
The risks and
benefits of
artificial hydration
must be
considered on an
individual basis
The insertion
site of the
subcutaneous
infusion should
be monitored
every four hours
The need for
subcutaneous
fluids should be
reassessed every
24 hours
Subcutaneous
infusions are a
medical treatment
and should only
be given when
doing so is in
the patient’s best
interests
2
3
4
5
“There is a real disconnect between
hospital and community services”
Angela Parry
p26
Box 1. Indications and contraindications for
use of Subcutaneous fluids
Indications for use
● Hypercalcaemia
● Nausea and vomiting
● Dysphagia
● To improve myoclonus (involuntary contractions of muscles)
● Assists sedation
Contraindications for use
● Congestive cardiac failure
● Fluid overload
● Patients in shock
● Fully anticoagulated patients (due to risk of bleeding)
● Severe oedema (affects fluid absorption) (Lopez and Reyes-Ortiz, 2010)
where it is viewed as an integral part of
essential care, than in hospices. Parry et al
(2013) noted that in hospices, where staff
are experienced in palliative and end-oflife care, artificial hydration is viewed less
favourably. As artificial hydration is
regarded as a medical treatment, it should
only be offered if it is considered to be in
the patient’s best interests.
Evidence supporting the use of
subcutaneous fluids
It is widely recognised that the need for
food and water decreases during the dying
process. Biochemical measurements show
that only 50% of patients have evidence
of dehydration within the final 48 hours of
life and then only to a mild or moderate
degree (Watson et al, 2011). There is no
evidence, however, that subcutaneous
hydration helps to treat thirst (Ersek, 2003)
and, as a result, it is not always clear why
decisions to give or withhold fluids are
made; more evidence is needed on this area
to provide specific recommendations
(Parry et al, 2013).
A Cochrane review (Good et al, 2014)
considered six studies investigating the
effect of artificial hydration on the quality
and length of survival of patients receiving
palliative care. Four of these studies (three
of which were randomised controlled
trials) showed no difference in outcomes
between artificial hydration and no hydration. One study looked at survival as an
outcome and found no difference between
the two groups. One study found that
better sedation was achieved in the group
receiving assisted hydration; another
found that hydration caused more fluid
retention symptoms such as pleural
effusion. The authors of the review concluded that there is moderate evidence
that hydration has benefits in some
patients but adverse effects or no effects
in others.
A large study by Bruera et al (2013)
compared hydration with a placebo and
found strong evidence that there is no
overall difference in survival, symptoms or
quality of life. A qualitative study undertaken with the same group of patients
and their families suggested that hydration had enhanced quality of life and comfort as perceived by the families (Cohen et
al, 2012).
Prescribing subcutaneous fluids
Given the lack of evidence to support the
use of subcutaneous fluids at the end of
life, the General Medical Council (2010) has
provided guidance that the risks and benefits of artificial hydration must be considered on an individual basis. The use of subcutaneous fluids is a medical treatment
and should be offered when there will be
an overall benefit to the patient.
Some indications for subcutaneous
hydration are listed in Box 1, along with
details of those situations in which it is not
appropriate to administer subcutaneous
fluids because they will have no benefit
and may result in further deterioration.
Procedure
Before administering subcutaneous fluids,
informed consent must be gained from the
patient (Nursing and Midwifery Council,
2008). This may not be possible when
patients are at the end of their life; in these
situations, where there are families and
carers, they must be involved in the decision-making process. A clear explanation
of the potential positive and negative
effects is vital to ensure they are able to
give informed choice.
Once consent is gained, the prescription and administration rate need careful
consideration. Amounts of fluid infused
can range between 1,000ml and 2,000ml
over a 24-hour period (Moriarty and
Hudson, 2001). Normal saline is the crystalloid most often used.
Using a clean technique:
» Clean the skin according to local policy;
» Insert the butterfly needle into the skin
at a 45-degree angle and cover with a
sterile, transparent dressing (Dougherty and Lister, 2011);
» Ensure the line is primed before
attaching it to the patient; and
» Attach the fluid bag and the administration set.
The most common sites for the butterfly needle to be inserted are the chest
wall, abdomen and thigh. It is important to
consider comfort and safety and whether
the patient is still able to get out of bed or
is in a confused state. It is recommended
that some areas are avoided, including the
following:
» Areas of ascites or lymphoedema;
» Areas of inflammation;
» Tumour sites;
» Close to broken skin; and
» Bony prominences.
It is essential to document the site, location , start time and the date of administration according to local policy. The infusion
must be checked at regular intervals
throughout the day and the patient should
be encouraged to report any pain at the
insertion site; the site should be rotated
every 72 hours to reduce the risk of complications (Dickman et al, 2007).
Complications
The use of large volumes of fluid intravenously has been reported to show quicker
deterioration in the condition of a patient
who is terminal than it is to show symptom
improvements (Morita et al, 2004). The
study also showed that, in patients with
lung and gastric cancer, the symptoms of
fluid retention and distressing bronchial
secretions reduced when the fluid volume
being infused was decreased. Looking at
subcutaneous
fluid
administration,
Torres-Vigil et al (2012), similarly noted
that the risks of fluid infusion can outweigh any benefits. If subcutaneous fluids
are commenced, they need to be reviewed
every 24 hours to check whether there is
any benefit to the patient.
An increase in fluid volume at the end
of life can overload the circulatory system
and result in pulmonary oedema and
increased respiratory secretions. An
increased urine output can also prove distressing for patients who are dying and
may struggle to get out of bed to use
www.nursingtimes.net / Vol 110 No 40 / Nursing Times 01.10.14 13
Nursing Practice
Review
signs of dehydration and acting appropriately to address these.”
The need for continuing education is
demonstrated by Stockdale (2013) who surveyed 50 junior doctors and found 20%
thought withholding hydration sped up
the time to death, while 30% thought it
improved survival and so prolonged suffering. It was also found that specific discussions with relatives about fluids at the
end of life were neglected, with only 5% of
patients having documented records of
these conversations.
To be able to discuss this emotive issue
with patients and families, health professionals should be aware of the latest evidence so they can give them the correct
information. Training in communication
skills is also essential to ensure that any
conversations that are had are handled
sensitively and empathetically.
Normal saline is the crystalloid most
often used for subcutaneous infusion
the toilet or sit on a bedpan, leading to further medical interventions – such as catheterisation – to maintain their comfort and
dignity (Watson et al, 2011).
Localised side-effects of subcutaneous
administration include pain, bruising,
redness and local inflammation around
the butterfly needle (Doherty and Lister,
2011.) “Pooling” of fluids in the surrounding tissues can lead to localised
oedema so the infusion site should be
checked every four hours to ensure fluid is
being absorbed. The infusion rate should
be no more than 1ml/minute to reduce the
risk of this.
SPL
Training and education
The GMC (2010) guidance states that before
artificial hydration is used in patients at
the end of life, each case must be looked
at individually and the decision taken in
the best interests of the patient, with consideration given to the wishes of their
family. Neuberger et al (2013) point out that
GMC guidance is not always followed and
recommend that royal colleges review
the efficacy of their training in shared
decision making; they also recommend
the NMC ensures nurses maintain their
competence via continuing professional
development.
The Leadership Alliance for the Care of
Dying People (2014) emphasises the importance of education:
“which must have the effect that registered
nurses must be able to assess and monitor
nutritional and fluid status… identifying
Mouth care
Education should focus on other aspects of
symptom control that can alleviate
patients’ symptoms, such as mouth care. A
dry mouth is often caused by mouth
breathing and medication, and will not be
alleviated by artificial hydration (National
Council for Palliative Care, 2007). Regular
oral care to maintain a moist, comfortable
mouth and alleviate any thirst is an essential part of care at the end of life. This care
can be given by family members, who
often gain great comfort from having a
practical role to play. The use of crushed
ice and saliva spray has also been found to
be beneficial (Prevost and Grach, 2012).
Conclusion
No clear evidence is available to support
blanket recommendations for using subcutaneous fluids at the end of life, and each
case must be considered on an individual
basis. Where such fluids are used, careful
monitoring of the site is crucial with
24-hourly reviews of the patient’s condition. The views of patients’ families must
be taken into consideration but subcutaneous infusions are a medical treatment
and should only be given if considered by
the multidisciplinary team to be in the
patient’s best interests. Expert, holistic
end-of-life care must be given regardless
of whether or not subcutaneous fluids are
administered. NT
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14 Nursing Times 01.10.14 / Vol 110 No 40 / www.nursingtimes.net
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For more on this topic go online...
Ethical issues around continuous
deep sedation without hydration
B
it.ly/NTSedationEthics

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