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How to manage terminal dehydration

  • U. Suchner
  • C. Reudelsterz
  • C. GogEmail author
Palliativmedizin und Supportivtherapie
  • 107 Downloads

Abstract

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.

Keywords

Palliative care Symptom assessment Evidence-based medicine Fluid therapy End of life care 

Behandlung einer terminalen Dehydratation

Zusammenfassung

Obwohl die Dehydratation ein schwerwiegendes Krankheitsbild darstellt, das bei Palliativpatienten sowie auch in allen anderen Patientengruppen mit einer signifikanten Morbidität und Mortalität einhergeht, bleibt die Behandlung widersprüchlich. Ein Review der Ursachen einer Dehydratation während des Lebensendes wurde durchgeführt, wobei dem Erscheinungsbild der terminalen Dehydratation besonderes Augenmerk gewidmet wird. Eine umfassende Literaturrecherche wurde durchgeführt, um relevante Artikel zu identifizieren, die zwischen 1960 und 2018 in englischer und deutscher Sprache veröffentlicht wurden. Aktuell verfügbare Optionen für eine Bed-side-Evaluation und therapeutische Vorgehensweisen wurden kritisch beurteilt und die Bereiche zukünftiger Forschung hervorgehoben. Folgenden Rückschlüsse können gezogen werden: 1. Die verfügbare Evidenz stützt keine klare Entscheidung für oder gegen eine Flüssigkeitstherapie während der Sterbephase. 2. Der Begriff „end-of-life care“ (ELC, Versorgung am Lebensende) ist nicht präzise genug, und es gibt nur eine unzureichende Differenzierung zwischen den Arten der Dehydratation bei Palliativpatienten. 3. Die Evaluation der Dehydratation basierend auf ihrem klinischen Erscheinungsbild wird als Methode der Wahl angesehen im Vergleich zu invasiven diagnostischen Verfahren. 4. Eine detaillierte klinische Beurteilung der Reversibilität der Symptome bei terminaler Dehydratation mittels einer entsprechenden „fluid challenge“ ist für den Entscheidungsprozess unabdingbar. 5. Kann trotz adäquater Rehydratationsmaßnahmen keine komplette Reversibilität des klinischen Erscheinungsbildes mehr erreicht werden, da der Zustand der Organsysteme sich zunehmend verschlechtert, kann eine Beendigung der klinisch-assistierten Hydrierung (CAH) in Betracht gezogen werden. 6. Falls die Dehydratationssysmptome nach einer „fluid challenge“ reversibel sind und keine anderen Patientenwünsche dagegen sprechen, sollte die Flüssigkeitstherapie im Rahmen der Symptomkontrolle fortgeführt werden. 7. Die Hyperhydratation stellt eine wesentliche Bedrohung während der Flüssigkeitstherapie dar, die mittels nichtinvasiver Überwachungsverfahren verhindert werden muss. Schlussfolgernd kann festgehalten werden, dass bei Anwendung einer CAH als Teil der ELC der Hydratationsstatus individuell beurteilt werden muss und alle therapeutischen Maßnahmen fortwährend an die Befunde sorgfältig durchgeführter Überwachungsverfahren angepasst werden müssen.

Schlüsselwörter

Palliativversorgung Symptombeurteilung Evidenzbasierte Medizin Flüssigkeitstherapie End-of-life care  

Notes

Acknowledgements

We wish to express our gratitude to Prof. Daren Heyland, Prof. Martin Welte and Dr. Harald Braun, who reviewed the manuscript and provided valuable comments improving the content of the contribution.

Compliance with ethical guidelines

Conflict of interest

U. Suchner reports personal fees from Fresenius-Kabi, outside the submitted work. C. Reudelsterz reports personal fees from B. Braun, Fresenius Kabi, Berlin Chemie and Medical Nutrition Industry, outside the submitted work. C. Gog declares that she has no competing interests. This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

This article does not contain any studies with human participants or animals performed by any of the authors.

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Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2019

Authors and Affiliations

  1. 1.Department of anesthesiology and intensive careKlinikum DarmstadtDarmstadtGermany
  2. 2.BerlinGermany
  3. 3.Palliative care sectionSana-Klinikum OffenbachOffenbachGermany

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