Recommendations for Artificial Hydration in a Terminally Ill Cancer Patient

Abstract

Cancer patients are often faced with decreased oral intake, anorexia/cachexia and malnutrition in the last phase of life. These conditions often correspond to a higher morbidity and mortality with poor prognosis. If oral intake is still possible, patients should be encouraged to eat their favorite foods and close attention should be paid to the psychosocial factors of eating. Pharmacologic drugs may be given to increase the appetite or relieve the symptoms that hinder eating.Artificial hydration may be given either enterally or parenterally. Enteral hydration, usually in the form of a nasogastric tube is often considered less invasive and can also be used for drainage of gastric contents to relieve abdominal distention. Parenteral hydration can be given via the intravenous route but when peripheral line access is difficult in a cachexic patient, then the less painful subcutaneous route should be used. Artificial hydration is most beneficial in patients with good performance status, anorexia due to bowel obstruction and opioid induced delirium. Experts suggest that artificial hydration is justifiable in patients with a Karnofsky score of 50% or more or a performance status lower than 2. Most studies recommend a hydration volume of 500~1000 ml/day but strong emphasis is placed on individualized treatment. Patients should be monitored for fluid retention symptoms as hydration of ≥ 1000~1500 ml/day can exacerbate pre-existing ascites, pleural effusion, bronchial secretion and peripheral edema. The sensation of thirst is often not alleviated by artificial hydration but rather by intensive oral nursing care.If artificial hydration is rendered to be beneficial and consistent with the treatment plan, then it can be given under the pretense that the patient must be monitored periodically. A time-limited therapeutic trial may be recommended if patients/families or physicians are indecisive about initiating or forgoing treatment. But if artificial hydration has been proven to be unbeneficial or harmful, then it must be discontinued immediately. Many patients and families often rely on the recommendations of their physician; thus it is the responsibility of physicians to update their knowledge on artificial hydration in order for patients to make the best informed decision.