Terminal Dehydration Research Articles

Legal considerations in the care of patients with "terminal dehydration" in Germany

The legal framework for fluid management in the palliative care setting varies between continents and even between countries. What legal implications must be taken into account in Germany in dealing with "terminal" dehydration? Relevant publications in English and German have been identified. Notably, German recommendations and guidelines were reviewed, whereas national mindsets were contrasted with those of other countries like the United Kingdom and Canada. Our legal considerations are in line with the recommendations of the German Federal Medical Association. Key components are "patient autonomy", "best possible symptom control" and a"steady therapeutic risk-benefit assessment". Dehydration should then continue to be regarded as a"symptom" that must be "controlled" as long as it can be improved by therapeutic means and as long as the patient is not opposed to this approach. However, if dehydration remains therapeutically refractory, it is justified either not to initiate clinically assisted hydration (CAH) or to stop the ongoing therapy. The "shared decision-making model" practiced in Canada is diametrically opposed to this approach, where paternalistic decision-making is possible, provided that patients or relatives appear to be ill-informed and unprepared to decide "correct" according to expert opinion. A"non-refractory" state of dehydration at the end of life must not be left untreated under German law and must not be used as an option to hasten the death process if the development of dehydration does not correspond to the patient's will or if this will cannot be determined.

Ethical implications in the therapeutic management of dehydrated patients at the end of life

The ethical framework for fluid management in the palliative care setting canvary. What are the relevant ethical implications related to dehydration during end-of-life care and what are the special requirements we need to consider as far as "terminal dehydration" is concerned? Acomprehensive literature search was conducted to identify relevant articles published in English and German. Our inferences represent an attitude rather than an evidence-based position-afact that is due to the underlying normative and ethical references which are hardly amenable to statistical evaluation. As far as ethical considerations are concerned, evidence is lacking to support clear decision-making and, thus, does not justify moving away from established concepts of clinically assisted hydration (CAH) at the end of life as long as measures can be effectually implemented. Dehydration must not be considered ameasure to hasten death. Hence, dehydration in the palliative care setting must be regarded a"symptom" that should be "controlled" if it can be corrected by therapeutic means and if the patient's will does not contradict that approach. However, if CAH is futile, it is justified to refuse or stop it.

How to manage terminal dehydration.

Although dehydration is aserious condition associated with significant morbidity and mortality in palliative care patients, as in any other patient group, treatment remains controversial. Anarrative review of the causes of dehydration during end of life was conducted paying special attention to the nature of terminal dehydration. Acomprehensive 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 aclear 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 aconsiderable threat during fluid management that needs to be prevented by noninvasive monitoring procedures. In conclusion, if CAH is applied as apart 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.

The Research of Grading Dehydration Technology on Slurry Pipeline Grade Conveyor

To solve the confusing problem of different grades of slurry in the grades pipeline, this paper presents a new technology for slurry sizing dehydration. The method realizes the grading treatment by making full use of dehydrating station agitation tank and thickener buffer storage capacity. Research has shown that the method can effectively solve the grading dehydration process after the arrival terminal dehydration station in different grade slurry, and ensure the multi-grade mineral classification sequence transportation process completed successfully.

The pathological features of Wernicke encephalopathy

Case reportA 47-year-old man with a history of alcoholic liver diseasewas found dead at his home address on the floor, lying facedown. He had been unwell for 2 months prior to death andhad complained of abdominal pain. He also had a diagnosisof prolonged QT interval.At autopsy there was no evidence of liver failurealthough the liver was fatty and fibrotic. There was acongenital anomaly of the coronary arteries with the cir-cumflex coronary artery arising from the right sinus ofValsalva with significant narrowing of the ostium. Therewas no evidence of trauma and toxicological screening ofblood was unremarkable. Biochemical analysis of vitreoushumor revealed elevated sodium (144 mmol/L) and creat-inine (217 lmol/L) levels in keeping with terminal dehy-dration and renal failure, with a normal b-hydroxy butyrate(thus excluding alcoholic ketoacidosis).Althoughthebrainappearedexternallyunremarkablewithnovermal atrophy of the cerebellum, sectioning of the mammillarybodiesdemonstratedsymmetricalhemorrhagehighlysuggestiveof Wernicke encephalopathy (Figs. 1, 2). Focal hemorrhagicareas were also noted within the walls of the third ventricle.Microscopically the mammillary bodies displayedrecent microhemorrhages and prominent microvascularproliferation with endothelial swelling typical of Wernickeencephalopathy (Fig. 3). The mammillothalamic tracts andthe walls of third ventricle also contained microhemor-rhages. There was patchy microvacuolation of the neuropilwith unremarkable neurons, fibrous astrocytes, and occa-sional perivascular macrophages containing hemosiderin,indicative of more chronic disease. Mild extravasation oferythrocytes and prominent congested vessels were notedwithin medullary dorsal motor vagal nuclei.Death was attributed to natural causes, most likelyinvolving a combination of cardiac and alcohol-relateddisease. The striking finding was of clinically unsuspectedWernicke encephalopathy.DiscussionWernicke encephalopathy is a neurological disorderresulting from thiamine (vitamin B-1) deficiency [1].Although in Western countries it occurs predominantly inalcoholics, related to poor dietary intake and impairedutilization, it can also be caused by a variety of otherconditions that interfere with normal thiamine metabolism.These include starvation, bariatric surgery, hyperemesisgravidarum, human immunodeficiency virus/acquiredimmunodeficiency syndrome (HIV/AIDS), and in infantsgiven thiamine-deficient formulas [1, 2].The clinical prevalence of Wernicke encephalopathy isuncertain as autopsy studies indicate that the condition islikely under-diagnosed during life [3]. Delay in diagnosismay result from nonspecific symptoms that resembleintoxication. The symptoms, severity, and the regions ofthe brain that are affected are also variable due to a

Withholding and withdrawing artificial nutrition/hydration

When a patient approaches the end of life, healthcare professionals are faced with a number of ethical issues relating to the decision to withhold (not start) or withdraw (stop) treatment. These include whether life should be maintained at all costs, using all available means, even if the treatment is a great burden for the patient, or whether it is preferable to accept the imminence of death and focus on the patient’s comfort. Ethical principles can help professionals, the patient and loved ones weigh up the benefits, burdens and risks of a specific treatment. Today’s healthcare system considers artificial nutrition and hydration (ANH) to be a major life-sustaining treatment, but opinions over this are divided. Research shows that ANH is not always beneficial to patients when they have stopped oral intake. On the contrary, it has been found that caloric deprivation and terminal dehydration provide a number of benefits for the patient. This article will discuss the dilemmas that confront practitioners in relation to withholding and withdrawing treatment, in particular ANH, at the end of a patient’s life. Conflicts of interest: none

Artificial hydration: the role of the nurse in addressing patient and family needs

When caring for terminally ill patients and their families, nurses are confronted with the subject of terminal dehydration and the question of artificial hydration at the end of life. Terminal dehydration and artificial hydration are still controversial topics of discussion and, to this day, data remain insufficient to reach a final conclusion on the benefits or harm of dehydration in terminally ill patients (Ersek, 2003; Fainsinger, 2008). Nurses, just like physicians, have different attitudes about the usefulness of artificial hydration. Personal and professional experiences, cultural influences, and the place of care, as well as education and available resources, are guiding clinical practice (Morita et al, 2002; Pasman et al, 2004). Since there is no ethically or medically based gold standard, each decision for or against hydration at the end of life needs to be taken on an individual basis. This article reflects on the meaning of dehydration for the patient and their family, and reviews the role of the nurse within the decision-making process. Arguments for or against artificial hydration are illuminated through patient situations which took place in the clinical setting of a hospice. The article further highlights the importance of recognising dehydration in frail and elderly patients, and critically assesses policies that may hinder its optimal palliation in different settings in Switzerland.

15-Deoxy-Δ12,14-prostaglandin J2 rescues PC12 cells from H2O2-induced apoptosis through Nrf2-mediated upregulation of heme oxygenase-1: Potential roles of Akt and ERK1/2

Oxidative stress induced by reactive oxygen intermediates has been implicated in a variety of human diseases including rheumatoid arthritis and neurodegenerative disorders. 15-Deoxy-Δ12,14-prostaglandin J2 (15d-PGJ2), a terminal dehydration product of prostaglandin D2, is an endogenous ligand of peroxisome proliferator-activated receptor-γ and exhibits a number of biological activities including the proapoptotic activity. Recent studies have revealed that this cyclopentenone prostaglandin, at non-toxic concentrations, can also exert antiapoptotic or cytoprotective effects. In this study, the underlying mechanisms involved in the protective effects of 15d-PGJ2 on the H2O2-induced cytotoxicty were explored using cultured rat pheochromocytoma (PC12) cells. PC12 cells treated with H2O2 underwent apoptosis, which was attenuated by pretreatment with non-toxic concentrations of 15d-PGJ2. Treatment of the PC12 cells with 15d-PGJ2 resulted in increased nuclear translocation, DNA-binding and transcriptional activity of NF-E2-related factor 2 (Nrf2), leading to upregulation of heme oxygenase-1 (HO-1) expression, which provided an adaptive survival response against the H2O2-derived oxidative cytotoxicity. Transfection of PC12 cells with dominant-negative Nrf2 gene abolished the 15d-PGJ2-derived induction of HO-1 expression. Moreover, the 15d-PGJ2-mediated increases in Nrf2-ARE binding and ARE luciferase activity were suppressed by the dominant-negative mutation as well as the pharmacological inhibition of Akt/protein kinase B or extracellular signal-regulated kinase 1/2 (ERK1/2). Taken together, these findings suggest that 15d-PGJ2 augments cellular antioxidant defense capacity through activation of Akt and ERK signal pathways that leads to Nrf2 activation, and subsequently HO-1 induction, thereby protecting the PC12 cells from H2O2-induced oxidative cell death.

Palliative care professionals’ perceptions of nutrition and hydration at the end of life

The provision of medically administered nutrition and hydration (MNH) for the terminally ill patient is a controversial issue and there has been much debate in the literature concerning this sensitive subject. This article reports on a qualitative research study that explores palliative care nurses' and doctors' perceptions and attitudes to patient nutrition and hydration at the end of life. Participants were from an urban and rural palliative care service. Three main discourses were identified: carers' distress at the non-provision of MNH; palliative care doctors' and nurses' position that terminal dehydration lessened the burden of suffering for dying patients; and polarisation between the acute care setting and the palliative care setting. Overlaying these three main discourses are contesting discourses involving cure vs comfort, and acute care vs palliative care. Importantly, the findings of this study reveal that palliative doctors and nurses believe that medically assisted nutrition and hydration at the end stage of life rarely benefits patients, and as long as adequate mouth care is given, patients do not suffer. However, family members do experience emotional distress in dealing with this situation. In caring for dying people, the nurse's and doctor's role is one of education and communication, involving a team approach to manage this difficult issue.

Moral dilemmas associated with the withdrawal of artificial hydration

Withholding artificial hydration from unconscious terminally ill patients is a complex phenomenon identified as terminal dehydration. Towards the end of a terminal illness it is acknowledged that a patient's desire for fluid and food diminishes, followed by a period of unconsciousness (McAulay, 2001). Inconsistent care philosophies produce divergent opinions and often diametrically conflicting treatments (Craig, 1994). Additionally, literature disputes the detrimental effects of dehydration; therefore, decisions pivot on legal and ethical considerations. Consequently, the viewpoints of the medical and nursing staff can vary; furthermore, recognition must be made to the psychological impact of the relatives. As terminal illness is boundless, all areas of healthcare can be affected. Further investigation into this dilemma is required to identify the most appropriate care management plan.

Life and Death Decisions: Psychological and Ethical Considerations in End-of-Life Care

Life and Death Decisions: Psychological and Ethical Considerations in End-of-Life Care

Managing Dysphagia in the Adult Approaching End of Life

Managing Dysphagia in the Adult Approaching End of Life

“You’re not going to dehydrate mom, are you?”: Euthanasia, versterving, and good death in the Netherlands

In 1996, a debate erupted in the Netherlands about versterven: dying as a result of abstaining from eating and drinking. This discussion initially appeared to be one of the many side-shows to the wider Dutch euthanasia debate, but it continued to dominate the debate for the next few years, with newspaper headlines reporting “involuntary dehydration” in nursing homes. Part of the reason for this was the term itself. Introduced to refer to terminal dehydration, the word versterven had peculiar connotations and this, together with the way in which it was used, caused much confusion and controversy. Was versterven related to euthanasia? Did it denote dying naturally and peacefully or a horrible death imposed on helpless phychogeriatric patients? Was it (could it be) voluntary? Was the patient in control? Was it good death? This paper examines the discussion about, and the media representations of, versterven, focusing on its ambiguity and its relationship to good death.

Attitudes of Japanese physicians toward terminal dehydration: a nationwide survey.

To clarify physician attitudes toward terminal dehydration and identify the physician-related factors contributing to their attitudes. A cross-sectional survey of Japanese physicians with a self-reported questionnaire was used. A total of 584 responses were analyzed (response rate, 53%). In the vignette of a gastric cancer patient with an estimated survival of 1 month and almost impossible oral intake due to intestinal obstruction, 50% chose intravenous hydration of 1,000 mL/d, while 24% selected more than 1,500 mL/d. For a lung cancer patient with cachexia, 58% chose 1,000 mL/d, while 26% selected no hydration or 500 mL. Multivariate analyses revealed that the physicians with more positive attitudes toward intravenous hydration were significantly less involved in end-of-life care, more likely to regard the physiologic requirement of fluid and nutrition as important in initiating intravenous hydration, more likely to believe that intravenous hydration is effective for symptom palliation, and more likely to believe that intravenous hydration is the minimum standard of care. Physicians have considerably divergent attitudes toward intravenous hydration for terminally ill cancer patients. To resolve the discrepancy, the priority in hydration research should be to clarify the appropriate physiologic requirements of fluid and nutrition in dying patients, the effects of intravenous hydration on patient symptoms, and the reasons why physicians consider intravenous hydration to be the minimum standard of care.

Dehydration in terminally ill patients. Perceptions of long-term care nurses.

Dehydration in terminally ill patients has been found to be beneficial and to improve the quality of an individual's last few days of life. As the population continues to age, more individuals are cared for in long-term care (LTC) facilities, where they tend to spend their final days. Previous studies have examined the perceptions and attitudes of hospice nurses, acute care nurses, physicians, and caregivers; however, no such studies have evaluated LTC nurses. It is necessary to know LTC nurses' perceptions and attitudes so they can be offered the education needed to provide the best quality care for terminally ill patients. The purpose of this study was to describe how nurses working with elderly individuals in LTC perceived terminal dehydration (TD). Long-term care nurses (N = 64) were surveyed using a modified version of an established 10-item instrument. Significant findings included a positive correlation between age and positive perception of TD--as nurse age increaSed, a more positive view of TD was expressed. Also, the number of deaths witnessed was positively associated with the belief that TD was beneficial. In general, responses to the individual survey items were quite varied, representing inconsistencies in attitudes and care of dying LTC patients. The results of this descriptive study indicate the debate concerning the benefits of TD continues and remains an important topic for the LTC nurse.

The Jewish patient and terminal dehydration: a hospice ethical dilemma.

Culturally competent nursing care regarding the ethical dilemma of terminal dehydration (withholding or withdrawing food and fluid) for the Jewish hospice patient involves applying the ethical principles of justice, autonomy, beneficence, and nonmaleficence to nursing interventions by identifying outcomes that focus on the high value Jews place on life; avoiding stereotyping as to what it means to be Jewish; knowledge of various Jewish traditions surrounding death and dying; and good communication with the patient and his or her family.

MAKING DECISIONS ABOUT TUBE FEEDING FOR SEVERELY DEMENTED PATIENTS AT THE END OF LIFE: CLINICAL, LEGAL, AND ETHICAL CONSIDERATIONS

Caregivers and family members are forced to deal with questions about tube feeding at the end of life for hundreds of thousands of patients suffering from severe dementia every year. But decisions about accepting or forgoing artificial nutrition and hydration (ANH) tend to be made in haste, late in the game, without benefit of full information. Oftentimes, this leads to increased patient suffering and the inefficient use of medical resources. Surviving family members and caregivers may experience a haunting sense of guilt, wondering if they made the right decision at the right time. The professional literature suggests that forgoing ANH is an entirely appropriate alternative at the end of life. The vast majority of Americans say they do not want to be tube fed if mortally ill and are no longer able to eat on their own. Nonetheless, the provision of aggressive nutrition and hydration support for the severely demented population at the end of life is the norm in America. If there were more awareness of (a) the burdens typically associated with ANH; (b) the pathogenesis of terminal dehydration, and; (c) the medical, legal, and ethical acceptability of terminal dehydration, then forgoing of ANH might become more commonly considered.

Science, hospice, and terminal dehydration.

Science, hospice, and terminal dehydration.

Terminal Dehydration as an Alternative to Physician-Assisted Suicide

Letters15 December 1998Terminal Dehydration as an Alternative to Physician-Assisted SuicideFranklin G. Miller, PhD and Diane E. Meier, MDFranklin G. Miller, PhDChevy Chase, MD 20815Mount Sinai Medical Center; New York, NY 10029Search for more papers by this author and Diane E. Meier, MDChevy Chase, MD 20815Mount Sinai Medical Center; New York, NY 10029Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-129-12-199812150-00037 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSEDr. Stead's personal narrative exemplifies how a patient's decision to forgo food and water, accompanied by compassionate care, can produce a peaceful death. Dr. Miller, in contrast, is appalled at what he labels our endorsement of “willful starvation.” The common reference to starvation in this context is misleading because it has inaccurate connotations of a cruel death and because dehydration, not malnutrition, is much more likely to be the proximate cause of death when fluids are forgone. Unlike Dr. Miller, we regard a competent patient's refusal to eat and drink as the moral equivalent of refusing medical treatment, ...

Terminal Dehydration as an Alternative to Physician-Assisted Suicide

Terminal Dehydration as an Alternative to Physician-Assisted Suicide