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© 2000 American Society for Clinical Oncology
To Hydrate or Not to Hydrate: How Should It Be?C. L.Loprinzi, Consultant Editor The Art of Oncology
HERE’S THE CASE A 53 YEAR-OLD MAN was diagnosed 3 months earlier with inoperable adenocarcinoma of the pancreas. His disease progressed despite two courses of chemotherapy with fluorouracil and gemcitabine. He is mildly jaundiced, his weight has dropped by 15 kg, and he has mild abdominal pain that is well controlled with a low dose of slow-release morphine. He has profound anorexia and chronic nausea and has minimal oral intake. However, he continues to enjoy life, picking up his children from school, watching golf on television, and making a weekly visit to his local church. Today he comes for a visit to the center with the complaint of increased fatigue and somnolence. He notes that he is drinking less than 16 oz of fluid per day, but, when specifically questioned, he denies being thirsty. His wife questions the physician as to whether he should receive supplemental fluids .... WHAT IS THE RIGHT THING TO DO? MEDICAL VERSUS HOSPICE MODELS What is the most appropriate treatment for this patient? A traditional medical oncologist or internist might recommend hospital admission for the administration of intravenous fluids. Laboratory tests might be ordered to evaluate the patient for metabolic abnormalities such as hypercalcemia. Imaging tests might be ordered to establish the rate of tumor progression. Treatment might then need to be continued at home using an infusion service company. This could, in turn, create a substantial financial hardship for the patient and family, and would require a considerable number of health care professionals visiting the patient’s home on a regular basis. There is some justification for this approach. Dehydration can result in serious symptoms in an otherwise healthy person, causing profound fatigue, postural hypotension, renal failure, delirium, and ultimately death. Our patient might ultimately encounter these effects. Progressive dehydration will also decrease the renal excretion of active morphine metabolites and might result in further decreased mentation. If our patient consults a hospice physician or nurse, he or she may not recommend any parenteral fluids, as emphasis is placed on the value of staying at home free from painful and costly procedures. They might also emphasize the need to keep the home as a safe and comfortable environment and to avoid transforming it into a hospital-like setting by connecting patients to numerous tubings and having health care professionals coming in and out during the day and night. Finally, they would emphasize the importance of excellent mouth care to facilitate oral hydration. The debate between those who propose hydration versus nonhydration has much more significance for patients and their families, as well as for health care professionals, than do some other medical interventions. Providing food and drink to the dying may be regarded, by some, as the ultimate compassionate act. Its symbolism in most societies and religions can make this controversy particularly difficult to resolve. PATIENTS WILL OFTEN DO WHAT THE DOCTOR SUGGESTS One of the arguments that is frequently used by both groups is that the patients and their families should be asked to make the decision. However, this decision will greatly depend on what and how information is provided. Although there are no randomized controlled trials assessing the symptoms and function of patients receiving hydration as compared with those receiving no hydration, a recent study compared 100 patients seen in a palliative care unit in Edmonton, Canada (where physicians and nurses provided artificial hydration), with 100 patients in a palliative care unit in Ottawa, Canada (where physicians and nurses did not provide regular hydration).1 All patients in the Edmonton group agreed to undergo hydration and all patients in the Ottawa group agreed not to undergo hydration. This suggests that, in the absence of strong evidence capable of generating consensus among health care professionals, patients will continue to be offered, and will accept, different treatments in different locations. SUBCUTANEOUS HYDRATION An uncommonly used alternate approach has been available for more than a decade.2-6 Subcutaneous hydration using a butterfly needle, which can remain in place for 5 to 7 days, allows for the administration of fluids by giving 500 ml of fluid over 1 hour two or three times a day, or as an overnight infusion. This allows patients to be free of intravenous lines. It also avoids the need for expensive portable infusion devices both in the hospital and at home. In most cases, this technique can be managed by the patient’s own family. Our patient would be presented with a much easier decision if he was able to receive hydration at home by a minimally invasive and simple technique that has limited financial cost, may decrease his level of fatigue, and might better allow for the elimination of toxic morphine metabolites. However, none of the two groups in the hydration debate has uniformly adopted subcutaneous hydration. This may be due, in part, to the fact that the adoption of any innovation in health care takes a long period of time, especially when there is no company marketing it.7 This attitude may also be due to the intermediate nature of this therapeutic advance. It may not allow for what might be considered to be the ideal type and volume of intravenous fluids, as well as for the careful measurement of input and output that might be desirable to the "prohydration" group. On the other hand, it is still parenteral fluid administration and requires some connection of patients to tubing, and this is probably less acceptable to the "nonhydration" group. OTHER CASES Subcutaneous hydration might be ideal for the patient detailed in the provided scenario; it might prevent a specific adverse event (failure to clear an opioid and its metabolites) and assist a functioning man to maintain a satisfactory home life for a little while longer. It would not necessarily address the needs of a Mr B, a 65-year-old man with non–small-cell lung cancer. This patient has progressive disease despite radiation therapy followed by two courses of chemotherapy. He has been a successful businessman who, for the first time, feels he cannot control a situation (his illness). He is terrified by his lack of control over his symptoms and his decaying function, and he very much enjoys the safety of the hospital. He is reassured by the feeling of receiving fluids, drugs, and some vitamins intravenously, and the presence of nursing staff and other health care professionals is comforting to him. Subcutaneous hydration at home would also be of limited value to Mrs C, a 65-year-old woman with far-advanced carcinoma of the breast. She emigrated from Poland 30 years ago as a single parent and raised her child alone in North America while working full time. She has a small network of support consisting of two neighbors and is completely terrified of hospitals, needles, and strangers. She does not want to be admitted to the hospital and fears any injections at home. SUMMARY Although the problem of inadequate fluid intake combined with recurrent progressive disease is common to all three cases, our first patient with advanced pancreatic carcinoma would probably feel that subcutaneous hydration at home is indicated. For Mr B, intravenous fluids in the hospital seem to be a better approach, and for Mrs C, minimal oral intake and mouth care at home seem appropriate. To conclude, decisions on hydration do not simply depend on biologic factors. Ethical considerations dictate that the patient, if competent, or a surrogate receive information on available options, including subcutaneous fluid administration. The information provided should enable the patient to make the decision that is appropriate for his or her current goals. The decision to hydrate or not to hydrate is not binary; time-limited trials are sensible if there is doubt about the wisdom of instituting hydration. In any event, the profound psychologic importance of the decision on patient and family is such that the oncologist should carefully observe the patient and family and offer continued counsel. REFERENCES 1. MacDonald N, Fainsinger R: Indications and ethical considerations in the hydration of patients with advanced cancer, in Bruera E, Higginson I (eds): Cachexia-Anorexia in Cancer Patients. Oxford, United Kingdom,Oxford University Press, 1996; pp 186-189
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Bruera E, Neumann CM, Calder K, et al: A randomized controlled trial of local injections of hyaluronidase versus placebo in cancer patients receiving subcutaneous hydration. Ann Oncol 10:1-4, 1999 3. Sethna RH: Hypodermoclysis, an old idea resurrected. Modern Med Can 41:8-12, 1986 4. Molloy DW, Cunje A: Hypodermoclysis in the care of old adults: An old solution for new problems? Can Fam Physician 38:2038-2043, 1992 5. Collaud T, Rapin C: Dehydration and dying patients: Study with physicians in French-speaking Switzerland. J Pain Symptom Manage 6:230-240, 1991[Medline] 6. Bruera E, de Stoutz ND, Fainsinger RL, et al: Comparison of two different concentrations of hyaluronidase in patients receiving one-hour infusions of hypodermoclysis. J Pain Symptom Manage 10:505-509, 1995[Medline] 7. Landrum BJ: Marketing innovations to nurses, Part I: How people adopt innovation. J Wound Ostomy Continence NURA 4:194-199, 1998 This article has been cited by other articles:
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Copyright © 2000 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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