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Discussion

Quick Question about comfort measures

I'm at work so I'll check back later. Family members asked me if fluids are considered comfort measures. Their mom is dying of cancer and they are struggling with what to do. Will hydration make her more comfortable?

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Originally posted by 3rdShiftGuy

I'm at work so I'll check back later. Family members asked me if fluids are considered comfort measures. Their mom is dying of cancer and they are struggling with what to do. Will hydration make her more comfortable?

I was always led to believe that dying of thirst was worse than starvation, so if it was my family member, I'd want at least a KVO IV infusing along with a MSO4 drip for basic "comfort".

i'm a hospice nurse, is the pt able to make a decision? What we tell our families is that, as the body is dying, things start to shut down, to help with this process. It causes an antesthetic effect in the brain stem, a numbing effect. Adding fluids at this point can actually cause more problems. Fluid in the lungs, edema, ascites, more discomfort. Hope this helps

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I have a lot of training in palliative care, and basically, what skrainbow said above is correct. If the patient can take fluids by mouth, fine. But if they're too ill to swallow, generally an IV isn't going to help. HOWEVER good mouth care will. I would be moistening and cleaning the mouth every little while with plain water, or a weak solution of NS. Glycerine swabs actually dry the mucus membranes out further, and are a no-no.

Former hospice nurse here, and now back in hospice nursing again. If the pt can't tol po's, parenteral fluids do not really do much good; I had a pt basically "drown" in fluid overload because the family demanded hydration at the last minute.

When I took the hospice course at Fox Chase Cancer Center in Philly, one of the things an instructor said was that the body "knows what it's doing" when the need for food and fluids decreases....kind of like a protective mechanism.

Agree with Jay-Jay; glycerine swabs are a no-no. You can get artificial saliva spray (that sounds gross but it does help) if the pt mouth gets dry and use it in addition to good mouth care.

skrainbow is right. If the patient askes for water, give her a sip, but parenteral fluids will prevent the comfortable dehydration that helps dying patients achieve a peaceful comfort from endorphin release.

Every case is different and we don't really know how bad off this pt. is. If they can drink then yes, if not, then maybe some ice chips or just wet the lips. I know the family wants to do *something*. It's hard sitting around waiting for death.

-Russell

Not sure if I agree with above answers. My mother died at home and for a few days before she died she had nothing to drink or eat. Her death was very restless - she did not look comfortable - her legs were constantly moving. It was probably connected to low potassium but I think dehydration may have played a part in her restlessness. I have heard it is a painful way to die. I don't think the pt needs a lot of fluid but I see nothing wrong with a small amount - can't see how it is going to make the patient live days longer.

She may have pain, terminal restlessness, fear, many issues. As I said before, not all deaths go quietly and peacefuly, despite our best efforts.

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She more or less is totally out of it and is sedated. Wakes up in panic attacks, occasionally, but doesn't take in po.

Thanks everyone for your responses. I'll remind the nurse about oral care, and reassure the family that holding fluids isn't witholding a comfort measure.

I knew I could count on you guys!!!

"parenteral fluids will prevent the comfortable dehydration that helps dying patients achieve a peaceful comfort from endorphin release."

Right. Exiting due to dehydration is MUCH faster (often 3 days or so) and less uncomfortable than exiting due to starvation (often over 30 days). Which would you choose?

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Tweety, we use Ativan sublingual for panic and restlessness. It's especially useful for patients suffering distress due to shortness of breath.

I have had cases where the family asked for hydration, and it was done. The one time I felt it WAS appropriate was for a man with Ca. of the prostrate, who had a bowel obstruction, and kept vomiting. The obstruction was an on-again-off-again sort of thing, and on a good day, he could keep down oral fluids. He was awake and lucid almost until the very last day.

Another case where I did not feel it was appropriate was a young lady with Ca. of the lung who was already drowning in her own fluids. The husband 'saw the light', and was convinced by the palliative care doc. to D/C the hydration.

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Originally posted by sjoe

"parenteral fluids will prevent the comfortable dehydration that helps dying patients achieve a peaceful comfort from endorphin release."

Right. Exiting due to dehydration is MUCH faster (often 3 days or so) and less uncomfortable than exiting due to starvation (often over 30 days). Which would you choose?

Sjoe, I'm guessing you've never worked in palliative care? This isn't the same situation as pulling a feeding tube on someone who's in a vegetative state, but otherwise has no active disease process. Terminal patients (usually Ca. patients) do NOT die from starvation or dehydration, but from the disease itself. The body goes through a very natural shutting down process, where the person does not WANT to eat or drink. Food and fluids should NOT be forced on them, as they serve no purpose. One sign that never fails to signal the end is near is a drop in urine output as the kidneys shut down. You want to give someone whose kidneys aren't working I.V. fluids??

I did have it happen once. The palliative doctor didn't realize just how end-stage this person was, so I carried out her order to start an IV on this poor guy. The lab paged the doctor in the middle of the night to tell her the patient's creatinine was through the roof, and she, in turn, called the patinent's home, and told his wife to turn off the IV pump, STAT!

The patient died the next day. My one regret was that I didn't question the doctor's order.

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