1. By: Emily Alpers, Marianne Lannen, Ryan Peggar, Deanna Warnock, and John Woodcox Ferris State University

2.   In end of life patients, what is the effect of natural dehydration on the process of dying/suffering when compared with providing interventions? PICO Statement

3.   Does allowing natural dehydration cause discomfort for a patient during end of life care?  Does providing a patient with artificial hydration increase comfort levels during end of life care? “One view is that the provision of ANH decreases suffering and discomfort by alleviating thirst and improving energy levels. The opposing view is that when ANH is introduced in advanced illness, it is poorly tolerated and results in increased discomfort” (Suter, Rogers, & Strack, 2008, p. 23). Different Views

4.   Artificial Nutrition and Hydration  Patient’s wishes  Family wishes  Prognosis  Religious views  Legal  Ethical  Comfort Other Considerations

5.  Misperceptions regarding ANH ◦ Patients feel starvation ◦ Patients feel dehydration ◦ Association of thirst with xerostomia Evidence regarding ANH ◦ Starvation and dehydration do not contribute to suffering and may in fact contribute to comfort and the end of life. Literature Review

6.   Most hospice patients deny thirst and hunger  Practitioners in many fields are split in their beliefs with ANH  Hospice setting seems to be unified in their position Investigation

7.  ANH and the Counterpalliative Effects: ◦ Increased urinary output = Increased need for urinary catheterization ◦ Diarrhea ◦ Nausea ◦ Vomiting: increased gastrointestinal fluid accumulation ◦ Pain ◦ Respiratory problems: increased need for suctioning ◦ Increased incidence of aspiration pneumonia Investigation

8.  Benefits of dehydration in the dying patient ◦ Analgesic effects ◦ Less frequent need for urination ◦ Decreased episodes of incontinence ◦ Decreased respiratory secretions Studies show no relationship between biochemical signs of dehydration and thirst Investigation

9.   Articles chosen for research were specific to our PICO in regards to hospice patients. These chosen articles were also current and written by individuals with experience in the field.  Articles were excluded for the following reasons:  Focus on ethical considerations based on New York law.  Research proved >15 years old.  Narrow focus only on cancer patients.  Written by authors and no verifiable credentials. Methods

10.   Articles chosen:  Artificial Nutrition and Hydration at the End of Life by Heuberger  Artificial Nutrition and Hydration at the End of Life: Ethics and Evidence by Ganzini  Artificial Nutrition and Hydration: Clinical Issues by Ersek  Comfort and Incidence of Abnormal Serum Sodium, Bun, Creatinine and Osmolality in Dehydration of Terminal Illness by Vullo-Navich et al.  Artificial Nutrition and Hydration for the Terminally Ill: A Research Approach by Suter et al. Critical Appraisal of the Evidence

11.   The author’s conclusions in this article suggest a stance discouraging use of artificial nutrition and hydration through educating patients and families on the lack of proven data of the benefits and existing data that supports natural progression and anesthetic value of starvation and dehydration for end of life. The author does suggest avoiding using a single approach regarding ANH and encourages individual assessment of patient wishes and needs. This conclusion is congruent with several other articles reviewed. Artificial Nutrition and Hydration at the End of Life by Heuberger

12.   The authors concluded that utilizing small amounts of intravenous fluids to improve quality of life or comfort in end of life cancer patients needs to be further studied. They did not find support that using PEG tubes for artificial nutrition prolonged life for dementia patients. They do support that theory may be benefits to using PEG tubes for comfort of ALS patients. Artificial Nutrition and Hydration at the End of Life: Ethics and Evidence by Ganzini

13.   While ANH is currently used frequently in the care of critically ill patients in order to achieve quality of life and prolong survival, the limited evidence currently suggests that ANH is not likely to promote comfort and enhance quality of life for end of life patients. Artificial Nutrition and Hydration: Clinical Issues by Ersek

14.   The conclusions of this study reinforce the idea that fluid depletion in dying patients has relatively benign symptoms. The limitations of a very small sample size would diminish the confidence of utilizing this data in a clinical setting without additional clinical research. This study recommends that hydration decisions should be closely related to patient’s comfort rather than lab values without identifying what comfort level goals would or would not initiate the need for hydration. Comfort and Incidence of Abnormal Serum Sodium, BUN, Creatinine and Osmolality in Dehydration of Terminal Illness by Vullo-Navich et al.

15.   This article did not provide a definitive support of either administering or withholding artificial nutrition. The authors suggest that nurses use the research discussed to educate patients and families about ANH and honor the goals and values of the patient in an unbiased way. Artificial Nutrition and Hydration for the Terminally Ill: A Research Approach by Sutter et al.

16.   Research has shown that a provider's experience and/or personal professional preference often determines whether or not ANH is utilized (Ersek, 2003).  It is important for the nurse to be aware of his or her personal feelings and/or experiences towards end of life care. Personal Experience

17.  In some cases, a provider may feel it is their ethical obligation to provide ANH to maximize comfort, regardless of what the evidence shows. Other providers may have been giving ANH for years and are reluctant to change their practice. A nurse who is used to regular inpatient hospital treatment may not realize the different physiological/pathological aspects of the terminally ill, thus not fully understanding the hydration decision (Suter et al, 2008). Biases

18.   Covers both ends of experiential spectrum:  A couple of the members who have no experience with hospice patients at all.  A couple members who have encountered patients who are preparing to enter a hospice program.  Some members of the group actually work in a hospice setting. Group Experiences

19.   There are many considerations when utilizing this evidence in practice:  Patient and family education  Pros and cons of its administration  Establish goals for the patient  Open lines of communication  Cost vs. effectiveness Utilization in EBP

20.   Ersek, M. (2003). Artificial nutrition and hydration. Journal of Hospice and Palliative Nursing, 5 (4), 221-230. Retrieved from http://0- www.ncbi.nlm.nih.gov.libcat.ferris.edu  Ganzini, L. (2006). Artificial nutrition and hydration at the end of life: Ethics and evidence. Palliative and Supportive Care, 4 (2), 135-143. doi: 10.1017/S1478951506060196  Heuberger, R. A. (2010). Artificial nutrition and hydration at the end of life. Journal of Nutrition for the Elderly, 29 (4), 347-385. doi: 10.1080/01639366.2010.521020  Sutter, P. M., Rogers, J., & Strack, C. (2008). Artificial nutrition and hydration for the terminally ill. Home Health Care Nurse, 26 (1), 23-29. Retrieved from http://0-www.ncbi.nlm.nih.gov.libcat.ferris.edu  Vullo-Navich, K., Smith, S., Andrews, M., Levine, A. M., Tischler, J. F.& Veglia, J. M. (1998). Comfort and incidence of abnormal serum sodium, bun, creatinine and osmolality in dehydration of terminal illness. American Journal of Hospice and Palliative Medicine, 15 (2), 77-84. doi: 10.1177/104990919801500205 References