{"id":1630,"date":"2021-03-17T12:02:28","date_gmt":"2021-03-17T12:02:28","guid":{"rendered":"https:\/\/blogs.bmj.com\/spcare\/?p=1630"},"modified":"2021-03-17T12:02:28","modified_gmt":"2021-03-17T12:02:28","slug":"what-now-for-assisted-hydration","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/spcare\/2021\/03\/17\/what-now-for-assisted-hydration\/","title":{"rendered":"What now for assisted hydration?"},"content":{"rendered":"

By Dr Arjun Kingdon, Academic Clinical Fellow & ST5 in Palliative Medicine<\/strong><\/p>\n

<\/em>Article reference:<\/strong> Kingdon A, Spathis A, Brodrick R, et al, What is the impact of clinically assisted hydration in the last days of life? A systematic literature review and narrative synthesis, BMJ Supportive & Palliative Care, 2021;11:68-74.<\/a><\/p>\n

\"\"<\/a><\/p>\n

It\u2019s hard to forget the furore surrounding the withdrawal of the Liverpool Care Pathway eight years ago. The specialty of palliative care has seldom felt more visible or more vulnerable, before or since. From Baroness Neuberger\u2019s \u201cMore Care Less Pathway\u201d review, through \u201cOne Chance To Get It Right\u201d, to the publication of NICE guidance on the care of dying adults in the last days of life, much of modern palliative care practice, thinking and policy has been influenced by the learning from that difficult time.<\/p>\n

Looking back to \u201cMore Care Less Pathway\u201d, it is striking that many of the broader findings as well as the individual stories of upset, pain and poor practice, centred around lack of provision of hydration, or lack of communication about hydration. Recommendations were made that \u201cspecialist services, professional associations and the Royal Colleges should run and evaluate programmes of education, training and audit about how to discuss and decide with patients and relatives or carers how to manage hydration at the end of life\u201d. These recommendations haven\u2019t been widely actioned on a national scale to date.<\/p>\n

Fast forward, and we see results from the National Audit of Care at the End of Life (NACEL) in 2018 and 2019 indicating that such conversations are held and documented with no more than 1 in 10 dying people and less than a third of their families. And that is in cases where dying is recognised in advance at all in hospital. By contrast, other NACEL parameters are much closer to where they \u201cought\u201d to be. The NICE guidance (NG31) is clear: \u201cdiscuss the risks and benefits of clinically assisted hydration with the dying person and those important to them\u201d.<\/p>\n

We don\u2019t have evidence about whether these conversations are simply not being held, or just not being documented, and we don\u2019t know why practice appears to be so at odds with guidance. And beyond the stories from \u201cMore Care Less Pathway\u201d, many of which make tough reading, we don\u2019t have much evidence about the perspectives of patients and their relatives. We know that this is an important topic and that when communication is poor or absent, the cost of this can be considerable upset, complaints, and difficult bereavements. But it\u2019s not clear why things are the way they are, or how best to fix it.<\/p>\n

BMJ Supportive and Palliative Care<\/em> has just published a systematic review of the literature concerning the impact of clinically assisted hydration in the last days of life. In short, despite broad inclusion criteria, the review found that there\u2019s still not enough evidence to guide clinicians in their decision-making. Intriguing results from a recent feasibility cluster randomised controlled trial suggest there may <\/em>be an impact of close to 24h of prolonged life, but for the most part we are reliant on our individual clinical judgments and little else. Evidence suggests practice varies considerably between individuals, countries, and different healthcare settings.<\/p>\n

Since we currently don\u2019t know whether assisted hydration in the final days of life affects symptoms or length of life, it becomes even more important to get the communication right, including open acknowledgement of the uncertainties. And to take action on the Neuberger report\u2019s recommendations as a matter of priority.<\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

By Dr Arjun Kingdon, Academic Clinical Fellow & ST5 in Palliative Medicine Article reference: Kingdon A, Spathis A, Brodrick R, et al, What is the impact of clinically assisted hydration in the last days of life? A systematic literature review and narrative synthesis, BMJ Supportive & Palliative Care, 2021;11:68-74. It\u2019s hard to forget the furore […]<\/p>\n

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