Water Under the Bridge: When Families are at Odds Over Hydration at the End-of-Life

• Published in: Journal of pain and symptom management 2024-05, Vol.67 (5), p.e534-e534
• Main Authors: Simpson, Jane M., Gula, Annie L., Ramos, Jacob, Stafford, Jensy, Nevins-Herbert, Christine
• Format: Article
• Language: English
• ISSN: 0885-3924
• DOI: 10.1016/j.jpainsymman.2024.02.310

1. Discuss the evidence for and against the use of fluids in end of life care, and explore the nuanced issues when using fluids at end of life through an ethical lens. 2. Practice applying a framework to support shared decision-making in a complex family dynamic. There is limited and conflicting research about the pros and cons of artificial hydration at the end of life. Patients, caregivers, and healthcare professionals may have strong and opposing opinions about artificial hydration when there is a limited prognosis. It is important to explore this controversial topic by reviewing the evidence through an ethical lens. Patients often have a decrease in oral intake of both solid food and liquids at the end of life (EOL). Artificial nutrition and hydration (ANH) may provide benefits including extending life, decreasing delirium, and decreasing dry mouth. However, negative effects of ANH include complications of increased fluid retention, such as edema, pleural effusions, and increased airway secretions. ANH at EOL requires shared decision making between the provider, patient, and family, and may also be influenced by the resources available in the patient's care setting. We examine the ethics of ANH at EOL through a case with complex medical decision-making. Mrs. Y is a 70 year old female with metastatic fallopian tube carcinoma who has completed years of treatments including surgical interventions and chemotherapy. She presented to the hospital with a small bowel obstruction. She was not a candidate for surgical or further cancer-directed therapies. She chose to pursue comfort based care and was transitioned to the inpatient hospice facility. Conflict arose between the patient and her surrogate medical decision-maker surrounding ANH due to discordant goals: her goal was to pass quickly and without pain while her husband's goal was to maintain life as long as possible in accordance with his religious beliefs. Decisions were also complicated by the concerns of her three children, who held various beliefs on ANH at the end of life. We explore the evidence on both sides of the issue of ANH at EOL in the context of this patient and her family, and the hospice setting. We present a framework to approach ANH at EOL and strategies to de-escalate conflict. We discuss barriers to preferred care and treatments. Given the ethical dilemma and practice variations, this presentation will engage the audience in discussion around their current practices and perspectives. M