Forum.
INTRODUCTION AND BACKGROUND
The use of hydration in the context of sedation is documented in the critical care literature, where sedation is recognised as a key tool in the management of patients in the intensive care unit (ICU) 1. The goal of therapy in critical care is to support the patient through the crisis in the expectation of recovery, hence the importance of fluid and, at times, nutritional support.
The purpose of this paper is to address the use of nutrition and hydration in a different setting, namely in palliative patients in whom recovery is no longer possible, and death is the expected outcome of the illness. The goal of sedation in this group of patients is to relieve severe suffering from symptoms that are unresponsive to all other measures. As is the case with ICU patients, sedation may occasionally be instituted as a temporary measure, in order to allow time for other interventions to take effect e.g. to allow time for drug-induced delirium to reverse. The intention in these patients is to lighten the sedation once other interventions are effective. In this subset of palliative patients improvement is anticipated, and attention should be paid to hydration/nutritional needs as for ICU patients.
There is a further group of patients: those who are imminently dying, in whom sedation may be instituted and continued until natural death occurs. We refer to this group of patients in this paper.
Aspects relevant to the consideration of sedation in the setting of the imminently dying palliative patient include the physical/physiological, ethical, legal, psycho-spiritual and cultural consequences of giving or withholding fluid and/or nutrition.
It is important to acknowledge that the outcome of decision-making may impact not only on the patient, but also on the patient’s family and friends, nursing, medical and lay carers and society as a whole. While the ethical principle of patient autonomy has emerged as being of paramount importance in the western world, there are many cultures that have different approaches. These include models of shared or collective decision-making, and delegation of decision making to a senior member of the family. Health-care workers must recognise and respect such cultural differences.
There is very little published high-level evidence to guide management of fluid and nutritional requirements in palliative patients, and there is none that relates specifically to imminently dying sedated patients. To develop a recommendation on nutrition and hydration during sedation requires the synthesis of evidence, much of which is indirect, from a number of fields including physiology, pathology, psychology, culture, ethics and the law.
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