Catholic Medical Quarterly Volume 67(3) August 2017
Maintaining Fluids in The Dying
Many thanks for you excellent February issue and especially for engaging constructively with the important issue of “maintaining fluid intake at the end of life” (article by Dr L. Bemand-Qureshi). It was good to see the medical pros and cons of IV fluids carefully explained, as well as the Church’s teaching. However I felt there was more to say concerning linking the two. Dr BernardQureshi concludes that, "Just as it is unethical to have a policy of not giving anyone artificial hydration when they are judged to be at the end of life, it is unethical to insist on giving fluids when there is no anticipation that they will provide effective nutrition and comfort." Surely there is quite a middle ground to be addressed: what is the norm for a dying person who is able to receive nutrition comfortably?
My understanding is that one should give fluids artificially if they will provide nutrition, except where significant suffering would likely be caused. Is that right? As the very helpful table about positive and negative effects showed, benefits and drawbacks will always have to be balanced. But this, I understand, should be in the light of the fact that nutrition is a basic right and duty.
Fr Hugh MacKenzie,
Chaplain St John and Elizabeth’s Hospital
Dear Father Hugh
I think the answer here is simple. Dr Bemand –Quereshi is absolutely right that
- It is unethical to have a policy of not giving fluids to anyone as they die.
- She is also absolutely right that insisting upon giving fluids to those who do not need them, and especially those who may become fluid overloaded of suffer as a result of the attempt to administer fluids.
But you too are right. There is a large middle ground in which people who are dying (and especially those who may suffer symptoms of thirst and dehydration as they die) should be offered fluids. The description of the two (unethical) extremes in Dr Bamand- Quereshi’s article was not, I suspect intended in any way to suggest that these people should be denied fluids. On the contrary, the default position should be that fluids are not denied unless there are specific and good reasons to do that. As you say “one should give fluids artificially if they will provide nutrition [hydration], except where significant suffering would likely be caused”.
An important point to add here is that that you use the word nutrition when I think you really mean hydration. Generally that means hydration with some glucose in the drip bag. Full nutrition is invasive and requires a PEG tube or central venous line. So if someone is symptomatic from dehydration we will most often offer a drip into the hand etc.
In my clinical practice and in my specific field of advanced dementia care, I have cared for many people as they die. Perhaps a good example of when you might deny oral fluids is when people have developed severe swallowing difficulties which means that when theytry to drink they just choke uncontrollably and go blue and become very distressed. At that point you will (of course) consider intravenous or subcutaeneous fluids. But it is of note that I have seen some people who, in the context of agitation and confusion pull out any tubes of drips with the result that the restraint and sedation required to keep those fluids in place makes one desist from offering them. You will appreciate that such circumstances are uncommon, but they do colour in a little the sort of scenarios that lie outside of the middle ground which you describe so well. And we should remember the option of subcutaneous fluids. They can work very well but have been increasingly forgotten as an option in recent decades.
Especially for someone like yourself, acting as a Hospital Chaplain, when you are worried about whether or not someone needs fluids, the way into a discussion with the medics and nurses is about whether or not thirst or dehydration is causing distress and whether or not therefore fluids should be given to alleviate that distress. You may find quite some resistance, but I suspect that it will be the best way into the issue.