Association Between Hydration Volume and Symptoms in Terminally Ill Cancer Patients with Abdominal Malignancies
Association Between Hydration Volume and Symptoms in Terminally Ill Cancer Patients with Abdominal Malignancies
Abstract & Commentary
Stuart M. Lichtman, MD, FACP, Associate Attending, Memorial Sloan-Kettering Cancer Center, Commack, New York, is on the Editorial board for Clinical Oncology Alert.
Synopsis: Artificial hydration therapy could alleviate membranous dehydration signs, but could worsen peripheral edema, ascites, and pleural effusions. It is suggested that the potential benefits of artificial hydration therapy should be balanced with the risk of worsening fluid retention symptoms. Further clinical studies are strongly needed to identify the effects of artificial hydration therapy on overall patient well-being, and an individualized treatment and close monitoring of dehydration and fluid retention symptoms is strongly recommended.
Source: Morita T, et al. Association between hydration volume and symptoms in terminally ill cancer patients with abdominal malignancies. Ann Oncol. 2005;16:640-647.
The goal of this paper was to explore the association between hydration volume and symptoms during the last 3 weeks of life in terminally ill cancer patients. The dehydration-rehydration problem has been one of the most important issues in palliative or end-of-life care literature. Current discrepancies in the practice of artificial hydration therapy for terminally ill cancer patients have the potential to cause serious clinical problems:patients could suffer from unnecessary dehydration-related symptoms or experience iatrogenic over-hydration symptoms. These discrepancies are largely due to the lack of evidence about the effects of artificial hydration therapy on patient well-being.
Traditionally, artificial hydration therapy has been thought not to benefit the terminally ill; however, some recent studies have demonstrated that appropriate hydration can contribute to patient comfort. The majority of studies on this topic are limited by methodological issues, and do not provide enough of a basis for the evidence-based practice of artificial hydration therapy in terminally ill patients. The aim of the present study was to explore systematically the associations between hydration volume and dehydration and fluid retention symptoms in the last 3 weeks of life in terminally ill cancer patients with abdominal malignancies.
COMMENTARY
This was a multicenter, prospective, observational study performed in Japan of 226 consecutive terminally ill patients with abdominal malignancies. Primary responsible physicians and nurses evaluated the severity of membranous dehydration (dehydration score calculated from 3 physical findings), peripheral edema (edema score calculated from 7 physical findings), ascites and pleural effusion (rated as physically undetectable to symptomatic), bronchial secretion, hyperactive delirium (Memorial Delirium Assessment Scale), communication capacity (Communication Capacity Scale), agitation (Agitation Distress Scale), myoclonus, and bedsores. Two hundred and twenty-six patients were evaluated. The mean hydration volume in the hydration group ranged from 838 to 1405 mL/day during the last 3 weeks, and the median hydration volume in the non-hydration group was 200 mL/day at all 3 observation points. At baseline, ascites were present but asymptomatic in 27% (n = 62) and symptomatic in 20% (n = 44) of all patients. Pleural effusion was present but asymptomatic in 12% (n = 27) and symptomatic in 6.6% (n = 15) of all patients. The percentage of patients whose dehydration score increased by 3 or more points in the final 3 weeks of life was significantly higher in the non-hydration group than in the hydration group [35% (n = 59) vs 14% (n = 8); P = 0.0020]. The number of patients whose edema scores increased by three or more points was significantly higher in the hydration group than in the non-hydration group [44% (n = 26) vs 29% (n = 49); P = 0.039]. The percentage of patients whose symptom score increased by one or more point during the final 3 weeks was significantly higher in the hydration group than in the non-hydration group [29% (n = 17) versus 8.4% (n = 14); P < 0.001]. There were no differences in the communication score, agitation score, presence of hyperactivity, delirium, bedsores, or myoclonus. Of the 149 dehydrated patients with dry axillary 24 h before death, 73%, 46%, and 19% had simultaneous edema, ascites or pleural effusion, respectively; and 81% had some fluid retention symptoms. This is, to the best of our knowledge, the largest and the first multicenter observation study to investigate the association between hydration volume and dehydration and fluid retention symptoms in terminally ill cancer patients. This study revealed that peripheral edema, ascites and pleural effusion in the hydration group were more likely to worsen in the last 3 weeks of life. The association between the hydration group and ascites severity was statistically significant after controlling all covariates and treatment settings, and in a subgroup of patients with peritoneal metastases there was a statistically significant interaction between hydration practice and changes in pleural effusion severity. The underlying mechanisms of fluid retention symptoms include a decrease in colloid osmotic pressure, an increase in membrane permeability, and an increase in hydrostatic pressure. The findings suggest that overhydration in the terminal phase could deteriorate fluid retention symptoms. It was found that dehydration scores increased in the last 3 weeks of life regardless of whether patients received artificial hydration, although scores increased less in the hydration than in the non-hydration group. The potential interpretations of this finding are that: a) the instruments for measurement of dehydration used in this study could not differentiate dehydration signs from changes related to progressed cachexia; b) current hydration volume was not sufficient to maintain hydration status and more active hydration could alleviate membrane dehydration signs; or c) artificial hydration therapy in the terminal stage could not effectively alleviate dehydration even if an appropriate volume was provided due to some pathological mechanisms (eg, fluid shift from the intravascular components to the third space). Therefore, it is suggested that while artificial hydration therapy may help alleviate membranous dehydration signs in some patients, the overall benefits of active hydration therapy are limited by the possibility of aggravating fluid retention symptoms. This study did not identify any beneficial effects on psychiatric symptoms. Their conclusion was that artificial hydration therapy might alleviate membranous dehydration signs in terminally ill patients, it could worsen peripheral edema, ascites and pleural effusions. Their findings suggest that the potential benefits of artificial hydration therapy should be balanced with the risk of worsening fluid retention symptoms. Further clinical studies are clearly needed to identify which subgroups of terminally ill patients may or may not benefit from artificial hydration therapy. This study was limited to patients with a survival of less than 3 weeks. A prospective, randomized trial in terminally ill patients showed that parenteral hydration decreased symptoms of dehydration in terminally ill cancer patients who had decreased fluid intake. Hydration was well tolerated, and a placebo effect was observed.1 An individualized treatment based on the comprehensive assessment followed by close monitoring of both dehydration and fluid retention symptoms is strongly recommended.
Reference
1. Bruera E, et al. Effects of parenteral hydration in terminally ill cancer patients: a preliminary study. J Clin Oncol. 2005;23:2366-2371.
Artificial hydration therapy could alleviate membranous dehydration signs, but could worsen peripheral edema, ascites, and pleural effusions. It is suggested that the potential benefits of artificial hydration therapy should be balanced with the risk of worsening fluid retention symptoms.Subscribe Now for Access
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