1.0 Introduction

As the number of persons aging across the globe continues to rise exponentially, demand for novel, more cost-effective and quality treatments becomes more inescapable. Hypodermoclysis also referred to as clysis, the instillation of isotonic fluids into the subcutaneous spaces is argued as a simple, secure from risk and cheap alternative for the rehydration of both palliative care and terminally ill persons at hospitals, at long-term care facilities and home. The method was introduced by Evans and Gaisford in the early years of the 20^th century for the hydration of children (Mei & Auerhahn, 2009). Based on the fewer adverse effects associated with the procedure and its relatively low cost, hypodermoclysis gained popularity in the few years following its inception.

The technique gained acceptance and popularity within the clinical world and was frequently used for the administration of fluids, especially in dehydrated children till around 1950, when intravenous hydration substituted it based on various publications citing the adverse effects generated (Cabañero-Martínez et al., 2015; Barua & Bhowmick, 2005). Exemplifying this is the incident of a 5-month infant who was infused with an unspecified amounts of normal saline and 5% glucose that resulted in near death, including other patients who suffered shock (Hugel et al., 2010; Mei & Auerhahn, 2009). With the prevalence of better research and understanding of the technique, the adverse effects were later pointed to the incorrect use of administration solutions and misuse of isotonic solutions (Maria, 2016).

Fast forward, the technique has once again given rise to heightened interest over the past few decades, especially in patients where the administration of fluids through the intravenous route is troublesome or has complications, particularly in elderly persons and patients at the end of their lives (Bowen, Mansfield, & King, 2013). The rationale behind the expansion of the use of hypodermoclysis in palliative care is that one of the serious complication associated with dehydration in this group of patients is high morbidity and mortality – especially in patients with concomitant chronic illness, diminished kidney function and reduced thirst sensation (Schols et al., 2009).  In these cases, dehydration often requires hospitalization for intravenous fluid replacement.

Does hypodermoclysis improve overall patient comfort at the end of life? Well, whereas definitions of patient discomfort at the end of life may include delirium, easy irritability, reduced cognitive sense, dry mouth and confusion, evidence linking these to dehydration is sparse (Bowen, Mansfield, & King, 2013). In answering this question, the paper will plunge into exploring the use of hypodermoclysis in palliative care, with an analysis of four key points: (a) The benefits and risks associated with artificial hydration of palliative care patients that must and before indicating fluid replacement therapies. (b) The basis of the raging discussions and controversies plaguing the use of hypodermoclysis to reverse dehydration at the end of life. (c) The guidelines, standards, and policies within the clinical practice that govern the institution of subcutaneous fluids in palliative care patients. (d) The paper will also give a description of the proper hypodermoclysis procedure, including its indications, contraindications, outlined advantages and disadvantages, additive solutions used, expected adverse outcomes. and complications.

2.0 Methods

2.1 Research question and specific objectives

Research question: does hypodermoclysis improve overall patient comfort at the end of life? Objectives:

1. To clarify the evidence base available around the relationship of subcutaneous hydration of terminally ill patients within the setting of palliative care in improving the overall comfort.
2. To identify other factors that might affect the use of hypodermoclysis in the treatment of hydration at the end of life. These other factors may include awareness of the procedure by primary providers of patient healthcare, patient, family, and medical staff perceptions of hypodermoclysis, standards and guidelines surrounding patient hydration at the end of life, ethical and legal considerations and hurdles to implementation of the technique.

2.2 Inclusion and Exclusion criteria

2.2.1 Inclusion Criteria

Table 1: Research inclusion criteria

2.2.1 Exclusion criteria

The primary research papers had to be within a 10-year period; between December 2016 and January 2005. Typical populations for whom hypodermoclysis is instituted, including pediatric patients, were excluded. Studies that did not at least relate topic surrounding the use of hypodermoclysis (and broadly artificial hydration) within the clinical setting many.

2.3 Search method

Table 2: Search criteria

2.4 Review method

Table 3: Review method used

2.4.1 Findings presented

Does hypodermoclysis improve overall patient comfort at the end of life? An exhaustive search of the literature salt, resulting in 23 studies on hydration at the end of life. Each study, based on its findings was then carefully evaluated to determine whether they focused specifically on the issue surrounding the use of hypodermoclysis in the clinical setting. These include standards and guidelines, ethical guidelines, perceptions of patient, caregivers, families and health care professionals, and the awareness of the medical staff of the method; 8 of the studies were retained.

2.4.2 Problems experienced

Systematic reviews, just like primary researchers have their limitations too. Reviews only review results from limited studies, therefore, before even beginning the research, there is an element of publication bias present. Furthermore, publication bias was reflected in the analysis of the literate, and may not have accounted for the less estimation of the effectiveness of the technique. Additionally, hypodermoclysis is an area that has had less research, which presented limited data.

3.0 Literature Review: Findings from Clinical Studies

3.1 Rapid appraisal of sources

Raijmakers et al., (2011), “Artificial nutrition and hydration in the last week of life in cancer patients: A systematic literature review of practices and effects.” In this study, the authors posit that the onerous and benefits of artificial hydration and artificial nutrition for terminally ill patients are unclear. In examining this area, they conducted a literature review of these two topics in the final days of cancer patients. Their study included a systematic search of papers in PubMed, CINAHL, PsycINFO and EMBASE between January 1998 and July 2009. The research materials and to meet the inclusion criteria of containing data on effects or occurrences of parenteral hydration and nutrition in the last few days of a cancer patient. They reported that percentages of patients receiving artificial hydration and nutrition in their last weeks of life had a variance of between 12 to 88% and 3% to 53% respectively. Five of the studies reviewed made a report on the outcomes of artificial hydration: two had acceptable outcomes (less signs of physical dehydration and less chronic nausea), two reported adverse effects (including increased intestinal drainage and ascites). Four others indicated that no overall effects were present on thirst, chronic nausea, terminal delirium, and fluid overload. No single study had a sole effect on artificial nutrition. They concluded that the institution of artificial hydration and nutrition for terminally ill patients was a frequent practice. The studies presented limited findings on the length of survival, improved comfort, and relieved symptoms. Further research within the area will confer to a better comprehension of this topic within the setting of end life.

Thomas et al., (2008) “Understanding clinical dehydration and its treatment.” Dehydration in clinical practices, as contrasted to its physiological explanation, makes reference to the loss of total body water, with or without salt, at a rate exceeding its replacement. In their position, the clinical exposition of dehydration, as the loss of total body water, is effective in addressing the medical needs of patients. From their literature, there exist two aspectual groupings of dehydration: water-loss dehydration (hyperosmolar, resulting from increased glucose or sodium) and hyponatremia (water and salt loss dehydration). To clinically diagnose this, health care providers need to conduct a patient appraisal, lab tests, clinical assessments and acquisition of proper patient history.

The authors point out that long-term care facilities have become more placid in having their practitioners make this diagnosis, partly citing that dehydration is a sentinel phenomenon thought to reflect inadequate care. Arguably, thereof, health care institutions ought to implement interdisciplinary educational mechanisms with a major attention on the prevention of dehydration in light of the poor results associated with its development. Furthermore, they also argue that dehydration rarely results from neglect of both formal and informal caregivers, but rather from a combination of disease (such as terminal cancer) and physiological (old age) processes. Relevantly, now that the recombinant enzyme hyaluronidase in commercially available, hypodermoclysis presents better opportunities for treating mild to moderate dehydration at homes and nursing homes.

Caccialanza et al. (2016), “Subcutaneous infusion of fluids for hydration or Nutrition: A review.” In this review of literature in the area of hydration, the authors explain that hypodermoclysis is a medical technique whereby fluids are infused into the subcutaneous spaces via small-gauge needles typically inserted in the abdomen, back, thighs or arms. In their review, the authors provide an overview of the technique, with a relevant summary of findings from studies that examine the use of the subcutaneous infusion of fluids for nutrition or hydration.

In a sum up, the authors note that evidence available suggest that when indicated, administration of fluids subcutaneously for either nutrition or hydration is adequate, with minimalist complications and a similar safety profile and effectiveness of the intravenous route. In their publication, the authors present some of the advantages of hypodermoclysis to intravenous infusion, including indications and contraindications of the procedure. In conclusions, the authors argue that the use of Hypodermoclysis is better suited for multiple settings including outpatient clinics, emergency departments, hospitals, long-term care, homes, and hospices

Cabañero-Martínez et al., (2015), “Perceptions of health professionals on subcutaneous hydration in palliative care: A qualitative study.” The authors posit that hypodermoclysis is a safe method of treating symptomatology associated with moderate to mild dehydration in patients whom the intake of fluids through the oral route is contraindicated. To the contrary, knowledge on this area is severely limited. In light to this, the authors conducted a qualitative study to inquire into the opinions, perceptions, and attitudes of health care professionals within the setting of palliative care in relation to the use of hypodermoclysis. The authors carried outdoor focus groups until data saturation, with a subsequent qualitative content analysis. The study involved 37 participants, nurses, and physicians recruited within different palliative care units in Spain.

856 units were selected, from which then 56 categories were extracted and grouped into 22 subthemes, mainly distributed into four themes: (a) ‘factors influencing the decision to institute hydration.’ (b) ‘Factors affecting the choice of hypodermoclysis.’ (c) ‘Awareness of hypodermoclysis’ and the prevalent (d) ‘performance guidelines and protocols.’ From the results, variables realized to influence often the use of subcutaneous route are connected to patient characteristics, the family, and healthcare team, including the context of professional subjective perspectives of this practice.

Barua & Bhowmick, (2005) “Hypodermoclysis – a victim of historical prejudice.” The authors posit that many patients in the terminal phases of diseases experience a decrease in the intake of oral fluids before their deaths, as to causes related to disease treatment or physiological changes. What obviously follows when oral intake of fluids is not adequate is malnutrition and dehydration. These patients, thereof are challenges presented to healthcare providers, with underlying ethical questions of whether or not to rehydrate them, and if so how.

The authors explain that hypodermoclysis has dropped into disrepute due to clinical outcomes that were as a result of improper clinical use. They explain that over other techniques, hypodermoclysis presents clear favorable outcomes over other parenteral hydration routes. By analyzing scientific pieces of evidence presented, they posit that the technique has stood scrutiny from the scientific world, but then has been unsuccessful in attempts to regain lost glory. Somehow attributed to this are ignorance and inability of the medical personnel to detach themselves from age-old prejudices.

Agreed upon is the fact that in terminal patients, adequate hydration levels are much lower as compared to normal populations. Healthcare providers, therefore, should assess the hydration needs of a patient through physical examination, personal histories and conduction of a laboratory evaluation before considering patient hydration, including the wishes of the patients and their families. In doubtful cases, the authors state that short trails of hydration may seem appropriate. In cases where clear hydration is indicated, alternative parenteral hydration methods are to be considered based on patient needs, including IV, proctoclysis, and subcutaneous hydration.

In their attempts to demystify the myths surrounding hypodermoclysis, the authors conclude that they hope that persons in palliative care, including the old, are not denied a method best suited for them.

Schols, De Groot, Van Der Cammen, and Olde Rikkert, (2009). “Preventing and treating dehydration in elderly during periods of illness and warm weather.” The authors aimed at translating available knowledge on dehydration and aging into the central message in clinical practice. The study included the systematic review of available materials on the topic of dehydration in elderly persons. Important points realized include the fact that elderly persons, compared to younger persons are more susceptible to dehydration. This partly arises from diminished sensation of thirst and alterations in sodium and water homeostasis that occur naturally as people age. Additionally, it is attributed to the fact that this group of patients often have various comorbidities and have a preposition to use numerous medications to treat these illnesses (polypharmacy).

Polypharmacy and multi-morbidity often overstress the normative age-related physiological changes in sodium and water balance and thereof heightens these people’s dangers of dehydration, to a greater degree in warm weather and inter-current infections. The authors argue that elderly persons, whether living in an institution or on their own and especially citing reasons of reduced cognitive, motor, sensory and ADL functions need external help to stay hydrated. One of the strategies posted as to countering dehydration in the elderly is just to ensure that they consume sufficient amounts of fluids (at least 1.7 liters within 24hours). When whatever reason compromises the intake of recommended fluid, it should be realized that these fluids can be instituted intravenously or by hypodermoclysis; with employment of IV in severe cases.

In conclusion, the authors posit that the signaling, prevention, and correction of dehydration in aged persons is a valued and significant multidisciplinary undertaking. Both informal and formal caregivers need to realize the signs and risk factors associated with dehydration in the elderly, especially when such patient have acute illnesses or during warm weather. There is an imperative need to provide standard professional care for high-risk patients.

Walsh, (2005) “Hypodermoclysis: An Alternate Method for Rehydration in Long-term care.” The author gives a comprehensive analysis of hypodermoclysis. He states that the technique has long-term benefits on the care of patients. The minor complications resulting from hypodermoclysis are easily corrected, and according to him, the technique has proved useful.

3.2 Critical review of the literature – including limitations noted

Fritzon (2012) posits that one of the main goals of palliative care from the inception of the hospice care movement has been to alleviate suffering a discomfort. The qualities that render hydration desirable, particularly in the last few days and weeks of life have had ambiguity in the status of attaining the mentioned goals. The relevant function of hydration – and repletion of lost volume – in palliative care patients within the British context has been a relatively “data free zone.” Admittedly, as palliative care providers, we are faced with established behaviors of providing parenteral fluids for all institutionalized patients; social norms that persons should always have to oneself a bottle of water to prevent dehydration; including a vast multitude of other religious, economic, ethical, and biomedical ideas from specific circumstances to underpin these firmly held positions (Cutcliffe & Ward, 2014).

Dalal and Bruera (2004) for example, made a new evaluation of the primary elements of body electrolyte and fluid homeostasis in normative persons and individuals within palliative care, with a discussion of the functional role of re-hydration in the alleviation or/and promotion of disagreeable symptomology. The literature reviewed presents different techniques to supplement fluids in palliative care patient groups, with a recognition of the favorable and unfavorable positions of each that must thereof be adjusted to address the special needs of each patient. The point mostly appreciated from the literature is the exposition of subcutaneous fluid replacement, one of the most neglected fluid replacement approaches appropriate patients in institutional care and at homes (Gabriel, 2014).

Therefore, the major question asked from the literature is that does the institution of fluids in terminal care patients cause or alleviate suffering and discomfort? Studies with primarily normal volunteers demonstrate an impressive display of distressful and in all likelihood self-perpetuating states of difficulties associated with dehydration, in part distinctive syndromes of hypernatremic and hyponatremic dehydration (Dalal and Bruera, 2004). Some of these observational have had loose understandings within the clinical setting but widely applied in medical practices, so that dehydration has become a frequent citation as the cause of symptoms and therefore indicated for treatment (Cutcliffe & Ward, 2014). Glancing the orders at patient chemotherapy infusion units has revelations of a significant number of patients instated hydration to “alleviate” body weakness, fatigue, and a constellation of other undefined symptomatology.

According to Dalal and Bruera, (2004), some pioneers in hospice care have made observations that dehydration does not seem to bother the dying patient, except for a dry mouth that good care alleviates. Some of their conclusions, some of which have flown in the face of established practices, have had a wide acceptance in the hospice movement. However, and admittedly thereof is the fact that there is a lack of systematic studies of the role of hydration in terminally ill patients. Investigators, as well as hospice researchers, have proved reluctant in subjecting patients on death beds to uncomfortable interventions which present no immediate and clear benefits but are a necessary evil to discern the effects of various states of hydration (Holloway, I. & Galvin, 2014; Hugel et al., 2010). Moreover, patients in their final stages of life may be troublesome to scrutiny due to their expeditiously changing medical states, unpredictable and brief lives in addition to flattened conscious levels (Caccialanza et al., 2016).  Of course, the withholding of dehydration commonly raises cultural, ethical, personal, as well as medical issues.

Discussions raging in the hospice literature have however contrasted the ills of overhydrating with benefits or benign consequences of dehydration. Such debates rarely, if at all, equate overhydration or dehydration with normative body fluid balance nor do they address differences existent between hypo-, hyper-, and normonatremic dehydration (Dalal & Bruera, 2004). As reflected in some of the papers, (for example in Mei & Auerhahn, 2009), the heightened constellation of symptoms in terminal care patients might be attributed to patient dehydration, including the existent variations in expositions of these symptoms. In their struggles to make meaning of imperfect facts, some of these authors have suggested that limited rehydration (without the inclusion of the clearly recognized prescriptions for hydration, like hypercalcemia and tumor lysis syndromes) has been “proved” to promote the well-being of terminally ill patients. Such also includes the hypothesis that the benefits are a reflection improved kidney metabolism of harmful metabolites, in part opioids and their metabolites (Holloway & Galvin, 2014; Lopez & Reyes-Ortiz, 2010).

Other researchers have picked out for example, and specifically, improvement of the status of cognition as a positive construct of patient hydration. Evidence outlined to support this point of view is unconvincing, though the hypothesis posited is both reasonable and attractive. Better and rigorous experimental support for this viewpoint is a welcome, with a presumption that it would utilize definable and relatively homogenous sample participants with specific pathology in their fluid homeostasis (Whittaker & Williamson, 2011; Tappen, 2010).

The designation of studies reviewed raises many pertinent questions within the theme of hypodermoclysis relieving patient symptomology, including:

(a) The arising conflicts in ethics when attempting to provoke and maintain specific psychological states – the anticipation of death when hyponatremia in severely ill patients results (Cabañero-Martínez et al., 2015). The clinical principles of equipoise—where clinicians become indifferent to a particular course of action because they are unable to clinically annunciate the effects caused by two or more medical treatments — are not easy to maintain in such situations (Whittaker, & Williamson, 2011; Tappen, 2010). We are thereof left to wonder what constitutes informed consents in these situations, and the potential for suffering must be carefully assessed.

(b) According to Cutcliffe and Ward (2014), it is important that study populations be defined prospectively, which demands for the separation of subpopulations for whom re-hydration may bring about varying outcomes than expected for “average” palliative care patients. These groups of patients include heart failure patients; renal failure or ascites not resulting from dehydration; those not on opioid medication or other treatments thereof that may be affected by body fluid status; and hyponatremic versus hypernatremic dehydration.

(c) The determination of the status of electrolyte and fluids in patients on their last days may require the utilization of cumbersome and sometimes behoove techniques, which may prove impractical external to the settings of research. An effective method of research thereof may require designs incorporating the usage of comparatively convoluted methodologies, which ideally may lead to practical clinical results; such techniques include urinalysis and physical exams (Burns, Grove & Gray, 2015; Dalal & Bruera, 2004).

(d) The effects of subcutaneous hydration in the settings of mild to moderate dehydration and the breakdown of medications commonly used in palliative care (primarily opioids) can be studied in other patients, not just those on their last days. The constellation of symptomatology resultant from particular regimens have not had good documentation, and thereof might form the basis of hypotheses designed to assess the effects of dehydration on palliative care patients receiving such medications.

(e) Inexplicit to these discussions is the demand to determine the function of electrolyte status and not mere water imbalances in palliative care persons. According to Raijmakers, et al., (2011), presenting the dichotomy between dehydration and over-hydration is a mere oversimplification of the underlying issue and does not present relevant defining for the clinical issue plaguing palliative care patients.  Additionally, the appropriate therapies for total body water losses or gains may not only entail the simple provision or restriction of fluids, but also take into account salt replacements and restrictions.

(f) A final critical question arising from the setting of this literature is on how symptoms are assessed. Tappen, (2010) points out that palliative care patients may not have the capacity to fill out survey questionnaires, and the clinical evaluations carried out may be less than specific or sensitive. Without due consideration of whatever sophistication researchers may have in assessing physiological and biochemical markers, the functions played by sodium, antidiuretic hormone, mineralocorticoids, and total body water in palliative care patients is poorly understood in relation to the perception of thirst (Polit, & Beck, 2010). As researchers, we are tasked with developing and using valid measures of symptom improvement to assess these correctly (Burns, Grove, & Gray, 2015).

According to Lopez and Reyes-Ortiz, (2010) debates construed around the provision of artificial hydration to palliative care patient, and more so at the end of life has continued to provoke impassionate arguments on both sides of the arguments, particularly pointing out the dire lack of conclusive evidence on the issue. Complication the situation further is the variance in clinical practice locally (within the British setting) and on a global scale, both of which is dependent on the physician and the reduces, the individualized to the patient and their family caregivers.

The study carried out by Cabañero-Martínez et al. (2015) on the perceptions of health care providers focused on the nurses’ and doctors’ perceptions, who in healthcare settings are considered forthwith creditworthy for the prescription and institution of parenteral hydration. No consideration of other healthcare team members was done, thereof limiting the generalization of the results. Polit and Beck, (2010) note that for example if the findings were analyzed from the perspectives of differences in medical practices, fundamentals underlying the variations in the use of hypodermoclysis are then those concerning: (a) Populations involved (patient and family characteristics). (b) The setting of healthcare (organization of multidisciplinary teams and the setting of care delivery) and, (c) Factors related to the primary provider of patient’s care (the health professionals’ perceptions of hypodermoclysis).

Identification of the above factors and understanding their explanations on the variations is the use of hypodermoclysis is crucial for the development of healthcare and clinical management strategies aimed at uncertainties, which is a major causation of variations in medical practice (Aveyard, 2014). Based on the results, therefore, strategies of management in health should incorporate: (1). The control of provision of palliative care services and supporting the systematization of evidence and research within the healthcare plan of action; (2). The expansion, refinement and usage of clinical thoroughfare focusing on palliative care patients from the viewpoints of managements in healthcare; (3). The advancement and application of evidence-based protocols including guidelines for the making of shared decisions (Ho & Krishna, 2015). The results posited also compose points of departure of hereafter quantitative and qualitative studies examining the perceptual structures of hypodermoclysis and its correlation to palliative care, including the latter development of healthcare and clinical management strategies aimed at controlling these variations in medical practices (Ho & Krishna, 2015, pg. 559).

In the absence of new evidence, it is agreeable that with literature authors in not advocating for a blanket policy on the use of hypodermoclysis, they agree to the utilization of both intravenous and subcutaneous fluid infusions based on prevalent circumstances (Aveyard, 2014). For most patients, they advocate for policies on not doing harm, which, implies avoid prescription of any methods for the replacemt of total body water in the absence of clear indications (Polit & Beck, 2010). The debate prevalent within the literate, which is a reflection of ideologies and suppositions that are unconvincing, is to be best supplanted by studies conducted well.

3.3 Hypodermoclysis: The Recommended Procedure

Walsh (2005) explains that hypodermoclysis is a straightforward method requiring minimal training to be applied. After the site is identified, a cannula (22- to 24-gauge needle) is inserted at a 45° angle into the subcutaneous space and aimed toward the thorax/head (Caccialanza et al., 2016).  Whereas both metallic and non-metallic cannula can be used, the duration of infusion may be longer with a non-metallic cannula. Alternatively, a Teflon™ pediatric cannula is recommended to avoid nickel irritation (Caccialanza et al., pg. 2).

Some of the common insertion sites include the outer/inner aspects of the thighs, the lateral walls of the abdomen, and the inter-scapular region. Other areas include the pectoral area in men and the outer surface of the upper arms/forearms (Barua & Bhowmick, 2005). Sites to be selected must have sufficient subcutaneous tissue (this can be determined by pinching the skin between fingers) and with reasonable skin turgor.  After insertion, the needle is then covered with a bandage or a transparent semi-permeable dressing and then connected to the fluid container (Lopez & Reyes-Ortiz, 2010).

Fluid delivery can be done by either gravity or an infusion pump. Gravity has an advantage of helping prevent localized edema as the infusion rate is naturally slowed when pressure in the subcutaneous spaces increases (Caccialanza et al., 2016). Infusion rates should remain within the limits of tissue perfusion; the average size adult should be infused continuously over 24 hours at a rate not exceeding 62 mL per hour (1500mL in total). However, up to 200mL can be infused within 24 hours with minor to no edema (Caccialanza et al., 2016, pgs. 2-4). If the infusion of fluids continuously for 24 hours is not feasible, a nocturnal infusion of 1000mL per 8 hours or a ceiling of 500 mL per 2 hours is recommended – with expectation of transient local edema and minimal patient discomfort (Barua & Bhowmick, 2005). The total volume of the infusate can be increased by concurrent infusion at multiple sites. The development of progressive infusion edema is an indication that the rate of fluid administration exceeds the absorption rate and the infusion should either be slowed or stopped (Gabriel, 2014).

Hypodermoclysis is typically used for up to 10 days to deliver nutrition/hydration; theoretically, however, it is possible to administer longer infusions provided adequate access to infusion sites (Ganzini, 2006). There exist no clear guidelines on the osmolality limits for fluids to be administered.  According to Caccialanza et al., (2016), some of the reported ranges include 154–845 mOsm per liter with the best range of 280–300 mOsm/L expected to be well tolerated. Infusion of nutrition showed that fluids with an osmolality of 845 mOsm/L were well tolerated (Caccialanza et al., page 2.)

3.4 Indications and contraindications of hypodermoclysis

Table 4: A listing of indications and contraindications of hypodermoclysis

4.0 Discussion

Water plays a vital part in our lives (Frank Sinatra 2011). A young adult on average has a body water composition of 60%, which, however, gets replaced as they age by fat deposits (Schols et al., 2009). These physiological fluid balances that take place as we age influence our bodies’ capacity to control fluid balance. The human kidney, for example, reaches its ultimate size and blood flow by the age of 30 years. Scales, (2011) further explains that years past the climacteric 30-year mark are characterized by continued decline in kidney size and renal function, and by the age of 90 years, it loses between to 30-40% of its maximal size. Many other normal key body functions continue to deteriorate with aging, including, a reduction in glomerular filtration rate (GFR), a 10% decline in blood flow every decade, and a decrease in the body’s ability to maintain a homeostatic balance of water, potassium, and sodium (Frank Sinatra 2011). Wotton, Crannitch, and Munt in Frank Sinatra (2011) suggest that the presence of dehydration in these patients heightens the risks of decubitus ulcers, renal failure, urinary tract infections, constipation, acute confusion, respiratory infections, medication toxicity, decreased muscle strength and falls, tachycardia, deep vein thrombosis and myocardial ischemia.

4.1 Pathophysiology involved in improper hypodermoclysis

Starling is accredited for describing hydrostatic and osmotic pressure as the primary causes of diffusion in 1909; he was later followed by Chinard and Perl who described perfusion in 1968 (Barua & Bhowmick, 2005). In 1894, Tubby and Starling made an observation that “constituents moved between fluid placed in the pleural cavity and blood in adjacent blood vessels so that each took from each other the constituents it did not possess” (Barua & Bhowmick, 2005, page 216). Their observation was that hypertonic salt or sugar solutions within the pleural cavity led to a copious drain of fluid into the cavity and such flow only ceased after attainment of the osmotic equilibrium. Thereof, whereas there exist room for differences in the fluids used in hypodermoclysis, it was crucially felt that if hydration was the initial intention, the infusate composition had to be of such status as not to draw intracellular sodium and water. Additionally, the rate of infusion should be within limits to allow adequate perfusion into tissues (Gabriel, 2014).

Physiologically, the rapid infusion of copious amounts of electrolyte-free solutions (such as the ones used before) in hypodermoclysis leads to an osmotic shift into the ‘clysis pool.’  The segregation of osmotically active solutes into the infusion site reduces the concentration of solutes within the extracellular spaces. Peter and Van Slyke in Barua and Bhowmick, (2005) made observations that if glucose was administered as the infusate, it would have a slower diffusion rate than either salt or water across vascular membranes, erythrocyte walls and across interstitial spaces. Such pool of non-diffusing glucose pool thereof draws water into cells, raising the hematocrit levels resultant from plasma constriction. In palliative care patients who may be volume, chloride, and sodium depleted, changes of sufficient magnitude can result in the fall of venous return, prolongation of circulatory time, and cardiac output leading to shock (Scales, 2011; Gabriel, 2014; Caccialanza et al., 2016).

4.2 Clinical relevance

Dalal and Bruera (2004) posit that caring for terminally ill patients involves ethical doings that ought to be in the best interests of the patient – a daunting task when health professionals, patients, and their families have to make difficult choices. According to Patricia (2008), the fear of thirst making patients uncomfortable encourages health care professionals and patient families to provide fluids to a dying patient when both nutrition has been discontinued, and the intake of oral fluids is declining. According to Mei and Auerhahn, (2009), dehydration, admittedly, is one complication linked to significant morbidity and mortality for many terminally ill patients experiencing concomitant comorbidities. The rationale underlying the expansion of the use of hypodermoclysis in palliative care is that dehydration is a serious complication associated with significant mortalities and morbidities for this group of patients who either suffer from concomitant chronic comorbidities, have a diminished sense of thirst or decreasing kidney function (Mei & Auerhahn, 2009, pg. 28-30).

In a hospital setting, it not uncommon that every now and then a sick person admitted requires an intravenous line, comparative to an unconscious knee jerk. To a higher degree in this setting, a poor on duty officer has to be called in the wee morning hours to pry for a fragile and shy vein that seemingly escapes cannulation. More often than not, in these cases, hypodermoclysis may seem more appropriate.

Hypodermoclysis is a technique often not taken into account especially in patients within the setting of palliative care. Cabañero-Martínez et al. (2015) posit that one of the primary reasons as to this as revealed is the unawareness of hypodermoclysis as a route of parenteral fluid administration, including unawareness of performance guidelines and protocols (Hugel et al., 2010). According to a study carried out by Torres-Vigil et al. in Cabañero-Martínez, et al. (2015) on clinical patterns associated with patient hydration revealed that only a mere 23% of the participant professionals had declared as a fact that they were aware of the existence of institutional clinical practice guidelines on parenteral hydration during the last few weeks of life. Unawareness of this modality may be based on the fact that it has not been in use for many years due to incidences of inappropriate use (Schols et al., 2009).

Circumstances described in patients’ and their family situations shed light to some of the complexities surrounding the controversial and widely debated topic of patient hydration at the end of their lives (Ho & Krishna, 2015). Relevantly, at the core of these debates is the desire to keep patients as comfortable as possible while minimizing unnecessary interventions as possible.  According to Barua and Bhowmick, (2005), as health care professionals make these decisions, they need to evaluate the expression of opinions, the biochemical changes and pathophysiology underlying terminal life stages, family, and cultural expectations. They also need to consider research that examines the variety of outcomes as well as reviews and consensus statements relevantly published on the topic. They are also the tasked with taking such diverse and sometimes conflicting information and attempt to apply them to specific situations, cultural backgrounds, and location of our palliative care patients (Cabañero-Martínez et al., 2015).

There exists no controversy that patients in palliative care, and thereof terminally ill ought to be encouraged to maintain adequate oral hydration. The debate apparently revolves around the concurrent supplementation of oral hydration with parenteral hydration (Dalal & Bruera, 2004). Although reports published highlight opposing perspectives, raging arguments for and against parental palliative care patient hydration have had varying summaries (Cabañero-Martínez et al., 2015). Reports asserting the avoidance of parenteral hydration include arguments that dehydration is one of the natural processes of death and is not associated with distress symptoms. Positively, it may contribute to the release of endogenous anesthetics that cause euphoria. Dehydration also decreases patient urine output, eliminating the need for additional bladder catheters, decreases nausea, decreases gastrointestinal fluid thus lessening vomiting. Additionally, dehydration alleviates respiratory problems such as pulmonary edema and coughing and attenuates ascites and peripheral edema. According to Schols et al., (2009), parenteral administration of fluids, as one of the efforts of alleviating dehydration may prolong the dying process and contribute to patient’s discomforts associated with decreased mobility due to alimentary and intravenous catheters.

On the other hand, assertions favoring the use of parenteral hydration in terminally ill patients include arguments that hydration a dehydrated patient makes them more comfortable (Hugel, 2010). Ho and Krishna, (2015) posit that proponents of parenteral hydration contend that there exists no proven evidence to suggest that the administration of fluids to a dying patient prolongs the dying process, and additionally it represents a minimum standard of patient care. The purported benefits of such proposition include diminished restlessness and confusion and decreased complaints of thirst and a dry mouth. Some of their concerns voiced include the fact that withholding parenteral hydration to a dying patient may detract efforts of improving patient comfort and general quality of life and may be a dangerous precedent, to the withholding of therapies to other compromised groups of patients (Schols et al., 2009).

Caccialanza et al. (2016) posit that most of the terminally ill patients dying in worldwide hospitals have an intravenous or a subcutaneous line at the time of their death unless they unexpectedly demised or had had a rapid deterioration of health. Such lines when in place present a risk access point for excessive infusion of fluids by unthinking policies of intravenous hydration for cathartic palliative care patients (such as terminally ill and advanced stage cancer patients) (Dalal & Bruera, 2004). Associated complications for such would include gastrointestinal and respiratory distress, whose incidences, and thereof prevalence enters the arguments and assertions against parenteral hydration. Healthcare professionals in the care of terminally ill patients have voiced concerns over the generalized use of intravenous fluids and the perceived adverse effects of such a management strategy by reporting their observations that the avoidance of parental palliative patient hydration has not been noted to bring about distress symptoms in such patients (Schols et al., 2009; Barua & Bhowmick, 2005).

However, as health care professionals, we need to recognize that dehydration causes restlessness and confusion in non-terminally ill patients and that associated problems of agitation and delirium are often reported in patients in their last stages of life (Fritzon, 2012). Moreover, the reduction in the total intravascular volume and the thereof associated decrease in the glomerular filtration rate have a tendency to precipitate pre-renal azotemia. The accumulation of opioid metabolites in the setting reduced renal excretion lead to patient confusion, seizures, and myoclonus. Such observations have supported the proposition that dehydration is a reversible component of these symptoms. According to Scales, (2011), failure to institute rehydration in palliative care patients may lead to a misguided use of drugs to manage thereof symptoms associated with dehydration. It could be considered illogical for a patient to receive medications for agitated delirium, seizures, and myoclonus when the problem could be potentially solved by the institution of parenteral hydration (Hugel, et al., 2010).

4.3 Existing standards and guidelines

Within the British setting, the existing standards and guidelines on patient hydration state that the provision of oral fluid forms parts of the basic patient care procedures and should not be withheld or withdrawn (Hugel et al., 2010). Artificial hydration either subcutaneously or intravenously has been classed as a medical treatment by common law, although such definition has not gained universal acceptance (Lopez & Reyes-Ortiz, 2010). Some of the blanket policies on the use of artificial hydration in the setting of palliative care and dying patients are unhelpful as they do not cite clear basis for their formulation. Decisions regarding the institution of hydration to patients should be individualized to the needs of a patient (Hugel et al., 2010, page 5-10).

Importantly, there is a dire lack of good evidence supporting the benefits and outlining the risks and burdens of artificial hydration in the last times of life (Fritzon, 2012; Ho, & Krishna, 2015). It is unclear whether dying patients develop dehydration symptoms or whether the institution of hydration alleviates these symptoms. According to Hugel et al., (2010) in the UK, the Mental Capacity Act outlines some important factors thereof discussed below that ought to be considered when making decisions on hydration at the terminal stages of life (page 7-11).

Multi-professional teams, patients, and their relatives should discuss decisions that surround the use of parenteral hydration in line with the provisions of the Mental Capacity Act (Hugel et al., 2010). Decisions to hydrate a patient should factor in the potential gains and side effects to the patients. In some patients, conduction of a time-limited trial to evaluate whether it improves symptoms may be appropriate. The institution of hypodermoclysis and thereof artificial hydration in palliative care patients should be reviewed on a daily basis. If artificial hydration is to be continued in the terminal phase, a rate of 1liter for over 24 hours either subcutaneously or intravenously, or via the PEG/PEJ is recommended (Schols et al., 2009).

4.4 Ethical aspects and their clinical relevance

In most local British settings, hydrating and feeding the dying and vulnerable is highly regarded as a sign of concern and love, and as a probable means of alleviating symptoms and prolonging life (Hugel et al., 2010). Thus to many, it is instinctive that hydration, be it natural or artificial, be continued, but yet, such practice may not take into consideration the realities surrounding palliative care at the end of life.

According to Ho and Krishna, (2015), proponents of hypodermoclysis, and thereof artificial patient hydration have based their arguments on it providing comfort through relieving the symptoms of thirst such as neuromuscular irritability and confusion. Additionally, they suggest that one of its main benefits is maintaining health, and if withheld or withdrawn, it may lead to premature demise. Based on this, it is an irrefutable human right and forms part of the core care requirements. It is a measure of hope, and one of the means of maintaining familial bonds and ties with primary health care providers (Lopez & Reyes-Ortiz, 2010; Hugel et al., 2010). From these perspectives, denial of such intervention is tantamount abandonment.

Lopez and Reyes-Ortiz, (2010) posits that opponents to hypodermoclysis and thereof artificial rehydration deniably argue that the failure to hydrate a patient at the end of their lives would result in their untimely death. Arguably, overhydrating rather than dehydration is ultimately bad for the patient. They suggest that fluids play a minimal role in maximizing patient comfort as long as the provision of meticulous mouth care is continued.  Based on findings of Fine in Patricia (2008) for example– who had a 20 years’ experience working with terminally ill patients – he suggested that the provision of oral hydration in addition to “comfort foods” had a therapeutic effect on the patients. The deprivation of water increases the body’s production of endogenous opiates that create a state of euphoria thereof associated with the reduction of pain (Gabriel, 2014). The provision of intravenous fluids of dying patients has potential adverse effects, including increasing urinary output, pulmonary excretions, nausea, generalized body edema and vomiting (Dalal & Bruera, 2004).

At the terminal stages of life, dehydration is one of the natural processes of a dying patient as oral intake of fluids decreases. Ketones in addition to other metabolic byproducts of dehydration may act as natural anesthetics within the central nervous system, thereof resulting in reduced levels of consciousness that alleviate suffering (Thomas et al., 2008). If patients who are conscious experience thirst, the institution of artificial hydration does not relieve thirst any more than natural oral measures. Provision of artificial hydration is also perceived as the perpetuation of unrealistic expectations of a cure that runs counter to goals of end live, which ought to have their focus on completing important life tasks such as nurturing relationships rather than a hydrating regimen (Ho & Krishna, 2015).

Additional perspectives from some of the older literature existent posit artificial hydration does not serve to prolong the lives of palliative care patients (such as advanced cancer patients and more elderly patients), who have a prognosis of days to few weeks (Scales, 2011; Hugel et al., 2010). Opponent literature notes that hydration has no correlation with thirst and neither does it relieve symptoms of dehydration such as myoclonus, hallucinations, fatigue and sedation. On the other hand, proponents argue that concerns about symptoms of fluid overload with hydration are unwarranted as hydration of patients with less than one liter is well tolerated. “Yet, before we are tempted to be led solely by this data, sociocultural factors that play just as significant a part in the provision of holistic care, cannot be ignored” (Cabañero-Martínez et al., 2015, pg. 560).

5.0 Conclusion

The use of hypodermoclysis has been under intense debate, often plagued by controversies and limited research into the area. The previous descriptions of adverse events formed the foundation of the negative publicity attached to hypodermoclysis within the review literature and in today’s’ standards cannot seem more than ridiculous.  These are ostensibly linked to improper use of hypodermoclysis rather than an inherently flawed technique – including the copious infusion of hypertonic fluids. In following pieces of literature where a better understanding of the physiology was garnered, experimentally have illustrated that the rapid infusion of electrolyte-free fluids has dire outcomes. Inappropriate clinical settings, quantity, nature and administration rate all are areas in need of proper illumination before we can get the best out of a technique with bountiful vantages to render. When correctly used, as demonstrated by various adroit persons in the review of literature and in experiments comparing it to intravenous fluid administration, hypodermoclysis has more often proved to be a useful, safe and effective method compared to the even the intravenous route.

Hypodermoclysis is an optional means of administering non-emergency fluids for both patients and their families who wish to continue their treatments at nursing homes or their homes – where there are no stresses, the environment is familiar, and without the additional inconveniences and expenses of hospitalization. At present times, there exist plenty of fog on whether the institution of fluids by hypodermoclysis serves to alleviate the symptomatology associated with death. The lack of globally approved nursing roadmaps on the subcutaneous institution of fluids worsens this situation. The majority of available studies evaluating hypodermoclysis are of poor quality. Citing the tremendous potential of benefits that stand to be accrued from the administration of fluids subcutaneously, there exists an imperative need to conduct further quality research on the efficacy of hypodermoclysis.

References

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