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• Letter to the Editor in response to "What is the impact of clinically assisted hydration in the last days of life?A systematic literature review and narrative synthesis"
  Andrew Davies, Niamh Mairead Cleary
  Published on: 3 April 2021

• Published on: 3 April 2021

  Letter to the Editor in response to "What is the impact of clinically assisted hydration in the last days of life?A systematic literature review and narrative synthesis"

  • Andrew Davies, Professor of Palliative Medicine Academic Department of Palliative Medicine, Our Lady's Hospice, Harold's Cross, Dublin D6W RY72
  • Other Contributors:
    • Niamh Mairead Cleary, Clinical lecturer

  Dear Editor

  We read with particular interest the recent systematic review and narrative synthesis of clinically assisted hydration in the last days of life [1]. Unsurprisingly, the authors concluded that “there is currently insufficient evidence to draw firm conclusions on the impact of CAH in the last days of life”, which supports the findings of previous reviews [2,3]. We agree with their conclusion, but would like to make some comments on the “quality” / applicability of some of the included (and excluded) studies.

  Our concerns relate to:

  1. Study type – end-of-life care should be evidence based, and the “gold standard” remains the randomised controlled trial (RCT).

  2. Study population – our study [4] excluded patients with dehydration (and with contraindications to CAH), but the Cerchetti et al RCT [5] involved patients with dehydration and renal failure, and the “excluded” Bruera et al RCT [6] specifically involved patients with dehydration. Hence, there is an issue about collating these data, and, importantly, extrapolating these data to the wider population.

  3. Study intervention – our study [4] used a variable volume of fluid, based on the patient’s weight (and in accordance with NICE guidance) [7], but the Cerchetti et al RCT [5], and the Bruera et al RCT [6], both used a fixed volume of fluid (e.g. 1 L / day). The rationale for this volume of fluid is unexplained, but it is much less than recommended for maintenance of hydration...

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  Dear Editor

  We read with particular interest the recent systematic review and narrative synthesis of clinically assisted hydration in the last days of life [1]. Unsurprisingly, the authors concluded that “there is currently insufficient evidence to draw firm conclusions on the impact of CAH in the last days of life”, which supports the findings of previous reviews [2,3]. We agree with their conclusion, but would like to make some comments on the “quality” / applicability of some of the included (and excluded) studies.

  Our concerns relate to:

  1. Study type – end-of-life care should be evidence based, and the “gold standard” remains the randomised controlled trial (RCT).

  2. Study population – our study [4] excluded patients with dehydration (and with contraindications to CAH), but the Cerchetti et al RCT [5] involved patients with dehydration and renal failure, and the “excluded” Bruera et al RCT [6] specifically involved patients with dehydration. Hence, there is an issue about collating these data, and, importantly, extrapolating these data to the wider population.

  3. Study intervention – our study [4] used a variable volume of fluid, based on the patient’s weight (and in accordance with NICE guidance) [7], but the Cerchetti et al RCT [5], and the Bruera et al RCT [6], both used a fixed volume of fluid (e.g. 1 L / day). The rationale for this volume of fluid is unexplained, but it is much less than recommended for maintenance of hydration (let alone treatment of dehydration) by NICE. So, again there is an issue about collating these data.

  4. Study duration – end-of-life studies should follow up the patient until death, since related problems are often more prevalent closer to death (e.g. “terminal agitation”, audible upper airway secretions), and survival has to be a major outcome.

  Finally, we agree with the authors’ assertion that “definitive studies are urgently needed to determine whether CAH has any impact on patients’ survival or symptoms”. However, such studies are expensive, and our failure to undertake a definitive study relates to a lack of funding (and not a lack of willing)!

  [1]. Kingdon A, Spathis A, Brodrick R et al. What is the impact of clinically assisted hydration in the last days of life? A systematic literature review and narrative synthesis. BMJ Support Palliat Care 2021; 11: 68-74.

  [2]. Good P, Richard R, Syrmis W et al. Medically assisted hydration for adult palliative care patients. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD006273.

  [3]. Parry R, Seymour J, Whittaker B, Bird L, Cox K. Rapid evidence review: pathways focused on the dying phase in end-of-life care and their key components; 2013. Available at: https://www.gov.uk/government/publications/review-of-liverpool-care-path.... [Accessed 31 March 2021]

  [4]. Davies AN, Waghorn M, Webber K et al. A cluster randomised feasibility trial of clinically assisted hydration in cancer patients in the last days of life. Palliat Med 2018; 32: 733-43.

  [5]. Cerchietti L, Navigante A, Sauri A et al. Hypodermoclysis for control of dehydration in terminal-stage cancer. International Journal of Palliative Nursing 2000; 6: 370-4.

  [6]. Bruera E, Hui D, Dalal S et al. Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial. J Clin Oncol 2013; 31: 111-8.

  [7]. National Institute for Health and Care Excellence. Intravenous fluid therapy in adults in hospital; 2013 (updated 2017). Available at: http://guidance.nice.org.uk/CG174 [Accessed 31 March 2021]

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  Conflict of Interest:
  None declared.

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