Aim To identify patients suitable for subcutaneous fluid administration (SCF) in the home/care home setting and standardise clinical approach to assessment, decision making and evaluation of response.
Methods A standardised decision support tool was developed which supported bedside assessments. Patient/carer information leaflets were given and documentation of discussions/outcomes recorded in relevant clinical records (EMIS or SystmOne). We evaluated clinical response over three days: symptoms, side-effects/complications, observations or bloods and collated case vignettes.
Results Between April 2020-Feb 2021, 28 patients were assessed, median age 87.5(43-97) years, 20(71%) female. Place of care: 13(46%) own home, the remaining 15 (54%) resided in care homes/extra care housing. Diagnoses: 19 dementia; 6 cancer, 2 heart failure, 1 Motor Neurone Disease. Frailty scores (Rockwood): median 7(6-9).
17(61%) received SCF. Equipment was sourced equally from hospice and local pharmacy. Four had clear benefit, symptom relief, admission avoidance, alive >1mth post-intervention. Six cases demonstrated psychological benefit for patient/family with no harm/side-effects (all died 4-17 days post-intervention). Two had possible benefit but diuretics were withheld/reduced concurrently (1 alive >1mth post intervention, 1 died 3wks).
Five had no clear benefit, but no harm. 6/11 cases where SCF were not given, died within a week (2-8 days). Five with dementia in care home/extra-care housing were managed with mouthcare/encouraging oral fluids (3 alive >1month post-assessment).
Fluids were stopped due to side effects in three patients: none experienced ongoing harm. Volumes of fluid given varied. Feedback from clinicians and families suggested the tool facilitated discussion/understanding of rationale for giving/withholding.
Conclusion SCF was of clinical benefit for some patients, with minimal harm. The tool increased clinicians’ confidence to assess benefits/harms of SCF and address family concerns in a structured way. Further robust data collection is needed to monitor use/outcomes of SCF in a community setting and to better identify patients who may benefit.
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