End of life care

What are your views on end of life care? Especially in terms of how much intervention should be offered, and at what point should people be left alone?

A generic hypothetical case, mrs S who has inoperable breast cancer with liver and bone metastases. No curative prospects, and care has been guided mainly by symptom management, eg pain control.
Towards the end, she is getting increasingly weak and ill, as is expected. The point arrives where she no longer eats or drinks for herself.

Do you give her IV fluids or any nutritional support at this point? What are your reasons either way?

Alex_G said:

Do you give her IV fluids or any nutritional support at this point? What are your reasons either way?

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Do we know what Mrs. S would have wanted ?... to me, that's the most important factor.

Scott1 said:

Do we know what Mrs. S would have wanted ?... to me, that's the most important factor.

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I agree.

A second consideration is whether she is conscious or not. Dying of thirst, so I hear, is rather horrible and painful. (And even if she is unconscious, it is questionable as to whether she can feel or not.)

Depending on Mrs. S's preferences, I'd much more be in favor of mercifully killing her with an overdose of morphine in that IV than by slowly and sadistically killing her by making her die of malnutrition and thirst.

Voted yes due to being in the situation with my grandfather who was responsive to IV fluids even though he could no longer drink himself so therefore as Falvun stated if we didn't then we would have been killing him of hunger and thirst otherwise.

I voted no - but it would be with the provision that the decision had been made via a living will already.

My grandmother had terminal cancer. When she reached the last week or so of her life, her stipulation was that she be kept comfortable, and her mouth be kept moist, but that no IVs be given to her.

She had a very peaceful and apparently painless ending to her life, and it was not prolonged unnecessarily by giving her fluids.

Falvlun said:

I agree.

A second consideration is whether she is conscious or not. Dying of thirst, so I hear, is rather horrible and painful. (And even if she is unconscious, it is questionable as to whether she can feel or not.)

Depending on Mrs. S's preferences, I'd much more be in favor of mercifully killing her with an overdose of morphine in that IV than by slowly and sadistically killing her by making her die of malnutrition and thirst.

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It is very possible to keep a patient comfortable though fluids are withheld, via morphine and substances which keep their mouth and throat hydrated.

It would also depend on the state of the patient - the timeline in other words. Withholding fluids several weeks or months before death is imminent is different from withholding fluids within the last few days of life.

I voted yes....with drugs to do whatever the patient wants, eg pain relief, pleasure, death.
When the time comes, make mine bacon falvored....then bring on the shovel!

Scott1 said:

Do we know what Mrs. S would have wanted ?... to me, that's the most important factor.

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Let's assume she didn't express any specific desire one way or another re: fluids, but wanted to die with dignity, and trusted the doctors to do what was best for her.

What about the family's concerns, how might they factor in too?

If I were Mrs S I would want the IV fluids.

Falvlun said:

I agree.

A second consideration is whether she is conscious or not. Dying of thirst, so I hear, is rather horrible and painful. (And even if she is unconscious, it is questionable as to whether she can feel or not.)

Depending on Mrs. S's preferences, I'd much more be in favor of mercifully killing her with an overdose of morphine in that IV than by slowly and sadistically killing her by making her die of malnutrition and thirst.

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Assume she is unconscious possibly a faint amount of consciousness. Remember that her inability to eat or drink is likely both a physical inability along with a mental inability, with no drive to self preserve. The state of terminal illness she is in has no prospect of getting better. Would fluid support just extend the suffering prior to death? Are there also any practical difficulties that might hinder one to give fluids? Or even a downside, like overload?

Scott1 said:

Do we know what Mrs. S would have wanted ?... to me, that's the most important factor.

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Exactly why most people write it down ... called a living will in some places, other names in others, but as far as I know, most countries have a legal provision for it .. it shouldn't be a hypothetical at all ... I've got mine down, that's for sure. The will executor has a copy. For this reason I abstained from voting. Mine states, 'no food or intravenous, unless I am able to communicate otherwise' ... something like that anyway. There are enough vegetables in my garden already.

It is absolutely possible, without much difficulty, to allow someone to die with dignity and pain free, without prolonging their suffering and death by giving them IV fluids. A good medical team can tell the family (and the patient when they are conscious) whether or not the patient will experience any discomfort associated with not providing an IV.

The logical answer seems to me to be to defer to the wishes of the patient, and if those wishes haven't been clarified beforehand, do whatever it is that will minimize suffering.

The hospice told us that when a person's death is imminent, their appetite and thirst level decreases to little or nothing. This was definitely true with my grandmother. She had no fluids for about four or five days, but we kept her mouth and throat hydrated. She was fully conscious till the last day or so, and was semi conscious till the very end, and not one time did she want us to give her any water or fluids (or food), though we asked her often.

She did appreciate her swabbing her lips and tongue with some substance that they provided that kept her mouth from drying out.

Enlighten said:

Voted yes due to being in the situation with my grandfather who was responsive to IV fluids even though he could no longer drink himself so therefore as Falvun stated if we didn't then we would have been killing him of hunger and thirst otherwise.

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I see, could you clarify what response to Iv fluid you witnessed? Of course it's important to remember the striking difference between denying fluid and nutrition to a patient who is incapacitated by a curable disease, such as pneumonia, and that of withholding it from those whose terminal illness is the very reason they have no drive or ability to drink and eat themselves. The first seems much more like 'killing' than the latter. what do you think?

Kathryn said:

It is absolutely possible, without much difficulty, to allow someone to die with dignity and pain free, without prolonging their suffering and death by giving them IV fluids. A good medical team can tell the family (and the patient when they are conscious) whether or not the patient will experience any discomfort associated with not providing an IV.

The logical answer seems to me to be to defer to the wishes of the patient, and if those wishes haven't been clarified beforehand, do whatever it is that will minimize suffering.

The hospice told us that when a person's death is imminent, their appetite and thirst level decreases to little or nothing. This was definitely true with my grandmother. She had no fluids for about four or five days, but we kept her mouth and throat hydrated. She was fully conscious till the last day or so, and was semi conscious till the very end, and not one time did she want us to give her any water or fluids (or food), though we asked her often.

She did appreciate her swabbing her lips and tongue with some substance that they provided that kept her mouth from drying out.

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From all your posts I can tell you've obviously had real first hand experience in this sort of situation. All of what you say has very much in common with current medical practice in general. Thats of course not to belittle other peoples perspectives, as outside philosophical consideration can and is very important.

It's true that such things as dry cracked mouth from dehydration can be effectively managed by good mouth care, and with appropriate analgesia, namely the strong opiods like morphine, one can keep a patient cared for without the need to provide Iv fluids or nutrients. Your distinction between end of life, and pre end of life (months) is important in how one should rationalise the decisions made regarding care.

An important question to ask oneself is, why am I giving the Iv fluids? For what purpose or what end is it for?

It's a subtle state of affairs, and good care, attention and appreciation for many factors is important in managing it effectively and successfully.

Vinayaka said:

Exactly why most people write it down ... called a living will in some places, other names in others, but as far as I know, most countries have a legal provision for it .. it shouldn't be a hypothetical at all ... I've got mine down, that's for sure. The will executor has a copy. For this reason I abstained from voting. Mine states, 'no food or intravenous, unless I am able to communicate otherwise' ... something like that anyway. There are enough vegetables in my garden already.

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In producing writing one needs it to be absolutely clear beyond doubt. So for example, someone with terminal cancer might sign something that says they don't want to be resuscitated if they go into cardiac arrest, but what if on their way to the outpatients clinic they get run over by a bus? This is months maybe years before they might expect to die from the cancer. Should the doctors honour the 'do not resuscitate'? No of course not, the document is rendered invalid due to not being specific enough.

Situation do arise that can't simply be solved by reference to a document made by the patient.

Alex_G said:

I see, could you clarify what response to Iv fluid you witnessed? Of course it's important to remember the striking difference between denying fluid and nutrition to a patient who is incapacitated by a curable disease, such as pneumonia, and that of withholding it from those whose terminal illness is the very reason they have no drive or ability to drink and eat themselves. The first seems much more like 'killing' than the latter. what do you think?

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Sure, he was terminally ill so I just wanted to make that clear, however when he could not longer drink/eat we had him on an IV drip to give him fluids. His body may have given up at that time however his mind certainly hadn't. After receiving the IV you could see his eyes brighten and he was more responsive to what we were saying, even had the odd day where his speech would return or he'd have a giggle.

When we saw that the IV was no longer providing what he needed, admittedly not very long after the IV process began, the IV fluids were changed to IV morphine which I don't need to fill in the blanks here.

You are right though the first you mention above is much more like killing compared to someone who is terminally ill, however I feel (infact I know) that if he didn't have these fluids then we would have in effect killed him before his time by with-holding them. I think each person has to be assessed on an individual basis before deciding on whether it is genuinely helping or whether moving directly to an alternative such as morphine is the best solution. In our case it was best to start with fluids then move to morphine.

So to stop me rabbiting on I suppose what I am getting at is that I think it should always be a first option to see if there are positive results.

These options are too black and white for me,, to many mitigating circimstances and such

Iti oj said:

These options are too black and white for me,, to many mitigating circimstances and such

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I think that is why I started to drivvel on so much so stopped myself writing more as kept thinking of more scenarios.

Enlighten said:

I think that is why I started to drivvel on so much so stopped myself writing more as kept thinking of more scenarios.

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Seems were comming from the same place. Id look at it in a case by case manor

Iti oj said:

These options are too black and white for me,, to many mitigating circimstances and such

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That's not a good enough answer. We can all back out of the difficult questions in life by similar reasons, but the reality is such decisions area made every day. Whether you agree either way on my binary proposition is to miss the point, the question under the question is what makes this important to you? What drives you to answer 'this is too black and white'?