Flüssigkeitsgabe am Lebensende

Zusammenfassung

Die Flüssigkeitsgabe am Lebensende ist ein sehr kontrovers diskutiertes Thema. Da keine international gültigen Leitlinien bestehen und die Evidenz nicht eindeutig ist, wird die Entscheidung häufig nicht nur aufgrund medizinischer, sondern auch aufgrund ethischer und emotionaler Gesichtspunkte getroffen.

Anhand eines Fallbeispiels werden das Vorgehen und die Bedeutung einer Flüssigkeitssubstitution diskutiert. Bei einer Patientin mit einer zerebralen Blutung und infauster Prognose wird aufgrund einer vorliegenden Patientenverfügung und des mutmaßlichen Willens jegliche Flüssigkeitsgabe sistiert. Trotzdem verstirbt die Patientin erst nach 21 Tagen. In dieser Zeit kommt es beim Ehemann zu schwierigen und wechselnden Verarbeitungsmechanismen, in welchen die Bedeutung der Flüssigkeitsgabe deutlich wird. Es zeigt sich, dass in der Palliativmedizin das Vorgehen und die Behandlung aufgrund von biologischen, psychologischen, sozialen und spirituellen Gesichtspunkten getroffen werden muss.

Abstract

Hydration at the end of life is a very controversially discussed subject. Due to the fact that no internationally valid recommendations and guidelines exist and the evidence is uncertain, the decision is made not only on the basis of medical but also on ethical and emotional points of view.

With the help of a case report the approach and the meaning of hydration at the end of life are discussed.

Complete hydration was stopped in a patient with a cerebral bleeding and poor prognosis. This approach was decided because of the advanced directives and the presumed will of the patient. Nevertheless she died only 21 days after stopping hydration. This time was a difficult process of accepting for her husband. In this context it becomes clear that in Palliative Care the approach and the treatment must be met on the basis of biological, psychological, social and spiritual aspects.

Schlüsselwörter

Flüssigkeitssubstitution - Lebensende

Keywords

hydration - end of life

• Literatur

• 1 Teasdale G, Jennett B. Assessment of Coma and impaired consciousness: A practical scale. Lancet 1974; 304: 81-84
• 2 Eychmüller S, Nauck F. Flüssigkeitssubstitution am Lebensende. In: Aulbert E, Nauck F, Radbruch L, Hrsg. Lehrbuch der Palliativmedizin. 3.. Aufl. Stuttgart: Schattauer; 2011: 357-365
• 3 Raijmakers N, Fradsham S, van Zuylen L et al. Variation in attitudes towards artificial hydration at the end of life: a systematic literature review. Curr Opin Support Care 2011; 5: 265-272
• 4 Dalal S, Bruera E. Dehydration in Cancer Patients: To Treat or Not To Treat. J Support Oncol 2004; 2: 467-487
• 5 Sarhill N, Walsh D, Nelson K et al. Evaluation and treatment of cancer-related fluid deficits: volume depletion and dehydration. Support Care Cancer 2001; 9: 408-419
• 6 Neuenschwander H, Chappuis Ch. Flüssigkeitszufuhr am Lebensende. Newsletter Palliativmedizin SGIM (Schweizerische Gesellschaft für Innere Medizin); 2008
• 7 Dicks B. Rehydration or dehydration?. Support Care Cancer 1994; 2: 88-90
• 8 Rayment C, Ward J. Care of the dying patient in hospital. Br J Hosp Med (Lond) 2011; 8: 451-455
• 9 Del Río MI, Bonati P, Palma A et al. Hydration and nutrition at the end of life: a systematic review of emotional impact, perceptions, and decision-making among patients, family, and health care staff. Psycho-Oncology 2012; 21: 913-921
• 10 Morita T et al. Attitudes of Japanese Physicians Toward Terminal Dehydration: A Nationwide Survey. J Clinical Oncol 2002; 20: 4699-4704
• 11 Huffman JL, Dunn GP. The Paradox of Hydration in Advanced Terminal Illness. J Am Coll Surg 2002; 194: 835-839
• 12 Burge FI, King DB, Willison D. Intravenous Fluids and the Hospitalized Dying: A Medical Last Rite?. Can Fam Physician 1990; 36: 883-886
• 13 Raijmakers NJ, Clark JB, van Zuylen L et al. Bereaved relatives' perspectives of the patient's oral intake towards the end of life: A qualitative study. Palliat Med 2013; 27: 665-672
• 14 Wilson D. Supporting life through tube feeding: factors influencing surrogate decision-making. Can J Aging 1993; 12: 298-309
• 15 Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th. Edition. New York: Oxford University Press; 2001: 57-282
• 16 Maio G. Mittelpunkt Mensch: Ethik in der Medizin. 1.. Aufl. Stuttgart: Schattauer; 2012: 119-123
• 17 Drane JF. Stopping Nutrition and Hydration Technologies: A Conflict Between Traditional Catholic Ethics and Church Authority. Christian Bioethics: Non-Ecumenical Studies in Medical Morality 2006; 12: 11-28
• 18 Burge FI. Dehydration and provision of fluids in palliative care. Can Fam Physician 1996; 42: 2383-2388
• 19 Mercadante S, Ferrera P, Girelli D et al. Patients’ and Relatives’ Perceptions About Intravenous and Subcutaneous Hydration. J Pain Symptom Manage 2005; 30: 354-358
• 20 Bruce A, Schreiber R, Petrovskaya O et al. Longing for ground in a ground(less) world: a qualitative inquiry of existential suffering. BMC Nursing 2011; 10: 2-9
• 21 van der Riet P, Higgins I, Good P et al. A discourse analysis of difficult clinical situations in relation to nutrition and hydration during end of life care. J Clin Nurs 2009; 18: 2104-2111
• 22 Fainsinger RL, Bruera E. When to treat dehydration in a terminally ill patient?. Support Care Cancer 1997; 5: 205-211
• 23 Ellershaw J, Sutcliffe JM, Saunders C. Dehydration in the Dying Patient. J Pain Symptom Manage 1995; 10: 192-197
• 24 Eychmüller S. Flüssigkeitssubstitution in der Terminalphase – eine kontroverse Diskussion. Schmerz 2001; 15: 357-361
• 25 Breitbart W, Strout D. Delirium in terminally ill. Clinic in Geriatric Medicine 2000; 16: 357-372
• 26 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: 111-118
• 27 Collaud T, Rapin Ch. Dehydration in Dying Patients: Study with Physicians in French-Speaking Switzerland. J Pain Symptom Manage 1991; 6: 230-240