From the Guidelines
Yes, you can still perform clysis even if a patient's MOLST form indicates "no IVF". This is because clysis, also known as hypodermoclysis, is technically different from intravenous fluid administration, as it involves delivering fluids into the subcutaneous tissue rather than directly into the bloodstream 1. The distinction is important because the MOLST form specifically addresses intravenous interventions, not subcutaneous ones.
Key Considerations
- Clysis can be performed using normal saline or half-normal saline, usually at rates of 20-80 ml/hour, with common sites being the abdomen, thighs, or upper arms.
- It's essential to consider the overall goals of care and the intent behind the MOLST directive.
- If the spirit of the directive was to avoid artificial hydration altogether, then a discussion with the healthcare proxy or surrogate decision-maker would be appropriate before proceeding with clysis.
Clinical Context
The clinical context and the patient's overall care goals should guide this decision, balancing respect for the documented wishes with appropriate symptom management. According to the ESPEN guideline on ethical aspects of artificial nutrition and hydration, artificial hydration can be achieved by tubes, intravenous, and subcutaneous administration 1.
Decision Making
In making this decision, it's crucial to prioritize the patient's quality of life, morbidity, and mortality, ensuring that the chosen course of action aligns with their best interests and respects their autonomy as expressed through the MOLST form.
From the Research
MOLST Form and Medical Treatment
- A MOLST (Medical Orders for Life-Sustaining Treatment) form is a document that outlines a patient's wishes for end-of-life medical treatment.
- The form typically includes instructions for procedures such as cardiopulmonary resuscitation (CPR), intubation, and intravenous fluids (IVF).
- If a patient's MOLST form indicates "no IVF," it means that the patient does not want to receive intravenous fluids.
Clysis and IVF
- Clysis refers to the administration of fluids subcutaneously, typically for hydration or medication.
- While IVF and clysis are both methods of fluid administration, they are distinct procedures with different indications and contraindications.
- There is no direct evidence in the provided studies to suggest that a MOLST form indicating "no IVF" would necessarily preclude the use of clysis 2, 3, 4, 5, 6.
Medical Decision-Making
- Medical decisions should be made on a case-by-case basis, taking into account the patient's individual needs, wishes, and medical history.
- The Precautionary Principle, as discussed in 2, suggests that in the absence of certainty, the appropriate course of action is to err on the side of caution.
- However, this principle does not provide clear guidance on the specific question of whether clysis can be administered to a patient with a MOLST form indicating "no IVF."
Conclusion Not Provided as per Request
- As per the request, no conclusion will be provided. The information provided is based on the available studies and should not be considered as a substitute for medical advice or guidance.