For a terminal metastatic cancer patient in hospice who is unable to eat or drink, has hypotension, and declines hospital admission, are IV crystalloid fluids and vasopressor agents appropriate to improve comfort?

IV Fluids and Vasopressors Are Not Appropriate in This Dying Patient

In dying patients with metastatic cancer who are no longer eating or drinking, IV fluids and medications to raise blood pressure should not be used, as they provide no benefit and may prolong the dying process. 1

Why These Interventions Are Not Indicated

Parenteral Hydration Provides No Benefit

• Artificial hydration and nutrition are unlikely to provide any benefit for most dying patients and treatment should be based solely on comfort. 1
• The normal hypotension, hypoxia, and hypercapnia that underlie the natural course of dying may actually be prolonged when patients receive rehydration fluids. 1
• During terminal hypometabolism, normal amounts of energy and substrates may be excessive and induce metabolic distress rather than providing comfort. 1

Evidence Shows No Improvement in Outcomes

• Routine hydration showed no improvement or only limited effects on symptoms and quality of life in imminently dying cancer patients. 1
• Multiple studies demonstrate that artificial nutrition and hydration did not influence survival in terminal cancer patients. 2
• Hunger is rare in imminently dying patients, and minimal amounts of desired food may provide appropriate comfort without medical intervention. 1

Vasopressors Have No Role in Comfort Care

• The goal of care in dying patients is comfort, not physiologic stabilization. 1
• Low blood pressure in the dying phase is part of the natural process and does not require correction unless it is causing distressing symptoms (which it typically does not). 1

The One Exception: Acute Confusional State

Consider a short and limited trial of hydration (approximately 1000 ml subcutaneously) only if the patient develops acute confusion, to rule out dehydration as a reversible precipitating cause. 1, 3, 4

This exception applies when:

• The patient suddenly becomes confused or agitated 3
• You need to determine if dehydration is contributing to the confusion 1
• The trial should be brief and discontinued if no improvement occurs 1, 4

What You Should Do Instead

Focus on Symptom Management

• Provide oral care measures (ice chips, lip lubrication) for dry mouth and thirst, which are more effective than increased fluid volume. 4
• Thirst and dry mouth do not correlate with hydration status or fluid volume given. 4
• Use low-dose opioids for dyspnea and pain as needed. 1
• Consider palliative sedation with low-dose sedatives if the patient is experiencing severe distress. 1

Address Family Concerns Through Communication

• Relatives and caregivers frequently demand artificial nutrition or hydration for terminally ill patients. 1
• It is mandatory to explain that the goal is comfort and to communicate the pros and cons of continued nutritional treatment with patients, family members, and the care team. 1
• Explain that not eating or drinking is part of the natural dying process and does not cause suffering. 1

Common Pitfalls to Avoid

• Do not confuse the family's distress with the patient's needs. The desire to "do something" often drives requests for IV fluids, but these interventions do not improve comfort. 1
• Do not mistake the dying phase for a reversible acute illness. This patient has metastatic cancer with no further treatment options and is clearly in the terminal phase. 1
• Avoid the misconception that hydration prevents suffering. Dehydration in the terminal phase is often neither painful nor uncomfortable. 4