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To characterize the practice of subcutaneous hydration provision in the Beer-Sheva home care hospice unit. We also explore the potential connection between the provision of subcutaneous hydration and the incidence of death rattle. This was a prospective observational study involving 120 hospice patients. During the 6 days before death, hospice staff recorded whether or not fluids were administered orally and/or subcutaneously; the duration, timing, and quantity of fluid administration; the incidence, timing, and duration of death rattle; and whether medications that can affect death rattle were given. Fifty-three percent of the patients received subcutaneous hydration. The mean daily volume administered in the hydration group was 434 ml. There was a significant association between the duration of treatment in the hospice unit and provision of subcutaneous hydration (mean of 51 days in hydration group vs. 31 days in non-hydration group, p = 0.03). Although not statistically significant, males were more likely to receive subcutaneous hydration than females (62% of males vs. 46% of females, p = 0.09). There was a higher incidence of death rattle in men compared to women (54.7% in men vs. 32.8% in women, p = 0.025). A statistically significant association between death rattle and the provision of subcutaneous hydration wasn’t demonstrated. The decision of whether to provide subcutaneous hydration is individualized taking into consideration the values of the patients and their families. The provision of 500 ml per day of subcutaneous saline during the last 6 days of life does not significantly increase the incidence of death rattle.

Much is unknown about assisted hydration at the end of life: why rates of usage vary so highly between institutions, cultures and countries, what beneficial or burdensome effects this treatment has, whether there is a place for subcutaneous hydration in the home setting, and how best to communicate about this difficult topic with dying people and their families. In light of a recently published systematic review concerning the impact of assisted hydration at the end of life, this article explores these questions and related issues, concluding that individualisation and shared decision-making are essential aspects of high-quality end-of-life care.

Long-term subcutaneous hydration has not been described in pediatrics. A case of a 4-year-old born prematurely with subsequent intestinal failure, large vessel thrombi, and repeated central line-associated bloodstream infections prompting catheter removal is discussed. Chronic dehydration ensued and was managed with long-term subcutaneous fluid infusions with no serious complications.

Aims and objectives: To evaluate the availability of, adherence to, and perceived usefulness of guidelines and protocols for managing hydration and subcutaneous hydration in palliative care settings. Background: Hydration at the end of life and the use of a subcutaneous route to hydrate generate some controversy among health professionals for different reasons. Having guidelines and protocols to assist in decision‐making and to follow a standard procedure may be relevant in clinical practice. Design: Cross‐sectional telephone survey, with closed‐ended and open‐ended questions designed specifically for this study. Methods: Data were obtained from 327 professionals, each from a different palliative care service. Mean, standard deviation, minimum and maximum were calculated for continuous variables; frequency distributions were obtained for categorical variables. A qualitative content analysis was performed on the open‐ended questions. The article adheres to the STROBE guidelines for reporting observational studies. Results: Only 24.8% of the participants had guidelines available to assist in making decisions regarding hydration, and 55.6% claimed to follow them ‘always or almost always’. Of the participants, 38.8% had subcutaneous hydration protocols available, while 78.7% stated that they ‘always or almost always’ followed these protocols. The remaining participants considered the protocols as useful tools despite not having them available. Conclusions: Only 25% of the participants' services had guidelines for hydration, and less than 40% had protocols for subcutaneous hydration. However, adherence was high, especially in cases where protocols existed. Among the participants who did not have guidelines and protocols, attitudes were mostly favourable, but mainly as a reference and support for an individualised clinical practice. Relevance to clinical practice: Guidelines and protocols on hydration in palliative care may be more useful as a solid reference and support for individualised practice than as instruments for standardising care. From this perspective, their development and availability in palliative care services are recommended. This study has been funded by a grant from the Institute of Health Carlos III (PI10/00847) of the Ministry of Economy and Competitiveness (Spain) and the European Regional Development Fund (FEDER).

ObjectiveTo synthesize the current evidence for subcutaneous hydration and medication infusions from systematic reviews and to assess their methodological quality.IntroductionPeripheral intravascular cannula/catheter insertion is a common invasive procedure for administering fluids and medications. Venous depletion is a growing concern for several patient populations. Subcutaneous access for the administration of isotonic solutions and medications is an alternative; however, vascular access assessment and planning guidelines rarely consider this route.MethodsSystematic review of systematic reviews (PROSPERO CRD42018046504). We searched 6 databases published in English language from 1990 to June 2020, identifying subcutaneous infusions an alternate route for fluids or medication. Methodological quality was evaluated using AMSTAR 2 criteria and data for mechanisms of infusion and outcomes related to effectiveness, safety, efficiency and acceptability extracted. The Johanna Briggs Institute's grades of recommendation informed the strength of recommendation.ResultsThe search yielded 1042 potential systematic reviews; 922 were excluded through abstract and duplicate screen. Of the remaining articles, 94 were excluded, and 26 were included. Overall, evidence is strong for recommending subcutaneous hydration infusions for older adults, weak for pediatric patients and inconclusive for palliative patients. There is strong evidence for 10 medications; weak evidence supporting 28 medications; however, there are eight medications with inconclusive evidence to make a recommendation and four medications not appropriate for subcutaneous delivery.ConclusionSubcutaneous access should be considered alongside intravenous therapy for hydration in older adults, and several medications. There are additional benefits in terms of ease of use and cost-effectiveness of this mode. Inclusion of subcutaneous access in clinical guidelines may promote uptake of this route to help preserve vessel health of vulnerable patients. Further high-quality research is needed to inform subcutaneous infusion therapy in a variety of populations (including pediatrics and palliative care) and medications and clarifying the mechanism of delivery.

SummarySubcutaneous hydration, or hypodermoclysis (HDC), is a very simple technique that should be practised more often by doctors and nurses who care for older patients. It involves less discomfort, generates less cost and has fewer adverse effects than the intravenous route and may reduce the need for admission to the emergency department. The main indication is the management of mild to moderate dehydration, and prevention of dehydration in patients who are intolerant of oral intake. It should not be administered in situations of severe dehydration, in emergency situations, or in patients with fluid overload. Isotonic or hypotonic solutions must be used with appropriate electrolytes. Certain medicines can be given simultaneously by HDC and this may be especially valuable in palliative care settings. In most cases there is no need to add hyaluronidase.

82 Background: Loss of oral route is common in patients with advanced cancer, particularly during end-of-life (EOL). EOL hydration may prevent the onset of symptoms associated with dehydration, mainly delirium, or decrease the severity of symptoms when they are present. Subcutaneous hydration (SCH) is the best way to hydrate the patients at home although it is infrequently used. Objectives: To evaluate the feasibility of receiving SCH at home administered by caregivers without previous experience and their subsequent perceptions. Methods: A prospective study of 52 patients with advanced cancer enrolled in a Home Palliative Care Program and their primary caregivers. Caregivers of patients were trained in SCH administration at home. Telephone controls were performed at 48 hours and at 7 days to assess adherence and complications. One month after the death, a survey to explore caregiver perceptions of SCH was performed. Results: Fifty-two patients were included, the median days with SCH were 12 (2-173) and 100% were able to maintain SCH for all the time indicated or until the patient died. The proportion of caregivers who reported that administering SCH had been easy or very easy were 35 (78%) and 26 (96%) at 48 hrs and at seven days, respectively. In the multivariate analysis, caregiver demographics were not associated with finding administration of SCH easy (Table 1). Adverse effects were mild and infrequent. Four weeks after the death, 98% (95% CI 0.88-0.99) of the caregivers reported that it was useful to have administered SCH to their relative.Conclusions: It is feasible to administer SCH to patients who are at home, by caregivers with no prior experience. Implement this technique at home will allow us to decrease the percentage of patients with dehydration at the EOL and to decrease the complications of being dehydrated. [Table: see text]

Dehydration is a common concern in palliative care, and can be an emotive issue for patients and their families (Patchett, 1998). Family members instinctively wish to continue caring for a dying relative, and no more so than by giving nourishment. When the time comes that food cannot be tolerated, giving fluid can seem to be the last way of providing the patient with comfort and nurture. Dehydration may be perceived as the reason for death, rather than a natural part of the dying process. Is it therefore reasonable to give patients fluid by an alternative method? Hypodermoclysis (HDC), or subcutaneous hydration, is sometimes used to administer fluids in the last days of life in a palliative care setting. This article aims to consider the benefits and problems associated with artificial rehydration in these circumstances.

Hydration during palliative care is a controversial topic. Most of the arguments are based on anedoctal reports that have not been substantiated with scientific data. Given that the choice is problematic from a clinical perspective, preferences of patients and family should dictate whether intravenous fluids are administered. The aim of this study was to evaluate patient and family perceptions about hydration and two modes of providing hydration. Fifty-four consecutive patients admitted to an acute pain relief and palliative care unit who required hydration completed a questionnaire regarding their perceptions on hydration and modes of hydration. Similarly, the principal family carer was chosen and similar questions were posed. For most items, patients and relatives agreed, considering hydration as a useful medical treatment that is able to provide some nutrition. The intravenous route was considered able to improve the clinical condition and to have a positive psychological meaning, representing an acceptable burden. The subcutaneous route was considered less effective, and not less bothersome than the intravenous route. Most patients and relatives agreed with continuing hydration at home, if necessary, preferring the intravenous route. Other than technical considerations, which can be variable according to the clinical setting, the perceived benefits of artificial hydration by the caregivers and patients are central to the ethical, emotional, and cultural considerations involved in their decision making. Most patients and relatives surveyed accepted and were in favor of intravenous hydration.

Relatório de prática clínica apresentado à Escola Superior de Saúde Dr. Lopes Dias do Instituto Politécnico de Castelo Branco para cumprimento dos requisitos necessários à obtenção do grau de mestre em Cuidados Paliativos. O presente relatório surge, no âmbito do 1º Mestrado de Cuidados Paliativos da Escola Superior Saúde Dr. Lopes Dias (ESALD), do Instituto Politécnico de Castelo Branco, numa abordagem pormenorizada e reflexiva da prática clínica, norteada pela consecução de objetivos e competências. Estruturalmente assenta em dois momentos: a prática clínica desenvolvida na ED e o projeto de intervenção e formação implementado na UCB objetivado na utilização da via subcutânea para terapia em pacientes com doença crónica avançada. Procura dar resposta aos objetivos: refletir criticamente sobre a tipologia e o modelo de organização da ED; rever criticamente e de modo integrado as competências adquiridas, nas áreas-chave dos cuidados paliativos (comunicação, controle de sintomas, apoio à família e no trabalho em equipa); demonstrar, pormenorizadamente, como as competências instrumentais, interpessoais e sistémicas foram adquiridas nas quatro áreas chave; descrever o projeto de intervenção/formação em serviço desenvolvido na UCB (área problema, objetivo, plano pedagógico da formação e de intervenção, fundamentando as suas diferentes etapas, desde o planeamento, à realização e avaliação); e demonstrar competências na implementação de um plano assistencial de qualidade à pessoa com doença crónica avançada, à sua família e ao seu grupo social de pertença, maximizando a sua qualidade de vida e diminuindo o sofrimento em conformidade com a filosofia dos cuidados paliativos, sempre em colaboração com a restante equipa interdisciplinar. De modo descritivo, reflexivo e crítico com sustentação em documentos empíricos, com preferência de fontes primárias, contempla:os elementos estruturais e funcionais da ED para a contextualização da prática clínica; a descrição da experiência domiciliária vivenciada em cuidados paliativos, junto desta equipa com a discriminação de competências adquiridas, objetivos atingidos e atividades desenvolvidas tendo como base de organização os pilares dos cuidados paliativos, a enumeração e justificação dos objetivos não atingidos; serão descritos todos os passos que permitiram dar consistência ao projeto de intervenção, passando pela avaliação de necessidades, procura de evidência científica, implementação, com relevância para a sessão formativa, e avaliação. A súmula de toda esta experiência enriquecedora pretende ser o fio guia para o interesse e motivação de outros profissionais para esta área do saber e do cuidado que tão fortemente dignifica a prestação de cuidados em saúde. Considerando a formação avançada em cuidados paliativos, num trajeto em que o acumular de cada momento foi a ressalva para o crescimento pessoal e profissional, em que a imensa aprendizagem permitiu consolidar competências nesta área, com o intuito de alcançar resultados de excelência ao nível da assistência ao doente e família através da avaliação contínua, global e holística baseada na evidência científica, acresce a responsabilidade de contribuir para a disseminação do que se consideram boas práticas neste âmbito. ABSTRACT: This report comes under the 1st Master of Palliative Care of Escola Superior Saúde Dr. Lopes Dias (ESALD), of Instituto Politécnico de Castelo Branco, on a detailed and reflexive approach of clinical practice, guided by the achievement of objectives and competencies. It is structurally based on two moments: the clinical practice developed in the ED and the project of intervention and training implemented at UCB linked to the use of subcutaneous therapy in patients with advanced chronic disease. This has implication in the response to the objectives: to critically reflect on the typology and organization model of ED and critically and seamlessly review the acquired skills in key areas of palliative care (communication, symptom control, family support and teamwork); demonstrate in detail how instrumental, interpersonal and systemic skills were acquired in the four key areas;describe the intervention/training project in service developed at UCB (problem area, goal, pedagogical plan of the formation and intervention, basing its different stages, from the planning, to the implementation and evaluation); and demonstrate competencies in the implementation of a quality health care plan to the person with advanced chronic disease, to his/her family and to his/her social group, maximizing his/her quality of life and reducing suffering in accordance with the philosophy of palliative care always in collaboration with the remainder interdisciplinary team. In a descriptive, reflective and critical way with support in empirical documents, preferably primary sources, it includes:the structural and functional elements of the ED to contextualize clinical practice; the description of the domiciliary experience in palliative care experienced with this team, with the detail of acquired skills, goals achieved and activities undertaken based upon the pillars of palliative care, a list and justification of the goals not achieved; and all the steps that allowed to give consistency to the project of intervention, through the needs assessment, seeking scientific evidence, implementation, with relevance to the training session, and evaluation. The sum of all this enriching experience aims to be the guiding thread for the interest and motivation of other professionals to this area of knowledge and care that so strongly dignifies the provision of health care. Considering the advanced training in palliative care, a path in which the accumulation of each moment was the provison for personal and professional growth, in which the immense learning made consolidate skills in this area, in order to achieve excellent results at the level of care to the patient and family through ongoing, global and holistic evaluation based on scientific evidence, adds the responsibility for the dissemination of good practices that are considered in this context.