In the Midst of Life

there are no noticeable side effects from the fluids or nutrition already being given, then there is no reason to stop them.
    A blanket policy on artificial hydration is not an individual approach to patient care. Each terminally ill patient should be assessed according to their personal need, present symptoms, and family carers’ concerns. Although caring for the patient and theirsymptoms is important, the patient needs to be cared for as part of a social unit, and it must be recognised how this will affect those close to them. The patient is not a solitary unit: they are part of a family unit, which needs care as a whole.
    Other thoughts concerning artificial hydration are that it is necessary, particularly when sedation is being used (Craig, 2002). This will help flush out the toxins from the medication used, and prevent over-sedation. If the aim of sedation is to cause the patient to become unconscious, hydration must be used to prevent death through dehydration (unless of course there are counter-indications for the use of fluids). Hydration may also be useful in patients experiencing delirium caused by abnormal electrolyte levels as it can increase the elimination of opioid metabolites. If a patient is experiencing terminal agitation and requiring sedation, it may be appropriate to continue the fluids unless the patient develops terminal secretions, at which point their body would not have been able to cope with the extra fluids. If fluids are not started, the nurses and doctors need to observe the patient to prevent too much sedation being given: enough to hold the symptoms at bay but not enough to sedate unnecessarily. This is done by starting with a low dose of sedative in a syringe driver and giving extra doses as required, and thus increasing the doses in the syringe driver according to requirements. If there are concerns about the patient needing hydration, as long as there are no terminal secretions present some fluids could be commenced subcutaneously, However, good mouth care can also help prevent [the patient] experiencing thirst. Remember, the assessment of the need for fluids is an individual one, based on many issues.
    Beauchamp and Childress (2001) describe the Doctrine of Double Effect as, ‘a single act having two foreseen effects, one good and one harmful’. In palliative care an example of this is the giving of an analgesic to a dying patient who is in pain. If a doctor or nurse gives something to intentionally kill them, this act is actually murder. However, if they give something for pain relief at an acceptable dose, but the patient quickly deteriorates and dies, then this is acceptable because the intention of giving the analgesicwas good. There are four elements to the double effects doctrine described by Beauchamp and Childress (2001):
     
The nature of the act: the act must be good in itself.
Intention: this must be for good effect. The bad effect may be noted but must not be intended.
Distinction between means and effects: the bad effect must be means to the good effect. If the good effect was the result of the bad effect the person doing the act would intend the bad effect in pursuit of the good.
The good effect must outweigh the bad: the bad effect is permissible only if a proportionate reason compensates for permitting the foreseen bad effect.
    The important thing about any patient care, whatever the disease, illness or situation, is that it must be appropriate. In end-of-life care there are now many drugs that can manage particular symptoms, such as pain, in the majority of patients. However, it is important not to reach for the drugs first, before ruling out other more simple interventions. For instance, if a dying patient seems agitated or in pain, they will be twitching, perhaps frowning, or groaning. Many healthcare professionals would assume the person is agitated either because of pain or simply because of terminal agitation (agitation which occurs when a patient is dying). This certainly may be the case. However, there are many causes of pain and agitation, not simply disease and the dying process. These must be ruled out first. For instance, simply changing a patient’s position can make a big difference and settle them immediately. Imagine lying in a bed in exactly the same position for several hours, and not being able to move yourself at all: you can begin to imagine why some patients do indeed become agitated. And dying patients still may need to empty their bowel