eli5: Patients in hospice care are often unconscious due to high doses of sedative drugs, and are given no intravenous fluids, which leads to death by dehydration. Why is this done? Is there any difference between this and physician-assisted suicide?
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Trigger warning: some unpleasant descriptions of symptoms
It would rarely be dehydration that the person dies of.
At the point when fluid is stopped, it is very near the end. The person is actively dying.
Likewise the sedation/unconsciousness is often not entirely due to drugs. At the end you’ll get some people who can be agitated and disorientated for a time before falling unconscious and drugs are often used to help this, but often very low doses to take the edge off of it and make them comfortable. If they are in a deep sleep type of unconsciousness, it’s more to do with dying.
One reason for not persisting with fluids is IV access. It often becomes increasingly difficult to place and keep a cannula working and repeated attempts in a person who is fading can be viewed as cruel when they may only have hours left (final stages of dying can be difficult to estimate how long they have left. It may last hours, it may be a few days).
But a big reason for withholding fluids at the end, is that being on the dry side helps symptoms, particularly breathing. At the end, swallowing automatically can become compromised and if there is excessive saliva, or even normal levels, they can choke repeatedly. This level of sudden oxygen starvation is a horrible sensation and not what to experience over and over if it can be avoided simply. But a big one is that as the heart becomes less effective, fluid can accumulate in the lungs tissue simply. This make breathing more difficult and can be distressing. It’s like slowly drowning. Reducing hydration levels a the end can reduce this to help the end be more peaceful, for both the patient and those around them.
Fluid restriction/stopping is only done when the person is actively dying and consciousness is affected, and if they are not already unconscious, they are nearly at that stage.
So, I just had a close relative pass away with hospice care so I have a little insight into this.
Once you get to hospice, you are in the last paragraph of the last chapter of the book. There is no more treatment for the underlying disease; the focus is on improving quality of life and making the passing as painless and dignified as it possibly can be.
This happens in stages. For a while, the person can be lucid and “active” but at some point they transition to the “actively dying” stage where the body is starting to shut down. They often become unresponsive and no longer want to eat or drink – the body is in the final stages of giving up for good. The last sentance of the last paragraph of the last chapter of the book, if you will.
At that point, it is about letting the body do what it is naturally going to do. Forcing anything that would prolong life – like intravenous fluids or nutrition – is no longer in the patent’s best interests. If they want something you give it to them, but otherwise you just let the body die. They only things you give are things that minimize discomfort. It is a passive process – you simply don’t intervene in what is naturally happening.
This is very different from assisted suicide, where you give them something that hastens death. A massive dose of sedative that would stop their breathing for example. This is an active process – you are stepping in and _doing something_ to specifically make death happen.
In most countries, withholding some aspects of care is not seen as assisting in death and is thus permissible for healthcare workers in certain situations.
I’m not entirely sure where you get this information from but having worked in hospice it’s not really accurate with my own experience. Generally speaking where I work we’re not really giving “high” doses of narcotics, typically liquid oral morphine and/or MAYBE liquid oral ativan, but it’s not a round the clock process and dosing may differ per nurse/physician discretion. Also, we typically define hospice as anticipating death within 6 months. We’ve had plenty of patients go on and off hospice for months or even years with fluctuations in their health. I’ve spoken to quite lucid hospice patients hours before they die.
TLDNR version. If you are going to die anyway it is ok to make it painless and as comfortable as possible. You just give enough to take the pain and fear away not speed things up.
It is quite simple actually. If someone is not peeing huge amounts of urine, not having diarrhea and not having profuse sweat, the water loss is quite small. People in hospice care often have constipation, reduced muscle mass, heart failure and a reduced hypothalamic activity (meaning loss of appetite and reduced capacity for fever reaction). They have no reason to get severe dehydration simply because they are not given parenteral fluids.
Consistent with that, research shows that people in hospice care that are evaluated to be in their last days of life that are given parenteral fluids (even subcutaneous fluids can be admininstered actually) have no better outcome than people who were not given fluids.
If there is not an objective end point that is improved, it means such therapy is futile. If admininstering IV fluids doesn’t lead to improved outcome, then not admininstering it doesn’t mean that care was withhold because IV fluids doesn’t even qualify as “care” at this period of time. This is different from withholding care say, for example, in a DNR scenario, where it is presumed that not doing resuscitative measures such as not initiating mechanical ventilation will certainly lead to a quicker death.
OP, what is the source of this description of hospice?
I feel like you are imagining people dying in hospice like they are up and around and some mean nurse knocks them out and dehydrates them till they die. That isn’t really the way hospice works.
Letting someone die in their own time as their body shuts down naturally is very different from intentionally ending their life.
This isn’t a value judgement. It’s just different.
This post makes me miss my dad, it’ll be three years since his passing this year. Bless all hospice workers
My father never made it to a hospice as he died the day before has was to go. (We were kind of managing to look after him at home.)
His pain gradually got worse and we slowly increased him morphine dose to deals with the pain.At the same time he gradually refused food and water. Both caused him pain.
So, by the end, he was getting a high dose of morphine and very little nutrition. His death was inevitable because of that. But it was anyway because of the cancer so increasing his morphine at least made his last weeks as comfortable as possible.
So yes, we kind of killed him. What we were doing was very clearly going to kill him. But there was no good alternative.
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