Quality statement 4: Hydration

Quality statement

Adults in the last days of life have their hydration status assessed daily, and have a discussion about the risks and benefits of hydration options.

Rationale

Drinking is a basic human need, but as death approaches the desire to take in fluid can diminish. Daily assessment enables changes in hydration status and associated symptoms to be identified, along with problems with oral hydration and any need for clinically assisted hydration. Discussing the risks and benefits of options for hydration with the person who is dying, and those important to them, allows their wishes and preferences to be taken into account. The normal route of hydration is oral, but some people who want to drink may not be able to do so, and may need support to drink or may benefit from clinically assisted hydration. Inadequate hydration can result in distressing symptoms, such as thirst and delirium, and can sometimes lead to death. However, drinking and clinically assisted hydration are not without risks; there can be swallowing problems and the risk of aspiration with drinking, and excessive assisted hydration can cause swelling and breathing difficulties.

Quality measures

Structure

a) Evidence of local arrangements to ensure that adults in the last days of life have their hydration status assessed daily.

Data source: Local data collection.

b) Evidence of local arrangements to ensure that adults in the last days of life, and the people important to them, have discussions about the risks and benefits of hydration options.

Data source: Local data collection.

Process

a) Proportion of adults recognised as being in the last days of life who have their hydration status assessed daily.

Numerator – the number in the denominator who have their hydration status assessed daily.

Denominator – the number of adults recognised as being in the last days of life.

Data source: Local data collection based on audits of patient care records.

b) Proportion of adults recognised as being in the last days of life who have a discussion about the risks and benefits of hydration options.

Numerator – the number in the denominator whose individual care plan shows that there has been a discussion about the risks and benefits of hydration options.

Denominator – the number of adults recognised as being in the last days of life.

Data source: Local data collection based on audits of patient care records and individual care plans. National data on the proportion of people who died in hospital who had a discussion regarding drinking and need for assisted forms of hydration are reported in the Royal College of Physicians' End of life care audit – Dying in hospital report for England.

Outcome

a) Proportion of adults who felt comfortable in the last days of life.

Data source: Local data collection based on feedback from adults in the last days of life and the people important to them.

b) Proportion of bereaved people who feel satisfied that the person who has died was supported to drink or receive fluids if they wished.

Data source: Local data collection. National data on bereaved people who agreed that the person who died had support to drink or receive fluid if they wished in the last 2 days of life are reported in the Office for National Statistics' National survey of bereaved people (VOICES).

What the quality statement means for different audiences

Service providers (such as hospitals, hospices, GP practices and district nursing services) ensure that systems are in place to ensure that adults in the last days of life have their hydration status assessed daily. They ensure that staff are aware of the risks and benefits of hydration options and discuss these with the dying person and those important to them, and capture their wishes and preferences.

Healthcare professionals (such as secondary care doctors, nurses, GPs, hospice doctors and district nurses) assess the hydration status of adults in the last days of life daily, including observations for signs and symptoms of overhydration and dehydration. They also discuss options for hydration, explaining the risks and benefits with the person who is dying and those important to them, and identify their wishes and preferences.

Commissioners (such as clinical commissioning groups) use contractual and service specification arrangements to ensure that providers assess the hydration needs of adults in the last days of life daily, discuss the risks and benefits of hydration options with the dying person and those important to them, and facilitate the provision of clinically assisted hydration in hospital and community settings.

Adults who are in the last days of life are checked every day to see if they are having problems with hydration. The different choices for hydration, such as having help to keep drinking or having fluids provided through a drip or tube, are explained, along with their risks and benefits. The person is asked which option they would prefer if they have problems staying hydrated.

Source guidance

Care of dying adults in the last days of life (2015) NICE guideline NG31, recommendations 1.4.1, 1.4.4 and 1.4.5

Definitions of terms used in this quality statement

Hydration status assessed

A clinical review to check for signs of dehydration (such as dry mouth, thirst, confusion and agitation) or overhydration (such as swelling and fluid overload), which could be carried out by a nurse or doctor. This would include objective and subjective measures (for example, hydration of oral mucosa, skin turgor, evidence of peripheral oedema or pulmonary congestion). Blood tests would not routinely form part of the assessment. However, if laboratory test results are present then they may form part of the assessment. Assessment occurs at least daily, but more frequent assessment may be needed because a person's condition can change quickly.

[Adapted from NICE's guideline on care of dying adults in the last days of life, full guideline and expert opinion]

Equality and diversity considerations

Adults in the last days of life with dementia, cognitive impairments, learning disabilities or language barriers may have difficulties communicating. Healthcare professionals caring for adults in the last days of life should establish the person's cognitive status, and if they have any speech, language or other communication needs; their current level of understanding; and if they would like a person important to them to be present when discussing hydration. All information provided should be accessible, as far as possible, to people with cognitive problems; and people receiving information should have access to an interpreter or advocate if needed.