Hydration and the dying process

I got an e-mail asking whether giving dying people water can keep them comfortable and/or aid in the dying process.

This is a frequently asked question, actually; it seems natural to attempt to hydrate someone who has stopped drinking. Family members often ask, “should we start IV fluids?” Or even “what about a feeding tube?” Approached without context, of course it seems cruel to avoid giving someone water. But there is a context.

My boss has been a hospice nurse for like 100 years or so, and one of the first things she said to me (after “when you’ve been doing this for a year, you MAY have some idea what you’re doing”) was that ultimately, our patients all die of dehydration. Which I thought was idiotic. She has a point, though. I’ve watched a lot of people die by now, and it does seem directly related to volume status.

That’s kind of the sticking point, though, isn’t it? If giving your loved one fluids will keep them from dying, why wouldn’t you do that?

Here’s why.

When a body shuts down, muscles stop working, even the little involuntary ones in the GI tract. If you put stuff down there and nothing is happening, it causes fullness and nausea. Think about how you feel when you have gastroenteritis (the “stomach flu”)...you feel like “oh God, please, I don’t want anything in there!” The dying person seems to naturally reach a similar place where they just don’t feel like eating or drinking anymore, probably because to do so causes discomfort.

What about IV hydration? It works for a while, but ultimately if the body is shutting down, it is shutting down, and it will stop being able to do anything with those fluids. They will seep out of the vasculature into the tissues and cause swelling, which by all accounts is uncomfortable (who enjoys being bloated?). At that point you are left at the same point as above, except now you have a lot more fluid to get rid of before death occurs.

Another way to think about it is like a car with a radiator. The car will run, at least kind of, as long as there is enough fluid in the radiator. The body is the same. Until the fluid runs out it can keep going and going and going and....

My concrete answer is this. As long as the person is thirsty, the body is probably able to use the water, and they should be offered fluids as usual. But when they stop being thirsty, it’s probably because the fluid is going to cause more harm than benefit, and that’s the time to stop fluid intake and change to moistening the mouth and lips only. But without question, fluids prolong the dying process, and that can be beneficial or not.