Improving the approach to end of life care

Dr holding the hands of a patient

In a UK first, researchers from the Marie Curie Palliative Care Institute Liverpool, based at the University of Liverpool, have utilised a novel assessment tool to help monitor the hydration levels of a critically ill patient with POEMS syndrome to improve care.

Hydration in critically ill patients is important and the accurate assessment of their fluid status can be challenging. For example, many people with advanced cancer may have less desire to drink as their condition worsens and we understand little of the effects of this both physiologically and clinically.

Currently, there is a lack of evidence to guide health professionals’ management of (de)hydration of critically ill patients and current methods for monitoring hydration status can be invasive. In addition, current methods can provide a flawed measurement of hydration as they provide no information about extravascular or intracellular fluid status.

Feasibility and validity

The study, which took place in the Royal Liverpool University Hospital in collaboration with Professor Andrew Pettitt, aimed to use bioelectrical impedance vector analysis (BIVA) to assist in guiding the care of a symptomatic patient with POEMS syndrome. Bioelectrical impedance vector analysis is a simple, safe, bedside method to measure body water content.

POEMS syndrome is an extremely rare multisystem disorder. POEMS stands for (P)olyneuropathy, disease affecting many nerves; (O)rganomegaly, abnormal enlargement of an organ; (E)ndocrinopathy, disease affecting certain hormone-producing glands that help to regulate sexual function, and certain metabolic functions; (M)onoclonal gammopathy or M proteins; and (S)kin abnormalities. The exact cause of POEMS syndrome is not known.

The researchers examined and evaluated the response of a 52-year-old female patient with POEMS syndrome to diuretic therapy. This therapy helps rid the body of salt (sodium) and water. Diuretics work by making the kidneys put more sodium into the urine. The sodium, in turn, takes water with it from the blood.

The patient was observed repeatedly over a period of a month and data was gathered as part of the assessment. The results of the study have been published in the British Medical Journal (BMJ) Supportive & Palliative Care.

Overcoming limitations

Dr Amara Nwosu, said: “This is the first study to use BIVA to evaluate hydration in POEMS syndrome. Furthermore, the evaluation of long term change in hydration in POEMS syndrome using BIVA, following intervention with diuretics, is novel.

“The advantage of BIVA is that it allows information to be obtained simultaneously about changes in tissue hydration or soft tissue mass, independent of regression equations, or body weight. This allows for accurate interpretation of BIVA readings even if patients are at extremes of weight or volume distribution.

Professor John Ellershaw, Director of the Marie Curie Palliative Care Institute Liverpool, said: “This case report highlights the potential to use BIVA to monitor hydration states over time in response to interventions. More research is needed to determine the potential of BIVA to improve the evaluation and management of hydration states in advanced cancer and chronic disease.”

The Marie Curie Palliative Care Institute Liverpool is a partnership between the University of Liverpool, the Royal Liverpool and Broadgreen University Hospitals NHS Trust and Marie Curie Cancer Care. The Institute aims to make a real and sustained difference to care at the end of life from bedside to policy through service innovation and improvement, research and development and knowledge transfer to inform clinical excellence.

The full paper, entitled ‘Longitudinal bioimpedance assessments to evaluate hydration in POEMS syndrome. BMJ Supportive and Palliative Care‘, can be found here.

Doctor giving pensioner in surgery comfort and consoling with holding hands

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