This document has been reviewed in line with the Policy Alignment Process for Liverpool Community Health NHS Trust Services. It is a valid Mersey Care document, however due to organisational change this FRONT COVER has been added so the reader is aware of any changes to their role or to terminology which has now been superseded. When reading this document please take account of the changes highlighted in Part B and C of this form.
Part A – Information about this Document
Policy Name / Subcutaneous Rehydration GuidelinesPolicy Type / Board Approved (Trust-wide) ☐ / Trust-wide ☐ / Divisional / Team / Locality ☒
Action / No
Change / ☐ / Minor
Change / ☐ / Major
Change / ☐ / New
Policy / ☒ / No Longer
Needed / ☐
Approval / As Mersey Care’s Executive Director / Lead for this document, I confirm that this document:
a)complies with the latest statutory / regulatory requirements,
b)complies with the latest national guidance,
c)has been updated to reflect the requirements of clinicians and officers, and
d)has been updated to reflect any local contractual requirements
Signature: / Date:
Part B – Changes in Terminology(used with ‘Minor Change’, ‘Major Changes’ & ‘New Policy’ only)
Terminology used in this Document / New terminology when reading this DocumentPart C – Additional Information Added(to be used with ‘Major Changes’ only)
Section /Paragraph No / Outline of the information that has been added to this document – especially where it may change what staff need to do
Part D – Rationale(to be used with ‘New Policy’ & ‘Policy No Longer Required’ only)
Please explain why this new document needs to be adopted or why this document is no longer requiredPart E – Oversight Arrangements (to be used with ‘New Policy’ only)
Accountable DirectorRecommending Committee
Approving Committee
Next Review Date
LCH Policy Alignment Process – Form 1
SUPPORTING STATEMENTS
This document should be read in conjunction with the following statements:
SAFEGUARDING IS EVERYBODY’S BUSINESSAll Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including:
- being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or by professional judgement made as a result of information gathered about the child / adult;
- knowing how to deal with a disclosure or allegation of child / adult abuse;
- undertaking training as appropriate for their role and keeping themselves updated;
- being aware of and following the local policies and procedures they need to follow if they have a child / adult concern;
- ensuring appropriate advice and support is accessed either from managers, Safeguarding Ambassadors or the trust’s safeguarding team;
- participating in multi-agency working to safeguard the child or adult (if appropriate to your role);
- ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation;
- ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session
EQUALITY AND HUMAN RIGHTS
Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership.
The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices.
Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act.
Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy
Title / Policy for the Administration of Subcutaneous Hydration by Liverpool Community Health
Guideline reference
number / 85
Aimand purposeof guideline / To support the administration of subcutaneous rehydration in the Community
Author / Intravenous TherapyTeam
Palliative Care Team
Type / NewPolicy
Reviewed PolicyX
Reviewdate / December 2019
Person/group accountable for
review / CommunityIntravenous TherapyTeam Palliative Care Team
Issue Date / 19th December 2017
Authorised by Clinical Standards Group / December 2017
EqualityAnalysis Assessment
Undertaken / Yes x Evidence collated – Yes x
NoNo
Document Control
Title / Policy for the administration of Subcutaneous hydration by Liverpool Community HealthStatus / Review guidelines- New policy
Version / 2
DateIssued / December 2017
ReviewDate / December 2019
Originator / Chris McBride Endof LifeOperationalLead
Alison SmithIVTOperational/Professional Lead
Reviewer / Reviewed by Victoria Ali Palliative Care Team Leader/Sara Caddick MMT/Debbie Doyle IV team
1.0Purpose ofPolicy
This policypurpose istomakeLiverpool Community Health staffaware of:
1.Indicationsforadministrationofsubcutaneousfluidsforpatients
2.Ethicaland Medicalconsiderations
3.Themethodofadministration ofsubcutaneousfluids
Thispolicyhasbeendevelopedto support Liverpool Community Health NHS Trust staff in decision making and administration of subcutaneous fluids in patients with a palliative diagnosis and is also supported by an associated standard operating procedure (SOP). The policy highlightstheneedfora collaborativeapproachwhenconsideringadministrationof subcutaneousfluidsinthecommunity.This policy also exploresthecomplexityof themedicalandethicalissuesinthedecisionmakingprocesswiththe aimofimprovingnursingpracticeandpatientoutcomes.Theyshouldbe readinconjunction with, and is based upon, the One Chance to get it Right document (2015),TheNationalCouncilforPalliativeCare: ChangingGearGuidelinesforManagingtheLastDaysofLifeinAdults (Nov2006), NICE Guidance: Care of dying adults in the last days of life (2015)andCheshire& Merseyside Palliative and End of Life Care Strategic Clinical NetworkStandards and Guidelines for the use of hydration in the dying patient(2017)
This policy isdesignedtoensurethatallstaffworkingfor,oron behalfofthetrust,providesanoptimumlevelofservicedeliverytothis specificpatientpopulation.Theadviceandguidancecontainedare researchbased andhavebeen agreedbyamultiprofessional group.
2.0Scope of policy
LiverpoolCommunityHealth NHS Trusthasdevelopedthis policy inorderto fulfiltherequirementsofpatients/serviceusersreceivingcarefrom DistrictNursesemployed byLiverpool Community Health NHS Trust.
3.0 Decision-making
Reduced oral intake is a common sign of deteriorating clinical condition, is common in the last few days of life and is part of the normal dying process. Oral fluids are part of basic patient care and as such should be encouraged whenever possible. Indecidingwhetherornottousesubcutaneoushydrationforadying patientthehealthcareprofessionalshavetoassessthebenefitsthe patientislikelytogainagainsttheburdenitimposesonthepatient.There is a general lack of robust evidence regarding the benefits and burdens of clinically assisted hydration at the end of life and as such decision should beindividualised to each patient. There is also no strong evidence whether sub-cutaneous rehydration will affect symptom control at end of life (NWCSN standards and guidelines 2017, Forbat et al 2017). The assessmentcanhelpguideapatientandfamily’schoiceofthe optionsavailabletothe patient.Thepatientmustalwaysbeinvolvedinthe assessmentofthebenefitsandburdensofanytreatment when this is possible.Inclusionof thefamilyandcarersisimportantinanydiscussion,althoughmaking choicesmayprovokeanxietyand bedistressingforfamilymembers. Familiesneedtohaveaclearunderstandingofwhatthesubcutaneous fluidsarebeingusedfor.Decision-making must be with the multi-professionalteam,patient andrelativeswhere appropriateandshould beclearlydocumentedincasenotes.
Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines(2017) have reviewed the most recent evidence and producedgeneralprinciples,guidelinesandstandardsregarding artificialhydration forpeoplewho areterminallyill. Inthecommunity settingindicationsshouldbesymptomled, both physical and psychological, and it will be based on palliation of symptoms rather than rectifying biochemical imbalance.Likewisewhether rehydrationshouldbecontinued,anassessmentshouldbemadeasto whetherthehydrationregimeisassistinginrelievingthesymptoms. This assessment should be undertaken on a daily basis.
Subcutaneousrehydrationisnotadequatetocorrectseveredehydration orelectrolyteimbalance; if this is appropriatethesepatientswill require assessment and may needinpatient servicesforassessmentandtreatment.
Indicationsforadministrationofsubcutaneousfluidsfor patients with palliative diagnosis/end of life
Dehydration can commonly occurinolderpeople and those approaching the end of life,bothathome andinstitutionalsettings.Acuteproblemssuchasmildinfections, vomiting,diarrhoea,andtemporaryconfusionduetochangesin medicationcouldallprecipitatedehydrationbecauseanadequatefluid intakecannotbe maintained.
Oral fluid intake will also naturally reduce as a person approaches the end of their life and this must be taken into account when assessing where artficial hydration is appropriate. Sub-cutaneous hydration may be appropriate for those with mild dehydration or to manage the symptoms of dehydration and thirst in palliative and end of life care.
Dehydration and reduced oral intake can be problematic, the reasons for this are often multifactorial,andisassociatedwithmanysymptoms,oneofthemost troublesomebeingthirst.Theprovisionoforalfluidsandoralhygiene formspartofbasiccareandshould notbewithdrawnorwithheld. This is supported by the SOP for the use of oral swabs with foam head for mouth care (see reference list). Howeveritisambiguous whether thesefluiddeficitsadverselyaffectthepatient’squalityoflife.
Contradictions for Subcutaneous Hydration
- Severe dehydration
- CardiacFailure
- Pre-Renal orRenal Failure
- Lowplateletorcoagulation disorders
- Existingfluidoverload
- Marked oedema
Hypercalcaemia can be a cause of dehydration and is classedisanionisedplasmacalciumconcentrationabovethe upperlimitofnormal.Diagnosisisbasedonahighlevelofclinicalsuspicionandconfirmedby appropriateblood tests.Afullmedicalassessmentisneededtoensurethatpatientswhorequire fluidreplacementsforcorrectionofspecificproblemsareidentified.Dependent upon the overall clinical picture treatment with Bisphosphonates and IV hydration may be more appropriate than less aggressive subcutaneous management, see Bisphosphonates policy for further guidance. ConsiderreferraltoIVteamfortreatmentof hypercalcaemiawithIVBisphosphonates and refer to the specialist palliative care team for future advice.
Familiesandcarersneedtobeinformed that thistreatmentwillbereviewedonadailybasisbya healthcareprofessional: thatthisformoftreatmentis largelytemporarybuttherewillbe exceptionstothis based on a MDT decision.If there is no improvement after 72 hours or treatment is not tolerated then it would be inappropriate to continue. Thefamilywillbeinformedofhow to monitor the site by observing the infusion and site integrityonceithasbeencommenced and ifthereareanyproblemstocontactDistrictNurse.
4.0EthicalandMedicalConsiderations
The assessmentshouldbeindividualised,involvemembersofthe multidisciplinaryteam,andincludetheviewsofthefamilyandcarers. Thesepatientswillrequirereferralto thespecialistpalliativecare team for review and ensuring that thedecisionfortreatmentmustoutweighthedisadvantagesofthe proposedtreatmenttakingintoaccounttheethicalandmedical considerations.PractitionersshouldalwaystakeintoconsiderationtheNMCCode: professional standardsofpractice and behaviours for nurse and midwives (2015) with regardstoclinicaljudgementandprofessionalaccountability.Artificialhydration suchasintravenous orsub-cutaneousfluidsisclassedasmedicaltreatmentincommon law. Theprimarygoalofanytreatmentinterminalcareshouldbethecomfort ofthepatientand the ethicalbasisof the clinicaldecisionisthe assessmentofthebenefit vs burden of treatment. It is unethical to have a blanket policy on clinically assisted hydration andcasesshouldbereviewed individuallyandmusttakeintoconsiderationanyadvanceddecisions made bypatients(referto MentalCapacity Act2005).
Theissuesraisedindecidingwhetherornottousesubcutaneous hydrationaresensitiveforallconcerned,thepatient,familyand healthcareprofessional.Thepatientandthefamilywillneedtobe supportedwith anydecisionmadebythemultidisciplinaryteam.For thesereasonsitisanticipatedthatamemberof thespecialistpalliativecareteamwouldbeinvolvedinthedecisionand supportofthefamily.Where the patient is felt to be in the last few days of life theEndofLifeCarePlan wouldbe inuseandsymptomsmanaged accordingly.
5.0Themethodofadministrationofsubcutaneousfluids
See accompanying SOP for the administration of sub-cutaneous fluids
Site ofInfusion:Torotatesitestominimizetissuedamage
Abdomen Chest
Lateralaspectofupper armorthigh
Donotuse on:Lymphoedematous and oedematoustissue or recently irradiated skin
It is recommenced to infusion 1 Litre of 0.9% Sodium Chloride over a 24 hour period. There is no evidence that supplementation of fluids with potassium is of benefit for patients in the last hours or days of life (NWCSN standards and guidelines 2017). Potassium should not to be administered subcutaneously and as such only 0.9% NaCl is for use via this route. There is also no evidence to support the reassessment of blood test in this clinical situation (NWCSN standards and guidelines 2017).
The manufactureroffluidsforinfusionappliedforandgrantedthe specific ProductLicense which is forthepurposeofIntravenousInfusiononly.Therefore theuseofthesesterilefluidsforthepurposeofSubcutaneous Infusionisunlicensed procedure.Assuchtheprescribermusttakefullresponsibilityfortheefficacyofthe medicine(infusionfluid)andforanyadverseeffectsresultingfromits use.
6.0TrainingandEducation
TheNMCstate that in order to revalidate their professional registration thatnursesmaintaintheircompetencevia ContinuedProfessionalDevelopment.Training willbeprovidedinadministrationofSubcutaneousFluidsaspartof theIntravenousTherapyTheoryTraining.Trainingincommunication skillsisessentialtoensureanyconversationsthattakeplaceatend oflifearehandledsensitivelyand empathetically. Training in intermediate communications skills are also advocated for staff caring for those at end of life.
7.0PatientMonitoring
Ateachvisitcheckthe infusionrateandalsocheckinfusionsitefor and document VIP score of infusion site within the patient’s clinical record. Monitor for:
- Redness
- Pain/tenderness
- Inflammation
- Anysignsofoedema (pulmonary and peripheral)
- Leakageatsite
- Abscessformation
- Bleeding/bruising
InformGPimmediatelyifpresentandstop infusion, complete clinical observations if this is suspected and escalate as per the observations policy
- The giving set should be changed each time the fluids are administered
- Theneedlesafebutterflyandgivingsetshouldbechangedevery72 hoursandrecorded (RCNStandardsforInfusionTherapy(2016)
- Theneedlesafecannula orneedlesafebutterflycan be capped off inbetween witha sterilebungorbionector if fluids not being administered continuously.
- Infectioncontrolpoliciesregardinghandwashingmustbefollowed atalltimes;theadministrationsystemmustonlybeaccessedby healthcareworkerswhohavewashedtheirhandsasperpolicy and arewearing theappropriatePPE.
- Patientandcarersmustalsobetaughtappropriatehandhygiene and encouragednottotouchtheadministrationsystem.
- Thepatientshouldbe monitoreddaily.
8.0Definitions
Community–referstothepatient’sownhomeandalsoincludes residentialandnursing homes.
Subcutaneous(SC)–referstoadministrationoffluidsintothe subcutaneoustissueinordertoachievefluidmaintenancesor replacementindehydrated patients.
Butterfly–refers totheshortneedlesafeperipheral devicethrough whichthefluidswillbegiven directlyintosubcutaneoustissue.
TPR+BP–Temperature,Pulse,RespirationandBloodPressure relating toclinicalcondition
GP-GeneralPractitioner
9.0References
Cheshire and Merseyside Palliative an End of Life Care Strategic Clinical Network Standards and Guidelines (2017) Guidelines for the use of hydration in the dying patient. Access electronically at
Document references available online
Forbat, L et al (2017) How and why are subcutaneous fluids administered in an advanced illness population: a systemic review. 26 (9) 1204-1216
Leadership Alliance for the Care of Dying People (2014) One Chance To Get It Right: Improving peoples experience of care in the last few days and hours of life. Access electronically at
MoriartyDHudsonE(2001)Hypodermocylsisforrehydrationinthe community.JournalofCommunityNursing.Vol6(9).
National CouncilforPalliativeCare ServicesandtheAssociation of PalliativeMedicineofGreatBritainandIreland (2007).Artificialnutrition and hydration:guidanceinend oflifecare foradults. London: NCHSPCS.
National Institute for Clinical Excellence (2015) Care of dying adults in the last days of life. Access electronically at
Royal College of Nursing(2016) Standards for infusion therapy (4thEdition),London: RCN
EqualityAnalysis CompletedNovember 2017
Held by author
Audit Tool:
An audit based on Duthie standards will be conducted in 2018/19 measuring against the following criteria:
- How often subcutaneous fluids are required in a sample three month period
- How many patients gained benefit from subcutaneous fluids and any complications that arose