Nutrition and Hydration

1
Nutrition and Hydration

• Purpose Review of residents needs and comfort
  or distress related to nutrition and hydration
  during the final stages of life and review of
  regulatory guidance on the use of parenteral and
  enteral feeding.

2
Objectives

• Understand that nutrition and hydration goals are
  based on the needs and wishes of each
  resident/surrogate.
• Recognize the IDTs responsibilities to help the
  resident meet all nutrition and hydration needs.
• Know that although food and hydration usually
  provide comfort and nourishment, in the end
  stages of life they may cause distress.

3
Objectives, cont.

• Maintain regulatory compliance with nutrition,
  hydration and artificial feedings.
• Provide families with information and support
  regarding nutrition and hydration at the
  end-of-life.

4
In Accordance with the Comprehensive Assessment
and Plan of Care

• World Health Organization (WHO)
• Palliative care defined as active total care of
  patients whose disease is not responsive to
  curative treatment..

5
Goal of Palliative Care

• WHO
• Goal of palliative care is to achieve the best
  quality of life for patients and their families.

6
The regulatory requirement for the
resident to achieve the highest level of
well-being in accordance with the comprehensive
plan of care applies to any resident at any time
during his or her stay and the LTC facility.
7
Appropriate Nutrition and Hydration Goals

• The primary goal of nutrition and hydration in
  terminal illness is comfort-improving quality of
  life by giving the resident maximum enjoyment
  from eating.

8
Appropriate Nutrition and Hydration Goals, cont.

• Another goal is to maintain the residents
  nutritional status or optimize the residents
  intake.

9
Goals Difficult to Balance in LTC
10
IDT Members

• Registered Dietician (RD)
• Dietary Manager
• Occupational Therapist
• Physical Therapist
• Charge Nurse
• Nurse Assistant
• RAI/MDS Coordinator
• Pharmacist
• Physicians

11
Inappropriate Nutrition and Hydration Goals

• Tradition goals of a balanced diet and
  achieving an ideal weight are not realistic or
  appropriate in end stages of life.
• Traditional diets that restrict salt,
  cholesterol, or sugar may no longer be
  appropriate unless the resident prefers the
  restriction.

12
Comfort versus Distress

• Primary goal always comfort!
• Highly individualized
• One size fits all care planning wont work
• End-of-life to imminent death broad category
• What brings comfort in early stage will bring
  distress is later stage.
• Staff must be aware of ongoing changes

13
Comfort versus Distress, cont.

• Offer frequent, smaller feedings.
• Cravings change from one moment to the next.
• Never make the resident feel guilty for not
  trying to eat.
• Forcing food and fluid can cause distress.
• Intake during the dying process does not improve
  the quality of life.

14
Comfort versus Distress, cont.

• Dehydration prevents distressing symptoms
• Dehydration is not painful
• Dehydration described as euphoria as endorphins
  are released
• Dry mouth and membranes will cause distress if
  not managed.

15
Nutrition and Hydration Regulatory Guidelines

• State Operations Manual, Appendix P
• Investigative Protocol
• If a resident is at end of life stage and has
  an advance directive, according to state law, or
  the resident has reached an end of life stage in
  which minimal amounts of nutrients fluids are
  being consumed or intake has ceased, and all
  appropriate efforts have been made to encourage
  and provide intake, then weight loss
  dehydration may be an expected outcome.

16
Nutrition and HydrationRegulatory Guidelines,
cont.

• Directions to surveyors, cont.
• Conduct observations to verify that palliative
  interventions, as described in the plan of care,
  are being implemented and revised as necessary,
  to meet the needs/choices of the resident in
  order to maintain the residents comfort and
  quality of life.

17
Medications

• First, all medications should be reviewed to
  ensure that they are necessary given the
  residents changing condition. Then medications
  that might improve appetite can be considered.

18
Medications to Improve Appetite

• Steroids
• Megace (megestrol)
• Periactin (cyproheptadine)
• Remeron (mirtazapine)
• Marinol (dronabinol)
• Pain control medications

19
Parenteral and Enteral Feedings

• Benefits and Burdens
• Discuss with resident and family
• Specialized roll in head and neck or esophageal
  cancers
• High incidence of aspiration, self-removal, and
  restraints
• Symptoms such as nausea, rattling pulmonary
  secretions, and diarrhea

20
Parenteral and Enteral Feedings, cont.

• GI system fails to absorb food at end of life
  resulting in weight loss, abnormal labs, and
  pressure sore development.
• Fluid overload can occur with artificial fluids,
  which can hasten death and aggravate the dying
  process.
• In case of doubt, a short trial of rehydration
  may be appropriate to flush drug by-products in
  cases of mental confusion.

21
Regulatory Compliance in the Use of Feeding Tubes

• 42 CFR 483.25. (g) F321
• Nasogastric Tubes
• Based on the comprehensive assessment of a
  resident, the facility must ensure that a
  resident who has been able to eat enough alone or
  with assistance is not fed by naso-gastric tube
  unless the residents clinical condition
  demonstrates that use of a naso-gastric tube was
  unavoidable.

22
Regulatory Compliance in the Use of Feeding Tubes

• Resident Assessment Protocal (RAP)
• Feeding Tubes
• ..informed consent is essential before
  inserting a feeding tube. Potential advantages,
  disadvantages, and potential complications need
  to be discussed. Resident preference is normally
  given the great weight in decisions regarding
  tube feeding. technical means of providing
  fluids and nutrition can represent extraordinary
  rather than ordinary means of prolonging life.

23
Family Attitudes

• Eating and drinking as symbolic gesture of giving
  love
• Food as a celebration and social event
• Refusing foods may be perceived as refusing love
• Help family refocus energy by providing
  nourishment for the mind and spirit
• Help family find meaningful ways to visit

24
Family Attitudes, cont.

• Ways to visit meaningfully
• Apply lotion to hands and feet
• Give a back massage
• Apply moisturizer to the lips
• Remember earlier times and happenings
• Play audio tapes of nature sounds and music
• Talk about past life memories/experiences
• Sit in silence and share the time

25
When Staff Become Family

• Be aware of one anothers emotional attachment to
  dying residents
• Staff become surrogate family
• Nurture caring relationships, allow for grief
• Grief counseling services for staff and families
• Manage all aspects of death and grieving in a
  healthy manner.
• Everyone needs good memories and support as they
  deal with difficult situations of living and
  helping others during their time of dying.