Nutrition and hydration in palliative care

1
Nutrition and hydration in palliative care

• Hannah Roberts
• Specialist Upper GI Cancer Dietitian
• Bradford Teaching Hospitals

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Aims

• Know the different types of nutrition support
  available
• Be able to choose and justify the most
  appropriate method of nutrition support for
  palliative patients
• Consider the ethical and moral arguments for
  artificial nutrition
• Understand the role of the dietitian in
  palliative care

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Quick Quiz!

• Name 2 benefits of nutrition support in
  palliative care
• Name 2 risks of nutrition support in palliative
  care
• Give an example of food fortification
• Give an example of a supplement drink that needs
  to be prescribed
• What is enteral nutrition? Give an example
• What is parenteral nutrition?

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Ethics and legality

• Hydration is basic care
• Spoon feeding is basic care
• Artificial nutrition is not basic care and
  classed as a medical intervention
• Key question
• Do the benefits outweigh the risks?

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Once started can you stop?

• Legal equivalence of withdrawal and withholding
• Can feel more comfortable not to start than to
  start and then discontinue
• Dont deny patient the right of a trial of
  therapy
• Can trial with agreed objectives and time for
  review

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Hydration

• Good hydration essential for well-being
• Adequate fluid provision should not impair
  appetite
• Nourishing fluids

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Benefits of nutrition support in palliative care

• Increase energy levels
• Resistance to infection
• Minimise muscle wasting and pressure sores
• Allows patient to retain some control over their
  illness
• Helps to maintain a sense of normality
• Can improve quality of life and sense of well
  being

8
Risks of nutrition support in palliative care

• Aspiration
• Sepsis
• Haemorrhage
• Can prolong death
• Evoke feelings of fear and despair

9
When to use nutrition support

• Disease related malnutrition
• Weight loss
• Reduced appetite and early satiety
• Swallowing difficulties
• Also depends on stage of disease
• Curative phase always appropriate
• Palliative phase usually appropriate
• Terminal phase rarely appropriate

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Types of nutrition support

• Oral
• Enteral
• Parenteral

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Oral nutrition

• High energy and high protein diet
• Food fortification
• Appetite stimulation

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Food Fortification

• Breakfast
• Porridge
• Toast butter
• Cup of tea
• Lunch
• Cup-a-soup
• Banana
• Evening meal
• Poached cod and jacket potato
• Yoghurt
• Extras
• Tea between meals
• Horlicks at supper
• Total 980 calories and 48g protein

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What difference can food fortification make?

• Breakfast
• Porridge.. Swap to whole milk and add golden
  syrup
• Toast butter.. Add jam
• Cup of tea.. Make with whole milk
• Lunch
• Soup.. Swap to a creamy soup
• Add bread and butter
• Banana.. Add custard
• Evening meal
• Poached cod.. Add a cheese sauce
• Jacket potato.. Add butter
• Yoghurt.. Swap to a trifle
• Extras
• Tea between meals.. Make with whole milk
• Horlicks at supper.. Make with whole milk
• Add 2 biscuits and a slice of cake
• Total 2070 calories and 75g protein
• Thats an extra 1090 calories and 27g protein!!

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Oral nutrition

• Supplements (many different types!)
• - high energy and high protein drinks
• - high energy medicine
• - puddings
• - powders

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Oral nutrition when to use it

• If a patient can eat let them eat!
• Majority of palliative care patients
• Encourage higher calorie options (if liked)
• Use of supplements if a patient cant eat enough

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Enteral nutrition

• using a tube
• Naso-gastric (NG)
• Naso-jejunal (NJ)
• Gastrostomy e.g. PEG, RIG
• Jejunostomy
• Artificial feed (as recommended by the dietitian)
  is put down the tube via a pump or syringe
• Medication and fluids can be put down too
• Can be sole source of nutrition or to supplement
  oral intake

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Enteral nutrition when to use it

• Depends on the individual patient
• Unable to take nutrition orally
• Persistent swallowing difficulties

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Parenteral nutrition

• Through a vein
• Requires appropriate access (usually through a
  central line)
• Home parenteral nutrition is rare in palliative
  care in England

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Parenteral nutrition when to use it

• Should it be used at all in palliative care?
• Non-functioning GI tract e.g. intestinal failure
• Do the risks outweigh the benefits?

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Case study 1

• 67 year old male with laryngeal cancer
• April 04 - total laryngectomy
• Oct 06 - dysphagia
• CT scan showed bulky lymph node recurrence
• Managing soft diet but not meeting nutritional
  requirements
• NG tube inserted. Discharged home with NG feed.
• Completed palliative chemoradiotherapy
• Feb 07 - weight gain and improvement in oral
  intake. NG tube removed
• July 07 - represented with lower oesophageal
  dysphagia on a liquidised diet and sip feeds.
  Oesophageal stent inserted and oral intake
  improved
• Dec 07 - general deterioration, weight loss,
  minimal oral intake, poor prognosis
• Patient and family could he have another NG
  tube please?

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Case study 1 issues raised

• Would NG feeding be of benefit to the patient?
• Do we have the right to refuse to artificially
  feed?

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Case study 2

• 60 year old female
• May 06 - Diagnosed with locally advanced
  pancreatic cancer
• For palliative chemotherapy
• 12 weight loss in 6 weeks
• Early satiety and poor appetite
• Steattorhoea
• Following a low fat diet
• Blood sugar readings 20 mmol/l
• What is the most appropriate method of nutrition
  support for this patient?

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Case study 2 issues raised

• Review of diabetes medication
• Commence pancreatic enzymes
• Not a low fat diet!
• Food first
• High energy and high protein diet
• Food fortification
• Nutritional supplements
• Avoid unnecessary consumption of simple sugars
  but not at the cost of energy intake

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The last few days

• Food and fluids for pleasure and comfort not for
  survival
• Consider patients wishes, anxiety and physical
  symptoms
• Nutrition support not usually appropriate
• Artificial hydration is controversial

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The role of the dietitian in palliative care

• Advice on
• poor appetite
• sore or dry mouth
• taste changes
• early satiety
• GI symptoms

• Assessing nutritional needs and problems
• Establishing which nutritional support measures
  are appropriate
• Use of appropriate supplements
• Enteral and parenteral nutrition support
• Advice and guidance to carers
• Training of staff and catering

• Bradford dietitians are based at St Lukes
  Hospital.
• Telephone number 01274 365108

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Conclusions

• Range of nutritional support options available to
  use in palliative care
• Deciding when to use nutrition support can be
  difficult
• Decision should be made as part of a
  multi-professional team (including the patient!)
• Discussions should happen earlier rather than
  later